{"hospital_name":"Agnesian Healthcare Inc.","last_updated_on":"2026-04-01","version":"3.0.0","location_name":["SSM Health St. Agnes Hospital-Fond Du Lac"],"hospital_address":["430 E Division St, Fond Du Lac, WI 54935"],"license_information":{"license_number":"120","state":"WI"},"type_2_npi":["1346228541","1598743726","1538147749"],"attestation":{"attestation":"To the best of its knowledge and belief, this hospital has included all applicable standard charge information in accordance with the requirements of 45 CFR 180.50, and the information encoded is true, accurate, and complete as of the date in the file. This hospital has included all payer-specific negotiated charges in dollars that can be expressed as a dollar amount. For payer-specific negotiated charges that cannot be expressed as a dollar amount in the machine-readable file or not knowable in advance, the hospital attests that the payer-specific negotiated charge is based on a contractual algorithm, percentage or formula that precludes the provision of a dollar amount and has provided all necessary information available to the hospital for the public to be able to derive the dollar amount, including, but not limited to, the specific fee schedule or components referenced in such percentage, algorithm or formula.","confirm_attestation":true,"attester_name":"John Snodsmith"},"financial_aid_policy":["45% off of facility standard gross charges."],"standard_charge_information":[{"description":"Acetaminophen Soln 160 MG/5ML","drug_information":{"unit":1.0,"type":"ML"},"code_information":[{"code":"100","type":"CDM"},{"code":"8890010010","type":"NDC"}],"standard_charges":[{"gross_charge":3.12,"discounted_cash":1.72,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Acetaminophen Soln 160 MG/5ML","drug_information":{"unit":20.3,"type":"ML"},"code_information":[{"code":"100","type":"CDM"},{"code":"39328003450","type":"NDC"}],"standard_charges":[{"gross_charge":5.23,"discounted_cash":2.88,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Famotidine For Susp 40 MG/5ML","drug_information":{"unit":50.0,"type":"ML"},"code_information":[{"code":"10010","type":"CDM"},{"code":"70954031610","type":"NDC"}],"standard_charges":[{"gross_charge":689.26,"discounted_cash":379.09,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Famotidine For Susp 40 MG/5ML","drug_information":{"unit":50.0,"type":"ML"},"code_information":[{"code":"10010","type":"CDM"},{"code":"68180015001","type":"NDC"}],"standard_charges":[{"gross_charge":689.26,"discounted_cash":379.09,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Famotidine Tab 20 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"10011","type":"CDM"},{"code":"904719361","type":"NDC"}],"standard_charges":[{"gross_charge":8.4,"discounted_cash":4.62,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Felbamate Tab 600 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"10025","type":"CDM"},{"code":"62559073101","type":"NDC"}],"standard_charges":[{"gross_charge":27.74,"discounted_cash":15.26,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Finasteride Tab 5 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"10037","type":"CDM"},{"code":"904683006","type":"NDC"}],"standard_charges":[{"gross_charge":11.61,"discounted_cash":6.39,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Flecainide Acetate Tab 50 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"10043","type":"CDM"},{"code":"50268032011","type":"NDC"}],"standard_charges":[{"gross_charge":23.6,"discounted_cash":12.98,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Flecainide Acetate Tab 50 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"10043","type":"CDM"},{"code":"50268032015","type":"NDC"}],"standard_charges":[{"gross_charge":23.6,"discounted_cash":12.98,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Fluconazole Tab 100 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"10044","type":"CDM"},{"code":"50268033711","type":"NDC"}],"standard_charges":[{"gross_charge":28.84,"discounted_cash":15.86,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Fluconazole Tab 100 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"10044","type":"CDM"},{"code":"50268033715","type":"NDC"}],"standard_charges":[{"gross_charge":28.84,"discounted_cash":15.86,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Fluconazole in NaCl 0.9% Inj 200 MG/100ML","drug_information":{"unit":100.0,"type":"ML"},"code_information":[{"code":"10049","type":"CDM"},{"code":"338604648","type":"NDC"}],"standard_charges":[{"gross_charge":46.86,"discounted_cash":25.77,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Fluconazole in NaCl 0.9% Inj 400 MG/200ML","drug_information":{"unit":200.0,"type":"ML"},"code_information":[{"code":"10050","type":"CDM"},{"code":"25021018467","type":"NDC"}],"standard_charges":[{"gross_charge":54.14,"discounted_cash":29.78,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Fludrocortisone Acetate Tab 0.1 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"10054","type":"CDM"},{"code":"904731761","type":"NDC"}],"standard_charges":[{"gross_charge":12.61,"discounted_cash":6.94,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Fluoxetine HCl Cap 10 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"10069","type":"CDM"},{"code":"65862019201","type":"NDC"}],"standard_charges":[{"gross_charge":18.0,"discounted_cash":9.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Fluoxetine HCl Cap 20 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"10070","type":"CDM"},{"code":"904734661","type":"NDC"}],"standard_charges":[{"gross_charge":8.51,"discounted_cash":4.68,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Fluoxetine HCl Cap 20 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"10070","type":"CDM"},{"code":"65862019301","type":"NDC"}],"standard_charges":[{"gross_charge":18.27,"discounted_cash":10.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Acetaminophen Tab 325 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"101","type":"CDM"},{"code":"904677361","type":"NDC"}],"standard_charges":[{"gross_charge":3.06,"discounted_cash":1.68,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Ganciclovir Sodium For Inj 500 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"10101","type":"CDM"},{"code":"70436008955","type":"NDC"}],"standard_charges":[{"gross_charge":133.96,"discounted_cash":73.68,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Glipizide Tab 5 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"10117","type":"CDM"},{"code":"904663761","type":"NDC"}],"standard_charges":[{"gross_charge":9.78,"discounted_cash":5.38,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Glycopyrrolate Tab 1 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"10130","type":"CDM"},{"code":"13107001401","type":"NDC"}],"standard_charges":[{"gross_charge":13.06,"discounted_cash":7.18,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Guanfacine HCl Tab 2 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"10150","type":"CDM"},{"code":"591045301","type":"NDC"}],"standard_charges":[{"gross_charge":12.53,"discounted_cash":6.89,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Haloperidol Decanoate IM Soln 100 MG/ML","drug_information":{"unit":1.0,"type":"ML"},"code_information":[{"code":"10162","type":"CDM"},{"code":"70756061681","type":"NDC"}],"standard_charges":[{"gross_charge":102.28,"discounted_cash":56.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Heparin Sodium (Porcine) Inj 1000 Unit/ML","drug_information":{"unit":0.5,"type":"ML"},"code_information":[{"code":"10176","type":"CDM"},{"code":"63323054007","type":"NDC"}],"standard_charges":[{"gross_charge":15.68,"discounted_cash":8.62,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Heparin Sodium (Porcine) Inj 1000 Unit/ML","drug_information":{"unit":0.5,"type":"ML"},"code_information":[{"code":"10176","type":"CDM"},{"code":"63323054033","type":"NDC"}],"standard_charges":[{"gross_charge":15.7,"discounted_cash":8.64,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Heparin Sodium (Porcine) Inj 1000 Unit/ML","drug_information":{"unit":0.5,"type":"ML"},"code_information":[{"code":"10176","type":"CDM"},{"code":"63323054015","type":"NDC"}],"standard_charges":[{"gross_charge":16.11,"discounted_cash":8.86,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Heparin Sodium (Porcine) Inj 5000 Unit/ML","drug_information":{"unit":1.0,"type":"ML"},"code_information":[{"code":"10181","type":"CDM"},{"code":"72572025525","type":"NDC"}],"standard_charges":[{"gross_charge":18.42,"discounted_cash":10.13,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Heparin Sodium (Porcine) Inj 5000 Unit/ML","drug_information":{"unit":1.0,"type":"ML"},"code_information":[{"code":"10181","type":"CDM"},{"code":"72572025501","type":"NDC"}],"standard_charges":[{"gross_charge":18.42,"discounted_cash":10.13,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Heparin Sodium (Porcine) Inj 5000 Unit/ML","drug_information":{"unit":1.0,"type":"ML"},"code_information":[{"code":"10181","type":"CDM"},{"code":"63323004710","type":"NDC"}],"standard_charges":[{"gross_charge":18.42,"discounted_cash":10.13,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Acetaminophen Tab 500 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"102","type":"CDM"},{"code":"904672060","type":"NDC"}],"standard_charges":[{"gross_charge":3.05,"discounted_cash":1.68,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Perflutren Protein-Type A Microspheres IV Susp","drug_information":{"unit":3.0,"type":"ML"},"code_information":[{"code":"102058","type":"CDM"},{"code":"407270703","type":"NDC"}],"standard_charges":[{"gross_charge":359.54,"discounted_cash":197.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Hydroxychloroquine Sulfate Tab 200 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"10235","type":"CDM"},{"code":"43598072101","type":"NDC"}],"standard_charges":[{"gross_charge":23.74,"discounted_cash":13.06,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Hydroxyurea Cap 500 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"10236","type":"CDM"},{"code":"68084028411","type":"NDC"}],"standard_charges":[{"gross_charge":54.24,"discounted_cash":29.83,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Ibuprofen Susp 100 MG/5ML","drug_information":{"unit":10.0,"type":"ML"},"code_information":[{"code":"10246","type":"CDM"},{"code":"68094050359","type":"NDC"}],"standard_charges":[{"gross_charge":4.8,"discounted_cash":2.64,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Ibuprofen Susp 100 MG/5ML","drug_information":{"unit":5.0,"type":"ML"},"code_information":[{"code":"10246","type":"CDM"},{"code":"68094049462","type":"NDC"}],"standard_charges":[{"gross_charge":4.17,"discounted_cash":2.29,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Ibuprofen Susp 100 MG/5ML","drug_information":{"unit":120.0,"type":"ML"},"code_information":[{"code":"10246","type":"CDM"},{"code":"904530920","type":"NDC"}],"standard_charges":[{"gross_charge":7.92,"discounted_cash":4.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Ibuprofen Susp 100 MG/5ML","drug_information":{"unit":5.0,"type":"ML"},"code_information":[{"code":"10246","type":"CDM"},{"code":"68094049459","type":"NDC"}],"standard_charges":[{"gross_charge":4.12,"discounted_cash":2.27,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Insulin Regular (Human) Inj 100 Unit/ML","drug_information":{"unit":10.0,"type":"ML"},"code_information":[{"code":"10289","type":"CDM"},{"code":"2821501","type":"NDC"}],"standard_charges":[{"gross_charge":90.44,"discounted_cash":49.74,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Insulin Regular (Human) Inj 100 Unit/ML","drug_information":{"unit":3.0,"type":"ML"},"code_information":[{"code":"10289","type":"CDM"},{"code":"2021301","type":"NDC"}],"standard_charges":[{"gross_charge":37.98,"discounted_cash":20.89,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Acetaminophen Suppos 120 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"103","type":"CDM"},{"code":"45802073230","type":"NDC"}],"standard_charges":[{"gross_charge":10.59,"discounted_cash":5.82,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Acetaminophen Suppos 120 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"103","type":"CDM"},{"code":"45802073200","type":"NDC"}],"standard_charges":[{"gross_charge":10.59,"discounted_cash":5.82,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Iopamidol Inj 41%","drug_information":{"unit":10.0,"type":"ML"},"code_information":[{"code":"10325","type":"CDM"},{"code":"270141111","type":"NDC"}],"standard_charges":[{"gross_charge":305.93,"discounted_cash":168.26,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Iopamidol Inj 41%","drug_information":{"unit":20.0,"type":"ML"},"code_information":[{"code":"10325","type":"CDM"},{"code":"270141125","type":"NDC"}],"standard_charges":[{"gross_charge":406.34,"discounted_cash":223.49,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Iopamidol Inj 51%","drug_information":{"unit":100.0,"type":"ML"},"code_information":[{"code":"10326","type":"CDM"},{"code":"270131702","type":"NDC"}],"standard_charges":[{"gross_charge":262.5,"discounted_cash":144.38,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Iopamidol Inj 51%","drug_information":{"unit":50.0,"type":"ML"},"code_information":[{"code":"10326","type":"CDM"},{"code":"270131705","type":"NDC"}],"standard_charges":[{"gross_charge":162.99,"discounted_cash":89.64,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Iopamidol Inj 61%","drug_information":{"unit":15.0,"type":"ML"},"code_information":[{"code":"10327","type":"CDM"},{"code":"270141215","type":"NDC"}],"standard_charges":[{"gross_charge":395.18,"discounted_cash":217.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Iopamidol IV Soln 76%","drug_information":{"unit":100.0,"type":"ML"},"code_information":[{"code":"10328","type":"CDM"},{"code":"270131635","type":"NDC"}],"standard_charges":[{"gross_charge":324.25,"discounted_cash":178.34,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Iopamidol IV Soln 76%","drug_information":{"unit":150.0,"type":"ML"},"code_information":[{"code":"10328","type":"CDM"},{"code":"270131637","type":"NDC"}],"standard_charges":[{"gross_charge":435.64,"discounted_cash":239.60,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Iopamidol IV Soln 76%","drug_information":{"unit":500.0,"type":"ML"},"code_information":[{"code":"10328","type":"CDM"},{"code":"270131695","type":"NDC"}],"standard_charges":[{"gross_charge":1483.25,"discounted_cash":815.79,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Iopamidol IV Soln 76%","drug_information":{"unit":200.0,"type":"ML"},"code_information":[{"code":"10328","type":"CDM"},{"code":"270131645","type":"NDC"}],"standard_charges":[{"gross_charge":611.15,"discounted_cash":336.13,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Iothalamate Meglumine Inj 17.2%","drug_information":{"unit":250.0,"type":"ML"},"code_information":[{"code":"10330","type":"CDM"},{"code":"19086250","type":"NDC"}],"standard_charges":[{"gross_charge":205.5,"discounted_cash":113.02,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Iothalamate Meglumine Inj 60%","drug_information":{"unit":50.0,"type":"ML"},"code_information":[{"code":"10333","type":"CDM"},{"code":"19095305","type":"NDC"}],"standard_charges":[{"gross_charge":112.88,"discounted_cash":62.08,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Isosulfan Blue Subcutaneous Soln 1%","drug_information":{"unit":0.5,"type":"ML"},"code_information":[{"code":"10358","type":"CDM"},{"code":"67457022005","type":"NDC"}],"standard_charges":[{"gross_charge":325.91,"discounted_cash":179.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Isosulfan Blue Subcutaneous Soln 1%","drug_information":{"unit":0.5,"type":"ML"},"code_information":[{"code":"10358","type":"CDM"},{"code":"67457022000","type":"NDC"}],"standard_charges":[{"gross_charge":325.91,"discounted_cash":179.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Formoterol Fumarate Soln Nebu 20 MCG/2ML","drug_information":{"unit":2.0,"type":"ML"},"code_information":[{"code":"103613","type":"CDM"},{"code":"70756060870","type":"NDC"}],"standard_charges":[{"gross_charge":75.28,"discounted_cash":41.40,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Formoterol Fumarate Soln Nebu 20 MCG/2ML","drug_information":{"unit":2.0,"type":"ML"},"code_information":[{"code":"103613","type":"CDM"},{"code":"70756060812","type":"NDC"}],"standard_charges":[{"gross_charge":75.28,"discounted_cash":41.40,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Formoterol Fumarate Soln Nebu 20 MCG/2ML","drug_information":{"unit":2.0,"type":"ML"},"code_information":[{"code":"103613","type":"CDM"},{"code":"49502060530","type":"NDC"}],"standard_charges":[{"gross_charge":84.63,"discounted_cash":46.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Itraconazole Cap 100 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"10364","type":"CDM"},{"code":"60687029995","type":"NDC"}],"standard_charges":[{"gross_charge":23.4,"discounted_cash":12.87,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Itraconazole Cap 100 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"10364","type":"CDM"},{"code":"60687029925","type":"NDC"}],"standard_charges":[{"gross_charge":23.4,"discounted_cash":12.87,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Pot Phos Monobasic w/Sod Phos Di & Monobas Tab 155-852-130MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"10365","type":"CDM"},{"code":"64980010401","type":"NDC"}],"standard_charges":[{"gross_charge":10.26,"discounted_cash":5.64,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Ketorolac Tromethamine Tab 10 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"10371","type":"CDM"},{"code":"70710171001","type":"NDC"}],"standard_charges":[{"gross_charge":43.13,"discounted_cash":23.72,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Labetalol HCl Tab 100 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"10373","type":"CDM"},{"code":"60687043901","type":"NDC"}],"standard_charges":[{"gross_charge":10.42,"discounted_cash":5.73,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Labetalol HCl Tab 100 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"10373","type":"CDM"},{"code":"60687043911","type":"NDC"}],"standard_charges":[{"gross_charge":10.42,"discounted_cash":5.73,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Leuprolide Acetate For Inj Kit 7.5 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"10392","type":"CDM"},{"code":"74364203","type":"NDC"}],"standard_charges":[{"gross_charge":3352.24,"discounted_cash":1843.73,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Trypan Blue Intraocular Soln Pref Syr 0.06%","drug_information":{"unit":0.5,"type":"ML"},"code_information":[{"code":"103951","type":"CDM"},{"code":"68803061210","type":"NDC"}],"standard_charges":[{"gross_charge":200.12,"discounted_cash":110.07,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Acetaminophen Suppos 325 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"104","type":"CDM"},{"code":"51672211600","type":"NDC"}],"standard_charges":[{"gross_charge":11.57,"discounted_cash":6.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Acetaminophen Suppos 325 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"104","type":"CDM"},{"code":"51672211602","type":"NDC"}],"standard_charges":[{"gross_charge":12.7,"discounted_cash":6.98,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Levothyroxine Sodium Tab 88 MCG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"10403","type":"CDM"},{"code":"60687048611","type":"NDC"}],"standard_charges":[{"gross_charge":11.12,"discounted_cash":6.12,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Levothyroxine Sodium Tab 88 MCG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"10403","type":"CDM"},{"code":"60687048601","type":"NDC"}],"standard_charges":[{"gross_charge":11.12,"discounted_cash":6.12,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Levothyroxine Sodium Tab 112 MCG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"10404","type":"CDM"},{"code":"904695461","type":"NDC"}],"standard_charges":[{"gross_charge":11.62,"discounted_cash":6.39,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Levothyroxine Sodium Tab 137 MCG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"10405","type":"CDM"},{"code":"42292004101","type":"NDC"}],"standard_charges":[{"gross_charge":11.25,"discounted_cash":6.19,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Levothyroxine Sodium Tab 137 MCG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"10405","type":"CDM"},{"code":"42292004120","type":"NDC"}],"standard_charges":[{"gross_charge":11.24,"discounted_cash":6.18,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Lidocaine Inj 0.5% w/ Epinephrine-1:200000","drug_information":{"unit":50.0,"type":"ML"},"code_information":[{"code":"10426","type":"CDM"},{"code":"409317716","type":"NDC"}],"standard_charges":[{"gross_charge":56.59,"discounted_cash":31.12,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Lidocaine Inj 1% w/ Epinephrine-1:100000","drug_information":{"unit":50.0,"type":"ML"},"code_information":[{"code":"10427","type":"CDM"},{"code":"409317818","type":"NDC"}],"standard_charges":[{"gross_charge":79.86,"discounted_cash":43.92,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Lidocaine Inj 1% w/ Epinephrine-1:100000","drug_information":{"unit":10.0,"type":"ML"},"code_information":[{"code":"10427","type":"CDM"},{"code":"63323048201","type":"NDC"}],"standard_charges":[{"gross_charge":57.06,"discounted_cash":31.38,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Lidocaine Inj 1% w/ Epinephrine-1:100000","drug_information":{"unit":20.0,"type":"ML"},"code_information":[{"code":"10427","type":"CDM"},{"code":"63323048227","type":"NDC"}],"standard_charges":[{"gross_charge":66.42,"discounted_cash":36.53,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Lidocaine Inj 1% w/ Epinephrine-1:100000","drug_information":{"unit":50.0,"type":"ML"},"code_information":[{"code":"10427","type":"CDM"},{"code":"409317803","type":"NDC"}],"standard_charges":[{"gross_charge":79.86,"discounted_cash":43.92,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Lidocaine Inj 1% w/ Epinephrine-1:200000 (PF)","drug_information":{"unit":30.0,"type":"ML"},"code_information":[{"code":"10428","type":"CDM"},{"code":"63323048707","type":"NDC"}],"standard_charges":[{"gross_charge":113.1,"discounted_cash":62.20,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Lidocaine Inj 1% w/ Epinephrine-1:200000 (PF)","drug_information":{"unit":10.0,"type":"ML"},"code_information":[{"code":"10428","type":"CDM"},{"code":"63323048717","type":"NDC"}],"standard_charges":[{"gross_charge":82.01,"discounted_cash":45.11,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Lidocaine Inj 1.5% w/ Epinephrine-1:200000 (PF)","drug_information":{"unit":5.0,"type":"ML"},"code_information":[{"code":"10429","type":"CDM"},{"code":"409120901","type":"NDC"}],"standard_charges":[{"gross_charge":60.54,"discounted_cash":33.30,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Lidocaine Inj 2% w/ Epinephrine-1:100000","drug_information":{"unit":50.0,"type":"ML"},"code_information":[{"code":"10430","type":"CDM"},{"code":"63323048301","type":"NDC"}],"standard_charges":[{"gross_charge":94.83,"discounted_cash":52.16,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Lidocaine Inj 2% w/ Epinephrine-1:100000","drug_information":{"unit":20.0,"type":"ML"},"code_information":[{"code":"10430","type":"CDM"},{"code":"63323048303","type":"NDC"}],"standard_charges":[{"gross_charge":66.9,"discounted_cash":36.80,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Lidocaine Inj 2% w/ Epinephrine-1:100000","drug_information":{"unit":20.0,"type":"ML"},"code_information":[{"code":"10430","type":"CDM"},{"code":"63323048327","type":"NDC"}],"standard_charges":[{"gross_charge":66.9,"discounted_cash":36.80,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Lidocaine Inj 2% w/ Epinephrine-1:200000 (PF)","drug_information":{"unit":10.0,"type":"ML"},"code_information":[{"code":"10431","type":"CDM"},{"code":"63323048917","type":"NDC"}],"standard_charges":[{"gross_charge":90.7,"discounted_cash":49.88,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Lidocaine Inj 2% w/ Epinephrine-1:200000 (PF)","drug_information":{"unit":20.0,"type":"ML"},"code_information":[{"code":"10431","type":"CDM"},{"code":"409318301","type":"NDC"}],"standard_charges":[{"gross_charge":63.29,"discounted_cash":34.81,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Lidocaine Inj 2% w/ Epinephrine-1:200000 (PF)","drug_information":{"unit":20.0,"type":"ML"},"code_information":[{"code":"10431","type":"CDM"},{"code":"409318311","type":"NDC"}],"standard_charges":[{"gross_charge":63.29,"discounted_cash":34.81,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Lidocaine-Prilocaine Cream 2.5-2.5%","drug_information":{"unit":30.0,"type":"GM"},"code_information":[{"code":"10434","type":"CDM"},{"code":"168035730","type":"NDC"}],"standard_charges":[{"gross_charge":97.5,"discounted_cash":53.62,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Lisinopril Tab 10 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"10449","type":"CDM"},{"code":"904679861","type":"NDC"}],"standard_charges":[{"gross_charge":8.28,"discounted_cash":4.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Lisinopril Tab 40 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"10450","type":"CDM"},{"code":"904720061","type":"NDC"}],"standard_charges":[{"gross_charge":8.74,"discounted_cash":4.81,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Lithium Carbonate Tab ER 300 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"10454","type":"CDM"},{"code":"68084064001","type":"NDC"}],"standard_charges":[{"gross_charge":10.22,"discounted_cash":5.62,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Lithium Carbonate Tab ER 450 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"10455","type":"CDM"},{"code":"68084065511","type":"NDC"}],"standard_charges":[{"gross_charge":11.36,"discounted_cash":6.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Loratadine Tab 10 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"10466","type":"CDM"},{"code":"68084024801","type":"NDC"}],"standard_charges":[{"gross_charge":11.12,"discounted_cash":6.12,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Loratadine Tab 10 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"10466","type":"CDM"},{"code":"68084024811","type":"NDC"}],"standard_charges":[{"gross_charge":11.12,"discounted_cash":6.12,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Lorazepam Inj 2 MG/ML","drug_information":{"unit":0.25,"type":"ML"},"code_information":[{"code":"10467","type":"CDM"},{"code":"641604601","type":"NDC"}],"standard_charges":[{"gross_charge":32.49,"discounted_cash":17.87,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Lorazepam Inj 2 MG/ML","drug_information":{"unit":0.25,"type":"ML"},"code_information":[{"code":"10467","type":"CDM"},{"code":"72572038001","type":"NDC"}],"standard_charges":[{"gross_charge":32.79,"discounted_cash":18.03,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Lorazepam Inj 2 MG/ML","drug_information":{"unit":0.25,"type":"ML"},"code_information":[{"code":"10467","type":"CDM"},{"code":"72572038025","type":"NDC"}],"standard_charges":[{"gross_charge":32.79,"discounted_cash":18.03,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Acetaminophen Suppos 650 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"105","type":"CDM"},{"code":"45802073032","type":"NDC"}],"standard_charges":[{"gross_charge":10.64,"discounted_cash":5.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Acetaminophen Suppos 650 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"105","type":"CDM"},{"code":"45802073030","type":"NDC"}],"standard_charges":[{"gross_charge":10.96,"discounted_cash":6.03,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Acetaminophen Suppos 650 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"105","type":"CDM"},{"code":"45802073000","type":"NDC"}],"standard_charges":[{"gross_charge":10.64,"discounted_cash":5.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Measles-Mumps-Rubella Virus Vaccines For Inj Soln","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"10512","type":"CDM"},{"code":"6468100","type":"NDC"}],"standard_charges":[{"gross_charge":183.71,"discounted_cash":101.04,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Measles-Mumps-Rubella Virus Vaccines For Inj Soln","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"10512","type":"CDM"},{"code":"6468101","type":"NDC"}],"standard_charges":[{"gross_charge":183.71,"discounted_cash":101.04,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Oseltamivir Phosphate Cap 30 MG (Base Equiv)","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"105153","type":"CDM"},{"code":"527459113","type":"NDC"}],"standard_charges":[{"gross_charge":47.0,"discounted_cash":25.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Oseltamivir Phosphate Cap 30 MG (Base Equiv)","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"105153","type":"CDM"},{"code":"64380079701","type":"NDC"}],"standard_charges":[{"gross_charge":47.0,"discounted_cash":25.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Megestrol Acetate Susp 40 MG/ML","drug_information":{"unit":5.0,"type":"ML"},"code_information":[{"code":"10521","type":"CDM"},{"code":"66689002001","type":"NDC"}],"standard_charges":[{"gross_charge":65.64,"discounted_cash":36.10,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Mesalamine Cap ER 250 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"10533","type":"CDM"},{"code":"54092018981","type":"NDC"}],"standard_charges":[{"gross_charge":22.03,"discounted_cash":12.12,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Metformin HCl Tab 500 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"10544","type":"CDM"},{"code":"904716261","type":"NDC"}],"standard_charges":[{"gross_charge":8.34,"discounted_cash":4.59,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Methimazole Tab 5 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"10553","type":"CDM"},{"code":"60687066911","type":"NDC"}],"standard_charges":[{"gross_charge":11.2,"discounted_cash":6.16,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Methimazole Tab 5 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"10553","type":"CDM"},{"code":"60687066901","type":"NDC"}],"standard_charges":[{"gross_charge":11.19,"discounted_cash":6.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Methylergonovine Maleate Inj 0.2 MG/ML","drug_information":{"unit":1.0,"type":"ML"},"code_information":[{"code":"10571","type":"CDM"},{"code":"51991014499","type":"NDC"}],"standard_charges":[{"gross_charge":96.2,"discounted_cash":52.91,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Methylergonovine Maleate Inj 0.2 MG/ML","drug_information":{"unit":1.0,"type":"ML"},"code_information":[{"code":"10571","type":"CDM"},{"code":"51991014417","type":"NDC"}],"standard_charges":[{"gross_charge":96.21,"discounted_cash":52.92,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Methylergonovine Maleate Tab 0.2 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"10572","type":"CDM"},{"code":"70010078612","type":"NDC"}],"standard_charges":[{"gross_charge":146.38,"discounted_cash":80.51,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Methylprednisolone Sod Succ For Inj 1000 MG (Base Equiv)","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"10577","type":"CDM"},{"code":"43598013074","type":"NDC"}],"standard_charges":[{"gross_charge":116.8,"discounted_cash":64.24,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Methylprednisolone Sod Succ For Inj 125 MG (Base Equiv)","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"10578","type":"CDM"},{"code":"9004725","type":"NDC"}],"standard_charges":[{"gross_charge":65.38,"discounted_cash":35.96,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Methylprednisolone Sod Succ For Inj 125 MG (Base Equiv)","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"10578","type":"CDM"},{"code":"9004722","type":"NDC"}],"standard_charges":[{"gross_charge":65.38,"discounted_cash":35.96,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Methylprednisolone Sod Succ For Inj 40 MG (Base Equiv)","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"10580","type":"CDM"},{"code":"9003930","type":"NDC"}],"standard_charges":[{"gross_charge":56.61,"discounted_cash":31.14,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Methylprednisolone Sod Succ For Inj 40 MG (Base Equiv)","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"10580","type":"CDM"},{"code":"9003928","type":"NDC"}],"standard_charges":[{"gross_charge":56.61,"discounted_cash":31.14,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Methylprednisolone Sod Succ For Inj 40 MG (Base Equiv)","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"10580","type":"CDM"},{"code":"9003932","type":"NDC"}],"standard_charges":[{"gross_charge":52.26,"discounted_cash":28.74,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Methylprednisolone Sod Succ For Inj 500 MG (Base Equiv)","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"10581","type":"CDM"},{"code":"43598012811","type":"NDC"}],"standard_charges":[{"gross_charge":89.08,"discounted_cash":48.99,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Metolazone Tab 2.5 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"10587","type":"CDM"},{"code":"72888005201","type":"NDC"}],"standard_charges":[{"gross_charge":15.98,"discounted_cash":8.79,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Metolazone Tab 5 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"10588","type":"CDM"},{"code":"51079002401","type":"NDC"}],"standard_charges":[{"gross_charge":22.36,"discounted_cash":12.30,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Metronidazole Vaginal Gel 0.75%","drug_information":{"unit":70.0,"type":"GM"},"code_information":[{"code":"10592","type":"CDM"},{"code":"781707787","type":"NDC"}],"standard_charges":[{"gross_charge":605.32,"discounted_cash":332.93,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Mexiletine HCl Cap 150 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"10595","type":"CDM"},{"code":"50742023901","type":"NDC"}],"standard_charges":[{"gross_charge":17.76,"discounted_cash":9.77,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Midodrine HCl Tab 2.5 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"10609","type":"CDM"},{"code":"904681706","type":"NDC"}],"standard_charges":[{"gross_charge":11.13,"discounted_cash":6.12,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Midodrine HCl Tab 5 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"10610","type":"CDM"},{"code":"72888011301","type":"NDC"}],"standard_charges":[{"gross_charge":22.38,"discounted_cash":12.31,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Midodrine HCl Tab 5 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"10610","type":"CDM"},{"code":"51079045301","type":"NDC"}],"standard_charges":[{"gross_charge":18.43,"discounted_cash":10.14,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Midodrine HCl Tab 5 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"10610","type":"CDM"},{"code":"51079045320","type":"NDC"}],"standard_charges":[{"gross_charge":18.43,"discounted_cash":10.14,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Minocycline HCl IV For Soln 100 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"10612","type":"CDM"},{"code":"70842016001","type":"NDC"}],"standard_charges":[{"gross_charge":496.3,"discounted_cash":272.96,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Minocycline HCl IV For Soln 100 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"10612","type":"CDM"},{"code":"70842016010","type":"NDC"}],"standard_charges":[{"gross_charge":496.3,"discounted_cash":272.96,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Misoprostol Tab 100 MCG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"10628","type":"CDM"},{"code":"70954044310","type":"NDC"}],"standard_charges":[{"gross_charge":12.36,"discounted_cash":6.80,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Misoprostol Tab 200 MCG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"10629","type":"CDM"},{"code":"59762500801","type":"NDC"}],"standard_charges":[{"gross_charge":12.62,"discounted_cash":6.94,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Mitomycin For IV Soln 40 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"10631","type":"CDM"},{"code":"67457052040","type":"NDC"}],"standard_charges":[{"gross_charge":2173.46,"discounted_cash":1195.40,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Mitomycin For IV Soln 5 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"10632","type":"CDM"},{"code":"16729011505","type":"NDC"}],"standard_charges":[{"gross_charge":513.18,"discounted_cash":282.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Mupirocin Oint 2%","drug_information":{"unit":22.0,"type":"GM"},"code_information":[{"code":"10674","type":"CDM"},{"code":"51672131200","type":"NDC"}],"standard_charges":[{"gross_charge":104.22,"discounted_cash":57.32,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Anticoagulant Sodium Citrate Soln 4%","drug_information":{"unit":250.0,"type":"ML"},"code_information":[{"code":"106758","type":"CDM"},{"code":"942950625","type":"NDC"}],"standard_charges":[{"gross_charge":83.29,"discounted_cash":45.81,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Lubiprostone Cap 8 MCG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"106825","type":"CDM"},{"code":"64764008060","type":"NDC"}],"standard_charges":[{"gross_charge":32.49,"discounted_cash":17.87,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Naltrexone HCl Tab 50 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"10685","type":"CDM"},{"code":"68084029121","type":"NDC"}],"standard_charges":[{"gross_charge":21.54,"discounted_cash":11.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Methylnaltrexone Bromide Inj 12 MG/0.6ML (20 MG/ML)","drug_information":{"unit":0.3,"type":"ML"},"code_information":[{"code":"106867","type":"CDM"},{"code":"65649055107","type":"NDC"}],"standard_charges":[{"gross_charge":183.94,"discounted_cash":101.17,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Nicotine Polacrilex Gum 2 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"10717","type":"CDM"},{"code":"536302923","type":"NDC"}],"standard_charges":[{"gross_charge":9.25,"discounted_cash":5.09,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Nicotine Polacrilex Gum 2 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"10717","type":"CDM"},{"code":"536302906","type":"NDC"}],"standard_charges":[{"gross_charge":9.9,"discounted_cash":5.44,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Nicotine Polacrilex Gum 2 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"10717","type":"CDM"},{"code":"536136206","type":"NDC"}],"standard_charges":[{"gross_charge":9.9,"discounted_cash":5.44,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Nimodipine Cap 30 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"10722","type":"CDM"},{"code":"23155051200","type":"NDC"}],"standard_charges":[{"gross_charge":58.63,"discounted_cash":32.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Nitrofurantoin Monohydrate Macrocrystalline Cap 100 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"10724","type":"CDM"},{"code":"60687063365","type":"NDC"}],"standard_charges":[{"gross_charge":24.5,"discounted_cash":13.48,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Nitrofurantoin Monohydrate Macrocrystalline Cap 100 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"10724","type":"CDM"},{"code":"70756040411","type":"NDC"}],"standard_charges":[{"gross_charge":23.72,"discounted_cash":13.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Regadenoson IV Inj 0.4 MG/5ML (0.08 MG/ML)","drug_information":{"unit":5.0,"type":"ML"},"code_information":[{"code":"107464","type":"CDM"},{"code":"71288020185","type":"NDC"}],"standard_charges":[{"gross_charge":123.4,"discounted_cash":67.87,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Metoprolol Tartrate IV Soln 5 MG/5ML","drug_information":{"unit":2.5,"type":"ML"},"code_information":[{"code":"107516","type":"CDM"},{"code":"36000003310","type":"NDC"}],"standard_charges":[{"gross_charge":16.34,"discounted_cash":8.99,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Alvimopan Cap 12 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"107642","type":"CDM"},{"code":"254301278","type":"NDC"}],"standard_charges":[{"gross_charge":328.5,"discounted_cash":180.68,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Alvimopan Cap 12 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"107642","type":"CDM"},{"code":"254301255","type":"NDC"}],"standard_charges":[{"gross_charge":328.5,"discounted_cash":180.68,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Coagulation Factor VIIa (Recomb) For Inj 1 MG (1000 MCG)","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"107771","type":"CDM"},{"code":"169720101","type":"NDC"}],"standard_charges":[{"gross_charge":43.97,"discounted_cash":24.18,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Diph-Tetanus-Acell Pert-Polio, IPV Vacc Susp Pref Syr 0.5 ML","drug_information":{"unit":0.5,"type":"ML"},"code_information":[{"code":"107776","type":"CDM"},{"code":"58160081243","type":"NDC"}],"standard_charges":[{"gross_charge":120.18,"discounted_cash":66.10,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Diph-Tetanus-Acell Pert-Polio, IPV Vacc Susp Pref Syr 0.5 ML","drug_information":{"unit":0.5,"type":"ML"},"code_information":[{"code":"107776","type":"CDM"},{"code":"58160081252","type":"NDC"}],"standard_charges":[{"gross_charge":120.18,"discounted_cash":66.10,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Coagulation Factor VIIa (Recomb) For Inj 2 MG (2000 MCG)","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"107788","type":"CDM"},{"code":"169720201","type":"NDC"}],"standard_charges":[{"gross_charge":43.97,"discounted_cash":24.18,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Bisacodyl Tab Delayed Release 5 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"1079","type":"CDM"},{"code":"904640761","type":"NDC"}],"standard_charges":[{"gross_charge":8.32,"discounted_cash":4.58,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Bisacodyl Tab Delayed Release 5 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"1079","type":"CDM"},{"code":"904674817","type":"NDC"}],"standard_charges":[{"gross_charge":8.2,"discounted_cash":4.51,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Barium Sulfate Susp 0.1%","drug_information":{"unit":450.0,"type":"ML"},"code_information":[{"code":"107979","type":"CDM"},{"code":"32909945031","type":"NDC"}],"standard_charges":[{"gross_charge":46.05,"discounted_cash":25.33,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Bisacodyl Suppos 10 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"1080","type":"CDM"},{"code":"574705012","type":"NDC"}],"standard_charges":[{"gross_charge":9.89,"discounted_cash":5.44,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Oxychlorosene Sodium Powder","drug_information":{"unit":2.0,"type":"GM"},"code_information":[{"code":"10811","type":"CDM"},{"code":"327000110","type":"NDC"}],"standard_charges":[{"gross_charge":44.63,"discounted_cash":24.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Oxycodone HCl Conc 100 MG/5ML (20 MG/ML)","drug_information":{"unit":0.5,"type":"ML"},"code_information":[{"code":"10812","type":"CDM"},{"code":"8888801373","type":"NDC"}],"standard_charges":[{"gross_charge":24.95,"discounted_cash":13.72,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Oxycodone HCl Conc 100 MG/5ML (20 MG/ML)","drug_information":{"unit":30.0,"type":"ML"},"code_information":[{"code":"10812","type":"CDM"},{"code":"121082601","type":"NDC"}],"standard_charges":[{"gross_charge":729.91,"discounted_cash":401.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Oxycodone HCl Tab 5 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"10814","type":"CDM"},{"code":"68084035411","type":"NDC"}],"standard_charges":[{"gross_charge":10.4,"discounted_cash":5.72,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Oxycodone HCl Tab 5 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"10814","type":"CDM"},{"code":"68084035401","type":"NDC"}],"standard_charges":[{"gross_charge":10.41,"discounted_cash":5.73,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Oxycodone HCl Tab 5 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"10814","type":"CDM"},{"code":"10702001801","type":"NDC"}],"standard_charges":[{"gross_charge":10.41,"discounted_cash":5.73,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"PEG 3350-KCl-Na Bicarb-NaCl-Na Sulfate For Soln 236 GM","drug_information":{"unit":4000.0,"type":"ML"},"code_information":[{"code":"10839","type":"CDM"},{"code":"64380076621","type":"NDC"}],"standard_charges":[{"gross_charge":97.6,"discounted_cash":53.68,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"PEG 3350-KCl-Na Bicarb-NaCl-Na Sulfate For Soln 236 GM","drug_information":{"unit":4000.0,"type":"ML"},"code_information":[{"code":"10839","type":"CDM"},{"code":"10572010001","type":"NDC"}],"standard_charges":[{"gross_charge":40.4,"discounted_cash":22.22,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"PEG 3350-KCl-Na Bicarb-NaCl-Na Sulfate For Soln 236 GM","drug_information":{"unit":4000.0,"type":"ML"},"code_information":[{"code":"10839","type":"CDM"},{"code":"52268010001","type":"NDC"}],"standard_charges":[{"gross_charge":40.4,"discounted_cash":22.22,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Paroxetine HCl Tab 20 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"10855","type":"CDM"},{"code":"68084004501","type":"NDC"}],"standard_charges":[{"gross_charge":18.74,"discounted_cash":10.31,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Paroxetine HCl Tab 20 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"10855","type":"CDM"},{"code":"68084004511","type":"NDC"}],"standard_charges":[{"gross_charge":18.74,"discounted_cash":10.31,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Midazolam HCl Inj 5 MG/5ML (Base Equivalent)","drug_information":{"unit":1.0,"type":"ML"},"code_information":[{"code":"108565","type":"CDM"},{"code":"72572043201","type":"NDC"}],"standard_charges":[{"gross_charge":36.1,"discounted_cash":19.86,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Midazolam HCl Inj 5 MG/5ML (Base Equivalent)","drug_information":{"unit":1.0,"type":"ML"},"code_information":[{"code":"108565","type":"CDM"},{"code":"72572043210","type":"NDC"}],"standard_charges":[{"gross_charge":36.1,"discounted_cash":19.86,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Gadoxetate Disodium IV Soln 0.25 MMOL/ML (181.43 MG/ML)","drug_information":{"unit":10.0,"type":"ML"},"code_information":[{"code":"108604","type":"CDM"},{"code":"50419032005","type":"NDC"}],"standard_charges":[{"gross_charge":499.46,"discounted_cash":274.70,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Bismuth Subsalicylate Susp 262 MG/15ML","drug_information":{"unit":15.0,"type":"ML"},"code_information":[{"code":"1090","type":"CDM"},{"code":"1490003904","type":"NDC"}],"standard_charges":[{"gross_charge":18.6,"discounted_cash":10.23,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Permethrin Creme Rinse 1%","drug_information":{"unit":59.0,"type":"ML"},"code_information":[{"code":"10918","type":"CDM"},{"code":"49348015078","type":"NDC"}],"standard_charges":[{"gross_charge":50.87,"discounted_cash":27.98,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Phentolamine Mesylate For Inj 5 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"10947","type":"CDM"},{"code":"51224001220","type":"NDC"}],"standard_charges":[{"gross_charge":761.45,"discounted_cash":418.80,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Phytonadione Inj 10 MG/ML","drug_information":{"unit":0.25,"type":"ML"},"code_information":[{"code":"11023","type":"CDM"},{"code":"43598040516","type":"NDC"}],"standard_charges":[{"gross_charge":33.46,"discounted_cash":18.40,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Phytonadione Inj 10 MG/ML","drug_information":{"unit":0.25,"type":"ML"},"code_information":[{"code":"11023","type":"CDM"},{"code":"43598040511","type":"NDC"}],"standard_charges":[{"gross_charge":33.46,"discounted_cash":18.40,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Phytonadione Tab 5 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"11024","type":"CDM"},{"code":"69238105103","type":"NDC"}],"standard_charges":[{"gross_charge":109.28,"discounted_cash":60.10,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Pneumococcal Vaccine Polyvalent Soln Pref Syr 25 MCG/0.5ML","drug_information":{"unit":0.5,"type":"ML"},"code_information":[{"code":"11037","type":"CDM"},{"code":"6494300","type":"NDC"}],"standard_charges":[{"gross_charge":197.67,"discounted_cash":108.72,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Hc Ed Emergent Level I","code_information":[{"code":"110374","type":"CDM"},{"code":"450","type":"RC"},{"code":"99281","type":"HCPCS"}],"standard_charges":[{"gross_charge":327.0,"discounted_cash":179.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Emergent Level Ii","code_information":[{"code":"110375","type":"CDM"},{"code":"450","type":"RC"},{"code":"99282","type":"HCPCS"}],"standard_charges":[{"gross_charge":661.0,"discounted_cash":363.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Emergent Level Iii","code_information":[{"code":"110376","type":"CDM"},{"code":"450","type":"RC"},{"code":"99283","type":"HCPCS"}],"standard_charges":[{"gross_charge":990.0,"discounted_cash":544.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Emergent Level Iv","code_information":[{"code":"110377","type":"CDM"},{"code":"450","type":"RC"},{"code":"99284","type":"HCPCS"}],"standard_charges":[{"gross_charge":1841.64,"discounted_cash":1012.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Emergent Level V","code_information":[{"code":"110378","type":"CDM"},{"code":"450","type":"RC"},{"code":"99285","type":"HCPCS"}],"standard_charges":[{"gross_charge":2574.0,"discounted_cash":1415.7,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Rocuronium Bromide IV Soln 50 MG/5ML (10 MG/ML)","drug_information":{"unit":5.0,"type":"ML"},"code_information":[{"code":"110722","type":"CDM"},{"code":"71288070005","type":"NDC"}],"standard_charges":[{"gross_charge":57.3,"discounted_cash":31.52,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Rocuronium Bromide IV Soln 50 MG/5ML (10 MG/ML)","drug_information":{"unit":5.0,"type":"ML"},"code_information":[{"code":"110722","type":"CDM"},{"code":"71288070006","type":"NDC"}],"standard_charges":[{"gross_charge":57.3,"discounted_cash":31.52,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Potassium Chloride Inj 20 mEq/100ML","drug_information":{"unit":100.0,"type":"ML"},"code_information":[{"code":"11076","type":"CDM"},{"code":"338070548","type":"NDC"}],"standard_charges":[{"gross_charge":52.81,"discounted_cash":29.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Potassium Citrate Tab ER 10 MEQ (1080 MG)","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"11083","type":"CDM"},{"code":"68382053701","type":"NDC"}],"standard_charges":[{"gross_charge":17.45,"discounted_cash":9.60,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Pravastatin Sodium Tab 10 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"11110","type":"CDM"},{"code":"60687088601","type":"NDC"}],"standard_charges":[{"gross_charge":10.63,"discounted_cash":5.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Pravastatin Sodium Tab 10 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"11110","type":"CDM"},{"code":"60687088611","type":"NDC"}],"standard_charges":[{"gross_charge":10.63,"discounted_cash":5.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Pravastatin Sodium Tab 40 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"11112","type":"CDM"},{"code":"50268066711","type":"NDC"}],"standard_charges":[{"gross_charge":24.53,"discounted_cash":13.49,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Pravastatin Sodium Tab 40 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"11112","type":"CDM"},{"code":"50268066715","type":"NDC"}],"standard_charges":[{"gross_charge":24.53,"discounted_cash":13.49,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Quetiapine Fumarate Tab ER 24HR 50 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"111157","type":"CDM"},{"code":"16729013212","type":"NDC"}],"standard_charges":[{"gross_charge":37.26,"discounted_cash":20.49,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Primidone Tab 50 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"11129","type":"CDM"},{"code":"50268068611","type":"NDC"}],"standard_charges":[{"gross_charge":12.25,"discounted_cash":6.74,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Primidone Tab 50 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"11129","type":"CDM"},{"code":"50268068615","type":"NDC"}],"standard_charges":[{"gross_charge":12.25,"discounted_cash":6.74,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Prochlorperazine Suppos 25 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"11138","type":"CDM"},{"code":"713013506","type":"NDC"}],"standard_charges":[{"gross_charge":41.71,"discounted_cash":22.94,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Promethazine HCl Suppos 12.5 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"11143","type":"CDM"},{"code":"713053612","type":"NDC"}],"standard_charges":[{"gross_charge":56.69,"discounted_cash":31.18,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Promethazine HCl Suppos 25 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"11144","type":"CDM"},{"code":"713052612","type":"NDC"}],"standard_charges":[{"gross_charge":56.69,"discounted_cash":31.18,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Acetazolamide Tab 125 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"112","type":"CDM"},{"code":"23155028701","type":"NDC"}],"standard_charges":[{"gross_charge":16.39,"discounted_cash":9.01,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Barium Sulfate Oral/Rectal Susp 105%","drug_information":{"unit":750.0,"type":"ML"},"code_information":[{"code":"112073","type":"CDM"},{"code":"32909016755","type":"NDC"}],"standard_charges":[{"gross_charge":101.45,"discounted_cash":55.80,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Lacosamide Tab 50 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"112239","type":"CDM"},{"code":"904724468","type":"NDC"}],"standard_charges":[{"gross_charge":13.69,"discounted_cash":7.53,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Lacosamide Tab 100 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"112240","type":"CDM"},{"code":"67877073460","type":"NDC"}],"standard_charges":[{"gross_charge":56.87,"discounted_cash":31.28,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Lacosamide IV Inj 200 MG/20ML (10 MG/ML)","drug_information":{"unit":5.0,"type":"ML"},"code_information":[{"code":"112243","type":"CDM"},{"code":"43598008758","type":"NDC"}],"standard_charges":[{"gross_charge":77.2,"discounted_cash":42.46,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Lacosamide IV Inj 200 MG/20ML (10 MG/ML)","drug_information":{"unit":5.0,"type":"ML"},"code_information":[{"code":"112243","type":"CDM"},{"code":"43598008711","type":"NDC"}],"standard_charges":[{"gross_charge":77.2,"discounted_cash":42.46,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Artificial Saliva - Solution","drug_information":{"unit":120.0,"type":"ML"},"code_information":[{"code":"112347","type":"CDM"},{"code":"59467510000","type":"NDC"}],"standard_charges":[{"gross_charge":87.62,"discounted_cash":48.19,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Pyridostigmine Bromide Tab 60 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"11239","type":"CDM"},{"code":"68382065906","type":"NDC"}],"standard_charges":[{"gross_charge":12.91,"discounted_cash":7.10,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Pyridostigmine Bromide Tab ER 180 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"11240","type":"CDM"},{"code":"64980022003","type":"NDC"}],"standard_charges":[{"gross_charge":76.22,"discounted_cash":41.92,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Vitamin E Oil","drug_information":{"unit":75.0,"type":"ML"},"code_information":[{"code":"112468","type":"CDM"},{"code":"30768002793","type":"NDC"}],"standard_charges":[{"gross_charge":52.04,"discounted_cash":28.62,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Amiodarone HCl Inj 900 MG/18ML (50 MG/ML)","drug_information":{"unit":3.0,"type":"ML"},"code_information":[{"code":"112584","type":"CDM"},{"code":"70436023250","type":"NDC"}],"standard_charges":[{"gross_charge":43.46,"discounted_cash":23.90,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Amiodarone HCl Inj 900 MG/18ML (50 MG/ML)","drug_information":{"unit":3.0,"type":"ML"},"code_information":[{"code":"112584","type":"CDM"},{"code":"67457015318","type":"NDC"}],"standard_charges":[{"gross_charge":44.24,"discounted_cash":24.33,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Rifabutin Cap 150 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"11290","type":"CDM"},{"code":"59762135001","type":"NDC"}],"standard_charges":[{"gross_charge":56.11,"discounted_cash":30.86,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Rifampin For Inj 600 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"11291","type":"CDM"},{"code":"68059701","type":"NDC"}],"standard_charges":[{"gross_charge":282.55,"discounted_cash":155.40,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Rifampin For Inj 600 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"11291","type":"CDM"},{"code":"63323035120","type":"NDC"}],"standard_charges":[{"gross_charge":242.68,"discounted_cash":133.47,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Rifampin Cap 150 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"11292","type":"CDM"},{"code":"68180065806","type":"NDC"}],"standard_charges":[{"gross_charge":8.21,"discounted_cash":4.52,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Rifampin Cap 300 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"11293","type":"CDM"},{"code":"60687058601","type":"NDC"}],"standard_charges":[{"gross_charge":16.59,"discounted_cash":9.12,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Lamotrigine Tab ER 24HR 100 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"113260","type":"CDM"},{"code":"13668034130","type":"NDC"}],"standard_charges":[{"gross_charge":46.57,"discounted_cash":25.61,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Risperidone Orally Disintegrating Tab 0.25 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"113272","type":"CDM"},{"code":"49884021252","type":"NDC"}],"standard_charges":[{"gross_charge":25.25,"discounted_cash":13.89,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Pancrelipase (Lip-Prot-Amyl) DR Cap 6000-19000-30000 Unit","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"113327","type":"CDM"},{"code":"32004670","type":"NDC"}],"standard_charges":[{"gross_charge":17.92,"discounted_cash":9.86,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Pancrelipase (Lip-Prot-Amyl) DR Cap 12000-38000-60000 Unit","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"113328","type":"CDM"},{"code":"32004770","type":"NDC"}],"standard_charges":[{"gross_charge":24.99,"discounted_cash":13.74,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Sertraline HCl Tab 100 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"11350","type":"CDM"},{"code":"60687025301","type":"NDC"}],"standard_charges":[{"gross_charge":10.36,"discounted_cash":5.70,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Sertraline HCl Tab 100 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"11350","type":"CDM"},{"code":"60687025311","type":"NDC"}],"standard_charges":[{"gross_charge":10.36,"discounted_cash":5.70,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Sertraline HCl Tab 50 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"11351","type":"CDM"},{"code":"60687024211","type":"NDC"}],"standard_charges":[{"gross_charge":9.79,"discounted_cash":5.38,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Sertraline HCl Tab 50 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"11351","type":"CDM"},{"code":"60687024201","type":"NDC"}],"standard_charges":[{"gross_charge":9.79,"discounted_cash":5.38,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Silver Nitrate-Potassium Nitrate Applicator 75-25%","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"11359","type":"CDM"},{"code":"12870000101","type":"NDC"}],"standard_charges":[{"gross_charge":12.03,"discounted_cash":6.62,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Simvastatin Tab 20 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"11365","type":"CDM"},{"code":"68084051201","type":"NDC"}],"standard_charges":[{"gross_charge":10.4,"discounted_cash":5.72,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Simvastatin Tab 20 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"11365","type":"CDM"},{"code":"68084051211","type":"NDC"}],"standard_charges":[{"gross_charge":10.4,"discounted_cash":5.72,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Simvastatin Tab 5 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"11367","type":"CDM"},{"code":"70377000114","type":"NDC"}],"standard_charges":[{"gross_charge":6.74,"discounted_cash":3.71,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Sincalide For Inj 5 MCG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"11368","type":"CDM"},{"code":"72266024805","type":"NDC"}],"standard_charges":[{"gross_charge":309.73,"discounted_cash":170.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Sincalide For Inj 5 MCG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"11368","type":"CDM"},{"code":"72266024801","type":"NDC"}],"standard_charges":[{"gross_charge":309.73,"discounted_cash":170.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Fluorouracil IV Soln 5 GM/100ML (50 MG/ML)","drug_information":{"unit":100.0,"type":"ML"},"code_information":[{"code":"113816","type":"CDM"},{"code":"63323011761","type":"NDC"}],"standard_charges":[{"gross_charge":206.64,"discounted_cash":113.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Ferumoxytol Inj 510 MG/17ML (30 MG/ML) (Elemental Fe)","drug_information":{"unit":17.0,"type":"ML"},"code_information":[{"code":"113859","type":"CDM"},{"code":"59338077501","type":"NDC"}],"standard_charges":[{"gross_charge":2824.05,"discounted_cash":1553.23,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Prasugrel HCl Tab 10 MG (Base Equiv)","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"113920","type":"CDM"},{"code":"60505464303","type":"NDC"}],"standard_charges":[{"gross_charge":53.39,"discounted_cash":29.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Prasugrel HCl Tab 10 MG (Base Equiv)","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"113920","type":"CDM"},{"code":"65162000203","type":"NDC"}],"standard_charges":[{"gross_charge":53.39,"discounted_cash":29.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Sodium Citrate & Citric Acid Soln 500-334 MG/5ML","drug_information":{"unit":10.0,"type":"ML"},"code_information":[{"code":"11394","type":"CDM"},{"code":"121119030","type":"NDC"}],"standard_charges":[{"gross_charge":17.39,"discounted_cash":9.56,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Iobenguane Sulfate I 123 IV Soln 10 mCi/5ML (2 mCi/ML)","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"113983","type":"CDM"},{"code":"17156023501","type":"NDC"}],"standard_charges":[{"gross_charge":6943.1,"discounted_cash":3818.70,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Technetium Tc 99m Exametazime IV For Soln Kit","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"113985","type":"CDM"},{"code":"17156002305","type":"NDC"}],"standard_charges":[{"gross_charge":10289.87,"discounted_cash":5659.43,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Technetium Tc 99m Medronate IV for Soln Kit","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"113998","type":"CDM"},{"code":"45567004001","type":"NDC"}],"standard_charges":[{"gross_charge":196.8,"discounted_cash":108.24,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Technetium Tc 99m Tetrofosmin IV for Soln Kit","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"113999","type":"CDM"},{"code":"17156002630","type":"NDC"}],"standard_charges":[{"gross_charge":3416.18,"discounted_cash":1878.90,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Acetazolamide Sodium For Inj 500 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"114","type":"CDM"},{"code":"143950301","type":"NDC"}],"standard_charges":[{"gross_charge":133.86,"discounted_cash":73.62,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Acetazolamide Sodium For Inj 500 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"114","type":"CDM"},{"code":"67457085350","type":"NDC"}],"standard_charges":[{"gross_charge":136.6,"discounted_cash":75.13,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Sodium Chloride Irrigation Soln 0.9%","drug_information":{"unit":500.0,"type":"ML"},"code_information":[{"code":"11403","type":"CDM"},{"code":"338004802","type":"NDC"}],"standard_charges":[{"gross_charge":68.18,"discounted_cash":37.50,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Sodium Chloride Irrigation Soln 0.9%","drug_information":{"unit":500.0,"type":"ML"},"code_information":[{"code":"11403","type":"CDM"},{"code":"264220110","type":"NDC"}],"standard_charges":[{"gross_charge":37.03,"discounted_cash":20.37,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Sodium Chloride Irrigation Soln 0.9%","drug_information":{"unit":500.0,"type":"ML"},"code_information":[{"code":"11403","type":"CDM"},{"code":"264220100","type":"NDC"}],"standard_charges":[{"gross_charge":28.13,"discounted_cash":15.47,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Sotalol HCl Tab 80 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"11421","type":"CDM"},{"code":"60505008000","type":"NDC"}],"standard_charges":[{"gross_charge":17.86,"discounted_cash":9.82,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Barium Sulfate Susp 40%","drug_information":{"unit":5.0,"type":"ML"},"code_information":[{"code":"114317","type":"CDM"},{"code":"32909011655","type":"NDC"}],"standard_charges":[{"gross_charge":11.25,"discounted_cash":6.19,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Barium Sulfate Susp 40%","drug_information":{"unit":5.0,"type":"ML"},"code_information":[{"code":"114403","type":"CDM"},{"code":"32909012154","type":"NDC"}],"standard_charges":[{"gross_charge":15.14,"discounted_cash":8.33,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Sucralfate Tab 1 GM","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"11442","type":"CDM"},{"code":"93221001","type":"NDC"}],"standard_charges":[{"gross_charge":11.57,"discounted_cash":6.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Barium Sulfate For Susp 40%","drug_information":{"unit":148.0,"type":"GM"},"code_information":[{"code":"114672","type":"CDM"},{"code":"32909010510","type":"NDC"}],"standard_charges":[{"gross_charge":42.25,"discounted_cash":23.24,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"AbobotulinumtoxinA For IM Inj 500 Unit","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"115065","type":"CDM"},{"code":"15054050001","type":"NDC"}],"standard_charges":[{"gross_charge":1563.07,"discounted_cash":859.69,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Terbutaline Sulfate Inj 1 MG/ML","drug_information":{"unit":0.25,"type":"ML"},"code_information":[{"code":"11507","type":"CDM"},{"code":"63323066501","type":"NDC"}],"standard_charges":[{"gross_charge":47.25,"discounted_cash":25.99,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Thrombin For Soln Kit 20000 Unit","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"11544","type":"CDM"},{"code":"60793021722","type":"NDC"}],"standard_charges":[{"gross_charge":646.69,"discounted_cash":355.68,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Thrombin For Soln 5000 Unit","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"11548","type":"CDM"},{"code":"60793021505","type":"NDC"}],"standard_charges":[{"gross_charge":208.33,"discounted_cash":114.58,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Timolol Maleate Ophth Soln 0.25%","drug_information":{"unit":5.0,"type":"ML"},"code_information":[{"code":"11561","type":"CDM"},{"code":"61314022605","type":"NDC"}],"standard_charges":[{"gross_charge":74.75,"discounted_cash":41.11,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Timolol Maleate Ophth Soln 0.5%","drug_information":{"unit":5.0,"type":"ML"},"code_information":[{"code":"11562","type":"CDM"},{"code":"61314022705","type":"NDC"}],"standard_charges":[{"gross_charge":82.45,"discounted_cash":45.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Timolol Maleate Ophth Soln 0.5%","drug_information":{"unit":15.0,"type":"ML"},"code_information":[{"code":"11562","type":"CDM"},{"code":"17478028812","type":"NDC"}],"standard_charges":[{"gross_charge":204.69,"discounted_cash":112.58,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Tobramycin Sulfate For Inj 1.2 GM","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"11565","type":"CDM"},{"code":"39822041201","type":"NDC"}],"standard_charges":[{"gross_charge":226.0,"discounted_cash":124.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Tobramycin-Dexamethasone Ophth Oint 0.3-0.1%","drug_information":{"unit":3.5,"type":"GM"},"code_information":[{"code":"11566","type":"CDM"},{"code":"78087601","type":"NDC"}],"standard_charges":[{"gross_charge":714.54,"discounted_cash":393.00,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Tobramycin-Dexamethasone Ophth Susp 0.3-0.1%","drug_information":{"unit":5.0,"type":"ML"},"code_information":[{"code":"11567","type":"CDM"},{"code":"24208029505","type":"NDC"}],"standard_charges":[{"gross_charge":351.62,"discounted_cash":193.39,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Tobramycin-Dexamethasone Ophth Susp 0.3-0.1%","drug_information":{"unit":5.0,"type":"ML"},"code_information":[{"code":"11567","type":"CDM"},{"code":"574403105","type":"NDC"}],"standard_charges":[{"gross_charge":267.97,"discounted_cash":147.38,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Triamcinolone Acetonide Inj Susp 10 MG/ML","drug_information":{"unit":0.25,"type":"ML"},"code_information":[{"code":"11584","type":"CDM"},{"code":"3049420","type":"NDC"}],"standard_charges":[{"gross_charge":33.79,"discounted_cash":18.58,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Sulfamethoxazole-Trimethoprim Tab 800-160 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"11599","type":"CDM"},{"code":"60687053111","type":"NDC"}],"standard_charges":[{"gross_charge":9.31,"discounted_cash":5.12,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Sulfamethoxazole-Trimethoprim Tab 800-160 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"11599","type":"CDM"},{"code":"904272561","type":"NDC"}],"standard_charges":[{"gross_charge":9.66,"discounted_cash":5.31,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Ursodiol Cap 300 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"11624","type":"CDM"},{"code":"42806050301","type":"NDC"}],"standard_charges":[{"gross_charge":32.26,"discounted_cash":17.74,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Vancomycin HCl Cap 125 MG (Base Equivalent)","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"11628","type":"CDM"},{"code":"62559039050","type":"NDC"}],"standard_charges":[{"gross_charge":76.87,"discounted_cash":42.28,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Vancomycin HCl Cap 250 MG (Base Equivalent)","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"11629","type":"CDM"},{"code":"23155085978","type":"NDC"}],"standard_charges":[{"gross_charge":27.8,"discounted_cash":15.29,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Vecuronium Bromide For Inj 10 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"11634","type":"CDM"},{"code":"55150023502","type":"NDC"}],"standard_charges":[{"gross_charge":49.3,"discounted_cash":27.12,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Vecuronium Bromide For Inj 10 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"11634","type":"CDM"},{"code":"55150023510","type":"NDC"}],"standard_charges":[{"gross_charge":52.78,"discounted_cash":29.03,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Cholecalciferol Oral Liquid 10 MCG/ML (400 Unit/ML)","drug_information":{"unit":2.5,"type":"ML"},"code_information":[{"code":"116362","type":"CDM"},{"code":"71399740105","type":"NDC"}],"standard_charges":[{"gross_charge":8.8,"discounted_cash":4.84,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Vehicle S","drug_information":{"unit":473.0,"type":"ML"},"code_information":[{"code":"11638","type":"CDM"},{"code":"574030716","type":"NDC"}],"standard_charges":[{"gross_charge":92.19,"discounted_cash":50.70,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Ibutilide Fumarate Inj 1 MG/10ML","drug_information":{"unit":10.0,"type":"ML"},"code_information":[{"code":"116624","type":"CDM"},{"code":"9379401","type":"NDC"}],"standard_charges":[{"gross_charge":1341.01,"discounted_cash":737.56,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Warfarin Sodium Tab 1 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"11664","type":"CDM"},{"code":"832121189","type":"NDC"}],"standard_charges":[{"gross_charge":10.71,"discounted_cash":5.89,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Zidovudine IV Soln 10 MG/ML","drug_information":{"unit":20.0,"type":"ML"},"code_information":[{"code":"11691","type":"CDM"},{"code":"49702021301","type":"NDC"}],"standard_charges":[{"gross_charge":165.83,"discounted_cash":91.21,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Zidovudine IV Soln 10 MG/ML","drug_information":{"unit":20.0,"type":"ML"},"code_information":[{"code":"11691","type":"CDM"},{"code":"49702021326","type":"NDC"}],"standard_charges":[{"gross_charge":165.83,"discounted_cash":91.21,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Zolpidem Tartrate Tab 5 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"11701","type":"CDM"},{"code":"13668000701","type":"NDC"}],"standard_charges":[{"gross_charge":25.81,"discounted_cash":14.20,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Glycerin Suppos 1 GM","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"117446","type":"CDM"},{"code":"58980040912","type":"NDC"}],"standard_charges":[{"gross_charge":11.75,"discounted_cash":6.46,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Barium Sulfate Tab 700 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"119186","type":"CDM"},{"code":"10361077831","type":"NDC"}],"standard_charges":[{"gross_charge":20.59,"discounted_cash":11.32,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Meningococcal (A, C, Y, and W-135) Oligo Conj Vac For Inj","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"119244","type":"CDM"},{"code":"58160095509","type":"NDC"}],"standard_charges":[{"gross_charge":277.93,"discounted_cash":152.86,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Haemophilus B Polysaccharide Conjugate Vaccine For Inj","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"11931","type":"CDM"},{"code":"49281054758","type":"NDC"}],"standard_charges":[{"gross_charge":43.86,"discounted_cash":24.12,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Haemophilus B Polysaccharide Conjugate Vaccine For Inj","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"11931","type":"CDM"},{"code":"49281054503","type":"NDC"}],"standard_charges":[{"gross_charge":43.86,"discounted_cash":24.12,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Pneumococcal 13-Valent Conjugate Vaccine Inj","drug_information":{"unit":0.5,"type":"ML"},"code_information":[{"code":"119466","type":"CDM"},{"code":"5197102","type":"NDC"}],"standard_charges":[{"gross_charge":374.62,"discounted_cash":206.04,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Tamsulosin HCl Cap 0.4 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"119475","type":"CDM"},{"code":"65862059801","type":"NDC"}],"standard_charges":[{"gross_charge":21.41,"discounted_cash":11.78,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Tamsulosin HCl Cap 0.4 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"119475","type":"CDM"},{"code":"68084029901","type":"NDC"}],"standard_charges":[{"gross_charge":21.4,"discounted_cash":11.77,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Tamsulosin HCl Cap 0.4 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"119475","type":"CDM"},{"code":"904738361","type":"NDC"}],"standard_charges":[{"gross_charge":16.25,"discounted_cash":8.94,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Tamsulosin HCl Cap 0.4 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"119475","type":"CDM"},{"code":"68788705003","type":"NDC"}],"standard_charges":[{"gross_charge":22.59,"discounted_cash":12.42,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Lidocaine HCl Local Preservative Free (PF) Inj 1%","drug_information":{"unit":30.0,"type":"ML"},"code_information":[{"code":"119686","type":"CDM"},{"code":"55150016300","type":"NDC"}],"standard_charges":[{"gross_charge":52.74,"discounted_cash":29.01,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Lidocaine HCl Local Preservative Free (PF) Inj 1%","drug_information":{"unit":2.0,"type":"ML"},"code_information":[{"code":"119686","type":"CDM"},{"code":"70756064025","type":"NDC"}],"standard_charges":[{"gross_charge":45.83,"discounted_cash":25.21,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Lidocaine HCl Local Preservative Free (PF) Inj 1%","drug_information":{"unit":5.0,"type":"ML"},"code_information":[{"code":"119686","type":"CDM"},{"code":"72572037025","type":"NDC"}],"standard_charges":[{"gross_charge":41.58,"discounted_cash":22.87,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Lidocaine HCl Local Preservative Free (PF) Inj 1%","drug_information":{"unit":5.0,"type":"ML"},"code_information":[{"code":"119686","type":"CDM"},{"code":"72572037001","type":"NDC"}],"standard_charges":[{"gross_charge":41.58,"discounted_cash":22.87,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Lidocaine HCl Local Preservative Free (PF) Inj 1%","drug_information":{"unit":30.0,"type":"ML"},"code_information":[{"code":"119686","type":"CDM"},{"code":"55150016330","type":"NDC"}],"standard_charges":[{"gross_charge":55.16,"discounted_cash":30.34,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Lidocaine HCl Local Preservative Free (PF) Inj 1%","drug_information":{"unit":30.0,"type":"ML"},"code_information":[{"code":"119686","type":"CDM"},{"code":"31722011733","type":"NDC"}],"standard_charges":[{"gross_charge":55.16,"discounted_cash":30.34,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Lidocaine HCl Local Preservative Free (PF) Inj 2%","drug_information":{"unit":5.0,"type":"ML"},"code_information":[{"code":"119687","type":"CDM"},{"code":"63323049504","type":"NDC"}],"standard_charges":[{"gross_charge":54.97,"discounted_cash":30.23,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Lidocaine HCl Local Preservative Free (PF) Inj 2%","drug_information":{"unit":10.0,"type":"ML"},"code_information":[{"code":"119687","type":"CDM"},{"code":"409428212","type":"NDC"}],"standard_charges":[{"gross_charge":75.73,"discounted_cash":41.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Lidocaine HCl Local Preservative Free (PF) Inj 2%","drug_information":{"unit":5.0,"type":"ML"},"code_information":[{"code":"119687","type":"CDM"},{"code":"55150016505","type":"NDC"}],"standard_charges":[{"gross_charge":51.6,"discounted_cash":28.38,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Lidocaine HCl Local Preservative Free (PF) Inj 2%","drug_information":{"unit":2.0,"type":"ML"},"code_information":[{"code":"119687","type":"CDM"},{"code":"55150016402","type":"NDC"}],"standard_charges":[{"gross_charge":52.5,"discounted_cash":28.88,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Lidocaine HCl Local Preservative Free (PF) Inj 2%","drug_information":{"unit":5.0,"type":"ML"},"code_information":[{"code":"119687","type":"CDM"},{"code":"63323049507","type":"NDC"}],"standard_charges":[{"gross_charge":54.97,"discounted_cash":30.23,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"RimabotulinumtoxinB IM Inj 5000 Unit/ML","drug_information":{"unit":0.5,"type":"ML"},"code_information":[{"code":"119696","type":"CDM"},{"code":"10454071110","type":"NDC"}],"standard_charges":[{"gross_charge":583.52,"discounted_cash":320.94,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"OnabotulinumtoxinA For Inj 100 Unit","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"119700","type":"CDM"},{"code":"23114501","type":"NDC"}],"standard_charges":[{"gross_charge":1206.3,"discounted_cash":663.46,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"KCl 20 MEQ/L (0.15%) in NaCl 0.9% Inj","drug_information":{"unit":1000.0,"type":"ML"},"code_information":[{"code":"119701","type":"CDM"},{"code":"63323068610","type":"NDC"}],"standard_charges":[{"gross_charge":68.18,"discounted_cash":37.50,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"KCl 20 MEQ/L (0.15%) in NaCl 0.9% Inj","drug_information":{"unit":1000.0,"type":"ML"},"code_information":[{"code":"119701","type":"CDM"},{"code":"264786500","type":"NDC"}],"standard_charges":[{"gross_charge":69.71,"discounted_cash":38.34,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"KCl 20 MEQ/L (0.15%) in NaCl 0.9% Inj","drug_information":{"unit":1000.0,"type":"ML"},"code_information":[{"code":"119701","type":"CDM"},{"code":"63323068601","type":"NDC"}],"standard_charges":[{"gross_charge":68.18,"discounted_cash":37.50,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Potassium Chloride 20 MEQ/L (0.15%) in Dextrose 5% Inj","drug_information":{"unit":1000.0,"type":"ML"},"code_information":[{"code":"119708","type":"CDM"},{"code":"264762500","type":"NDC"}],"standard_charges":[{"gross_charge":77.36,"discounted_cash":42.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"KCl 20 MEQ/L (0.15%) in Dextrose 5% & NaCl 0.9% Inj","drug_information":{"unit":1000.0,"type":"ML"},"code_information":[{"code":"119721","type":"CDM"},{"code":"264765200","type":"NDC"}],"standard_charges":[{"gross_charge":25.3,"discounted_cash":13.92,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"KCl 20 MEQ/L (0.15%) in Dextrose 5% & NaCl 0.45% Inj","drug_information":{"unit":1000.0,"type":"ML"},"code_information":[{"code":"119727","type":"CDM"},{"code":"264763500","type":"NDC"}],"standard_charges":[{"gross_charge":23.9,"discounted_cash":13.14,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"KCl 40 MEQ/L (0.3%) in Dextrose 5% & NaCl 0.45% Inj","drug_information":{"unit":1000.0,"type":"ML"},"code_information":[{"code":"119732","type":"CDM"},{"code":"990790409","type":"NDC"}],"standard_charges":[{"gross_charge":26.7,"discounted_cash":14.68,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Nitroglycerin Lingual Aerosol 400 MCG/SPRAY","drug_information":{"unit":4.1,"type":"GM"},"code_information":[{"code":"119892","type":"CDM"},{"code":"76299043004","type":"NDC"}],"standard_charges":[{"gross_charge":723.95,"discounted_cash":398.17,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Barium Sulfate Oral Paste 40%","drug_information":{"unit":5.0,"type":"ML"},"code_information":[{"code":"120091","type":"CDM"},{"code":"32909012554","type":"NDC"}],"standard_charges":[{"gross_charge":15.01,"discounted_cash":8.26,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Rifaximin Tab 550 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"120195","type":"CDM"},{"code":"65649030303","type":"NDC"}],"standard_charges":[{"gross_charge":143.07,"discounted_cash":78.69,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Sirolimus Tab 0.5 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"120234","type":"CDM"},{"code":"68462068201","type":"NDC"}],"standard_charges":[{"gross_charge":35.96,"discounted_cash":19.78,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Meclizine HCl Tab 12.5 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"12024","type":"CDM"},{"code":"60687077501","type":"NDC"}],"standard_charges":[{"gross_charge":11.16,"discounted_cash":6.14,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Meclizine HCl Tab 12.5 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"12024","type":"CDM"},{"code":"60687077565","type":"NDC"}],"standard_charges":[{"gross_charge":10.56,"discounted_cash":5.81,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Theophylline Tab ER 12HR 300 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"12098","type":"CDM"},{"code":"62332002531","type":"NDC"}],"standard_charges":[{"gross_charge":24.54,"discounted_cash":13.50,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Enoxaparin Sodium Inj Soln Pref Syr 30 MG/0.3ML","drug_information":{"unit":0.3,"type":"ML"},"code_information":[{"code":"121509","type":"CDM"},{"code":"25021041070","type":"NDC"}],"standard_charges":[{"gross_charge":19.7,"discounted_cash":10.84,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Enoxaparin Sodium Inj Soln Pref Syr 40 MG/0.4ML","drug_information":{"unit":0.4,"type":"ML"},"code_information":[{"code":"121510","type":"CDM"},{"code":"781324602","type":"NDC"}],"standard_charges":[{"gross_charge":31.13,"discounted_cash":17.12,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Enoxaparin Sodium Inj Soln Pref Syr 40 MG/0.4ML","drug_information":{"unit":0.4,"type":"ML"},"code_information":[{"code":"121510","type":"CDM"},{"code":"781324664","type":"NDC"}],"standard_charges":[{"gross_charge":31.13,"discounted_cash":17.12,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Enoxaparin Sodium Inj Soln Pref Syr 40 MG/0.4ML","drug_information":{"unit":0.4,"type":"ML"},"code_information":[{"code":"121510","type":"CDM"},{"code":"25021041076","type":"NDC"}],"standard_charges":[{"gross_charge":21.68,"discounted_cash":11.92,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Enoxaparin Sodium Inj Soln Pref Syr 60 MG/0.6ML","drug_information":{"unit":0.6,"type":"ML"},"code_information":[{"code":"121511","type":"CDM"},{"code":"63323056698","type":"NDC"}],"standard_charges":[{"gross_charge":24.52,"discounted_cash":13.49,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Enoxaparin Sodium Inj Soln Pref Syr 60 MG/0.6ML","drug_information":{"unit":0.6,"type":"ML"},"code_information":[{"code":"121511","type":"CDM"},{"code":"63323056663","type":"NDC"}],"standard_charges":[{"gross_charge":24.52,"discounted_cash":13.49,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Enoxaparin Sodium Inj Soln Pref Syr 80 MG/0.8ML","drug_information":{"unit":0.8,"type":"ML"},"code_information":[{"code":"121512","type":"CDM"},{"code":"781326204","type":"NDC"}],"standard_charges":[{"gross_charge":46.79,"discounted_cash":25.73,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Enoxaparin Sodium Inj Soln Pref Syr 80 MG/0.8ML","drug_information":{"unit":0.8,"type":"ML"},"code_information":[{"code":"121512","type":"CDM"},{"code":"75801801","type":"NDC"}],"standard_charges":[{"gross_charge":44.21,"discounted_cash":24.32,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Enoxaparin Sodium Inj Soln Pref Syr 80 MG/0.8ML","drug_information":{"unit":0.8,"type":"ML"},"code_information":[{"code":"121512","type":"CDM"},{"code":"781326268","type":"NDC"}],"standard_charges":[{"gross_charge":46.79,"discounted_cash":25.73,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Enoxaparin Sodium Inj Soln Pref Syr 80 MG/0.8ML","drug_information":{"unit":0.8,"type":"ML"},"code_information":[{"code":"121512","type":"CDM"},{"code":"75801810","type":"NDC"}],"standard_charges":[{"gross_charge":44.22,"discounted_cash":24.32,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Enoxaparin Sodium Inj Soln Pref Syr 100 MG/ML","drug_information":{"unit":1.0,"type":"ML"},"code_information":[{"code":"121513","type":"CDM"},{"code":"71288043688","type":"NDC"}],"standard_charges":[{"gross_charge":31.16,"discounted_cash":17.14,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Enoxaparin Sodium Inj Soln Pref Syr 100 MG/ML","drug_information":{"unit":1.0,"type":"ML"},"code_information":[{"code":"121513","type":"CDM"},{"code":"71288043689","type":"NDC"}],"standard_charges":[{"gross_charge":31.16,"discounted_cash":17.14,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Enoxaparin Sodium Inj Soln Pref Syr 120 MG/0.8ML","drug_information":{"unit":0.8,"type":"ML"},"code_information":[{"code":"121514","type":"CDM"},{"code":"63323065521","type":"NDC"}],"standard_charges":[{"gross_charge":34.13,"discounted_cash":18.77,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Enoxaparin Sodium Inj Soln Pref Syr 120 MG/0.8ML","drug_information":{"unit":0.8,"type":"ML"},"code_information":[{"code":"121514","type":"CDM"},{"code":"63323065599","type":"NDC"}],"standard_charges":[{"gross_charge":34.13,"discounted_cash":18.77,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Venlafaxine HCl Tab 25 MG (Base Equivalent)","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"12203","type":"CDM"},{"code":"68084089625","type":"NDC"}],"standard_charges":[{"gross_charge":15.96,"discounted_cash":8.78,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Venlafaxine HCl Tab 25 MG (Base Equivalent)","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"12203","type":"CDM"},{"code":"68084089695","type":"NDC"}],"standard_charges":[{"gross_charge":15.96,"discounted_cash":8.78,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Venlafaxine HCl Tab 50 MG (Base Equivalent)","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"12204","type":"CDM"},{"code":"68001015900","type":"NDC"}],"standard_charges":[{"gross_charge":15.93,"discounted_cash":8.76,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Venlafaxine HCl Tab 37.5 MG (Base Equivalent)","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"12207","type":"CDM"},{"code":"57237017301","type":"NDC"}],"standard_charges":[{"gross_charge":15.7,"discounted_cash":8.64,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Dornase Alfa Inhal Soln 2.5 MG/2.5ML","drug_information":{"unit":2.5,"type":"ML"},"code_information":[{"code":"12211","type":"CDM"},{"code":"50242010040","type":"NDC"}],"standard_charges":[{"gross_charge":330.03,"discounted_cash":181.52,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Bupivacaine HCl Inj 0.25%","drug_information":{"unit":50.0,"type":"ML"},"code_information":[{"code":"1222","type":"CDM"},{"code":"409116001","type":"NDC"}],"standard_charges":[{"gross_charge":54.69,"discounted_cash":30.08,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Bupivacaine HCl Inj 0.25%","drug_information":{"unit":50.0,"type":"ML"},"code_information":[{"code":"1222","type":"CDM"},{"code":"409116018","type":"NDC"}],"standard_charges":[{"gross_charge":54.69,"discounted_cash":30.08,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Buprenorphine HCl-Naloxone HCl SL Film 2-0.5 MG (Base Equiv)","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"122209","type":"CDM"},{"code":"378876516","type":"NDC"}],"standard_charges":[{"gross_charge":25.0,"discounted_cash":13.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Buprenorphine HCl-Naloxone HCl SL Film 2-0.5 MG (Base Equiv)","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"122209","type":"CDM"},{"code":"378876593","type":"NDC"}],"standard_charges":[{"gross_charge":25.0,"discounted_cash":13.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Bupivacaine HCl Preservative Free (PF) Inj 0.25%","drug_information":{"unit":30.0,"type":"ML"},"code_information":[{"code":"122215","type":"CDM"},{"code":"409115909","type":"NDC"}],"standard_charges":[{"gross_charge":40.21,"discounted_cash":22.12,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Bupivacaine HCl Preservative Free (PF) Inj 0.25%","drug_information":{"unit":10.0,"type":"ML"},"code_information":[{"code":"122215","type":"CDM"},{"code":"63323046417","type":"NDC"}],"standard_charges":[{"gross_charge":69.18,"discounted_cash":38.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Bupivacaine HCl Preservative Free (PF) Inj 0.25%","drug_information":{"unit":30.0,"type":"ML"},"code_information":[{"code":"122215","type":"CDM"},{"code":"409115902","type":"NDC"}],"standard_charges":[{"gross_charge":43.95,"discounted_cash":24.17,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Bupivacaine HCl Preservative Free (PF) Inj 0.5%","drug_information":{"unit":10.0,"type":"ML"},"code_information":[{"code":"122216","type":"CDM"},{"code":"409116218","type":"NDC"}],"standard_charges":[{"gross_charge":50.27,"discounted_cash":27.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Bupivacaine HCl Preservative Free (PF) Inj 0.5%","drug_information":{"unit":30.0,"type":"ML"},"code_information":[{"code":"122216","type":"CDM"},{"code":"55150017030","type":"NDC"}],"standard_charges":[{"gross_charge":51.32,"discounted_cash":28.23,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Bupivacaine HCl Preservative Free (PF) Inj 0.5%","drug_information":{"unit":10.0,"type":"ML"},"code_information":[{"code":"122216","type":"CDM"},{"code":"63323046617","type":"NDC"}],"standard_charges":[{"gross_charge":67.04,"discounted_cash":36.87,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Bupivacaine Inj 0.25% w/ Epinephrine 1:200000 (PF)","drug_information":{"unit":30.0,"type":"ML"},"code_information":[{"code":"122218","type":"CDM"},{"code":"63323046837","type":"NDC"}],"standard_charges":[{"gross_charge":103.47,"discounted_cash":56.91,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Bupivacaine Inj 0.25% w/ Epinephrine 1:200000 (PF)","drug_information":{"unit":30.0,"type":"ML"},"code_information":[{"code":"122218","type":"CDM"},{"code":"63323046802","type":"NDC"}],"standard_charges":[{"gross_charge":103.47,"discounted_cash":56.91,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Bupivacaine Inj 0.5% w/ Epinephrine 1:200000 (PF)","drug_information":{"unit":10.0,"type":"ML"},"code_information":[{"code":"122219","type":"CDM"},{"code":"409174910","type":"NDC"}],"standard_charges":[{"gross_charge":67.4,"discounted_cash":37.07,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Bupivacaine Inj 0.5% w/ Epinephrine 1:200000 (PF)","drug_information":{"unit":30.0,"type":"ML"},"code_information":[{"code":"122219","type":"CDM"},{"code":"63323046237","type":"NDC"}],"standard_charges":[{"gross_charge":108.74,"discounted_cash":59.81,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Bupivacaine Inj 0.5% w/ Epinephrine 1:200000 (PF)","drug_information":{"unit":30.0,"type":"ML"},"code_information":[{"code":"122219","type":"CDM"},{"code":"409420801","type":"NDC"}],"standard_charges":[{"gross_charge":63.43,"discounted_cash":34.89,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Bupivacaine Inj 0.5% w/ Epinephrine 1:200000 (PF)","drug_information":{"unit":10.0,"type":"ML"},"code_information":[{"code":"122219","type":"CDM"},{"code":"63323046217","type":"NDC"}],"standard_charges":[{"gross_charge":72.87,"discounted_cash":40.08,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Bupivacaine Inj 0.5% w/ Epinephrine 1:200000 (PF)","drug_information":{"unit":30.0,"type":"ML"},"code_information":[{"code":"122219","type":"CDM"},{"code":"409420810","type":"NDC"}],"standard_charges":[{"gross_charge":63.43,"discounted_cash":34.89,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Enoxaparin Sodium Inj Soln Pref Syr 150 MG/ML","drug_information":{"unit":1.0,"type":"ML"},"code_information":[{"code":"122222","type":"CDM"},{"code":"781329969","type":"NDC"}],"standard_charges":[{"gross_charge":74.2,"discounted_cash":40.81,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Enoxaparin Sodium Inj Soln Pref Syr 150 MG/ML","drug_information":{"unit":1.0,"type":"ML"},"code_information":[{"code":"122222","type":"CDM"},{"code":"781329905","type":"NDC"}],"standard_charges":[{"gross_charge":74.2,"discounted_cash":40.81,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Neomycin-Polymyxin-Dexamethasone Ophth Susp 0.1%","drug_information":{"unit":0.05,"type":"ML"},"code_information":[{"code":"122238","type":"CDM"},{"code":"61314063006","type":"NDC"}],"standard_charges":[{"gross_charge":18.45,"discounted_cash":10.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Neomycin-Polymyxin-Dexamethasone Ophth Oint 0.1%","drug_information":{"unit":3.5,"type":"GM"},"code_information":[{"code":"122239","type":"CDM"},{"code":"24208079535","type":"NDC"}],"standard_charges":[{"gross_charge":104.01,"discounted_cash":57.21,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Buprenorphine HCl-Naloxone HCl SL Film 8-2 MG (Base Equiv)","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"122276","type":"CDM"},{"code":"50742036430","type":"NDC"}],"standard_charges":[{"gross_charge":38.36,"discounted_cash":21.10,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Buprenorphine HCl-Naloxone HCl SL Film 8-2 MG (Base Equiv)","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"122276","type":"CDM"},{"code":"50742036401","type":"NDC"}],"standard_charges":[{"gross_charge":38.36,"discounted_cash":21.10,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Bupivacaine HCl Inj 0.5%","drug_information":{"unit":50.0,"type":"ML"},"code_information":[{"code":"1223","type":"CDM"},{"code":"55150025050","type":"NDC"}],"standard_charges":[{"gross_charge":54.21,"discounted_cash":29.82,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Bupivacaine HCl Inj 0.5%","drug_information":{"unit":50.0,"type":"ML"},"code_information":[{"code":"1223","type":"CDM"},{"code":"63323046757","type":"NDC"}],"standard_charges":[{"gross_charge":114.54,"discounted_cash":63.00,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Ondansetron HCl Inj 4 MG/2ML (2 MG/ML)","drug_information":{"unit":2.0,"type":"ML"},"code_information":[{"code":"122577","type":"CDM"},{"code":"641607825","type":"NDC"}],"standard_charges":[{"gross_charge":36.07,"discounted_cash":19.84,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Ondansetron HCl Inj 4 MG/2ML (2 MG/ML)","drug_information":{"unit":2.0,"type":"ML"},"code_information":[{"code":"122577","type":"CDM"},{"code":"641607801","type":"NDC"}],"standard_charges":[{"gross_charge":36.07,"discounted_cash":19.84,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Lidocaine HCl Local Preservative Free (PF) Inj 0.5%","drug_information":{"unit":50.0,"type":"ML"},"code_information":[{"code":"122600","type":"CDM"},{"code":"63323049101","type":"NDC"}],"standard_charges":[{"gross_charge":117.15,"discounted_cash":64.43,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Gemcitabine HCl For Inj 2 GM","drug_information":{"unit":0.0190114,"type":"EA"},"code_information":[{"code":"122953","type":"CDM"},{"code":"409018701","type":"NDC"}],"standard_charges":[{"gross_charge":55.05,"discounted_cash":30.28,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Ulipristal Acetate Tab 30 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"122955","type":"CDM"},{"code":"73302045601","type":"NDC"}],"standard_charges":[{"gross_charge":110.3,"discounted_cash":60.66,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Acetylcysteine Inhal Soln 20%","drug_information":{"unit":1.5,"type":"ML"},"code_information":[{"code":"123","type":"CDM"},{"code":"70069001901","type":"NDC"}],"standard_charges":[{"gross_charge":44.67,"discounted_cash":24.57,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Acetylcysteine Inhal Soln 20%","drug_information":{"unit":1.5,"type":"ML"},"code_information":[{"code":"123","type":"CDM"},{"code":"63323069030","type":"NDC"}],"standard_charges":[{"gross_charge":23.85,"discounted_cash":13.12,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Acetylcysteine Inhal Soln 20%","drug_information":{"unit":1.5,"type":"ML"},"code_information":[{"code":"123","type":"CDM"},{"code":"409330803","type":"NDC"}],"standard_charges":[{"gross_charge":22.88,"discounted_cash":12.58,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Acetylcysteine Inhal Soln 20%","drug_information":{"unit":1.5,"type":"ML"},"code_information":[{"code":"123","type":"CDM"},{"code":"70069001925","type":"NDC"}],"standard_charges":[{"gross_charge":44.67,"discounted_cash":24.57,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"AbobotulinumtoxinA For IM Inj 300 Unit","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"123323","type":"CDM"},{"code":"15054053006","type":"NDC"}],"standard_charges":[{"gross_charge":950.59,"discounted_cash":522.82,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Ceftaroline Fosamil for IV Soln 600 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"123423","type":"CDM"},{"code":"456060010","type":"NDC"}],"standard_charges":[{"gross_charge":448.03,"discounted_cash":246.42,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Ceftaroline Fosamil for IV Soln 600 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"123423","type":"CDM"},{"code":"456060001","type":"NDC"}],"standard_charges":[{"gross_charge":407.81,"discounted_cash":224.30,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Lurasidone HCl Tab 40 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"123433","type":"CDM"},{"code":"67877063930","type":"NDC"}],"standard_charges":[{"gross_charge":107.51,"discounted_cash":59.13,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Nicardipine HCl IV Soln 2.5 MG/ML","drug_information":{"unit":4.0,"type":"ML"},"code_information":[{"code":"12370","type":"CDM"},{"code":"143968901","type":"NDC"}],"standard_charges":[{"gross_charge":19.92,"discounted_cash":10.96,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Nicardipine HCl IV Soln 2.5 MG/ML","drug_information":{"unit":4.0,"type":"ML"},"code_information":[{"code":"12370","type":"CDM"},{"code":"143968910","type":"NDC"}],"standard_charges":[{"gross_charge":19.92,"discounted_cash":10.96,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Acetaminophen IV Soln 10 MG/ML","drug_information":{"unit":100.0,"type":"ML"},"code_information":[{"code":"123869","type":"CDM"},{"code":"781315695","type":"NDC"}],"standard_charges":[{"gross_charge":228.58,"discounted_cash":125.72,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Acetaminophen IV Soln 10 MG/ML","drug_information":{"unit":100.0,"type":"ML"},"code_information":[{"code":"123869","type":"CDM"},{"code":"24201010001","type":"NDC"}],"standard_charges":[{"gross_charge":88.85,"discounted_cash":48.87,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Acetaminophen IV Soln 10 MG/ML","drug_information":{"unit":100.0,"type":"ML"},"code_information":[{"code":"123869","type":"CDM"},{"code":"781927406","type":"NDC"}],"standard_charges":[{"gross_charge":228.58,"discounted_cash":125.72,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Acetaminophen IV Soln 10 MG/ML","drug_information":{"unit":100.0,"type":"ML"},"code_information":[{"code":"123869","type":"CDM"},{"code":"24201010024","type":"NDC"}],"standard_charges":[{"gross_charge":88.85,"discounted_cash":48.87,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Penicillin G Benzathine IM Susp Pref Syr 1200000 Unit/2ML","drug_information":{"unit":1.0,"type":"ML"},"code_information":[{"code":"124645","type":"CDM"},{"code":"60793070102","type":"NDC"}],"standard_charges":[{"gross_charge":407.42,"discounted_cash":224.08,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Penicillin G Benzathine IM Susp Pref Syr 1200000 Unit/2ML","drug_information":{"unit":1.0,"type":"ML"},"code_information":[{"code":"124645","type":"CDM"},{"code":"60793070110","type":"NDC"}],"standard_charges":[{"gross_charge":407.42,"discounted_cash":224.08,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Levofloxacin in D5W IV Soln 250 MG/50ML","drug_information":{"unit":50.0,"type":"ML"},"code_information":[{"code":"124699","type":"CDM"},{"code":"143931501","type":"NDC"}],"standard_charges":[{"gross_charge":18.09,"discounted_cash":9.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Levofloxacin in D5W IV Soln 250 MG/50ML","drug_information":{"unit":50.0,"type":"ML"},"code_information":[{"code":"124699","type":"CDM"},{"code":"143931524","type":"NDC"}],"standard_charges":[{"gross_charge":18.09,"discounted_cash":9.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Levofloxacin in D5W IV Soln 500 MG/100ML","drug_information":{"unit":50.0,"type":"ML"},"code_information":[{"code":"124700","type":"CDM"},{"code":"36000004724","type":"NDC"}],"standard_charges":[{"gross_charge":19.7,"discounted_cash":10.84,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Levofloxacin in D5W IV Soln 750 MG/150ML","drug_information":{"unit":50.0,"type":"ML"},"code_information":[{"code":"124701","type":"CDM"},{"code":"143972024","type":"NDC"}],"standard_charges":[{"gross_charge":19.0,"discounted_cash":10.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Poliovirus Vaccine, IPV Inj Susp","drug_information":{"unit":0.5,"type":"ML"},"code_information":[{"code":"124707","type":"CDM"},{"code":"49281086010","type":"NDC"}],"standard_charges":[{"gross_charge":88.29,"discounted_cash":48.56,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Amikacin Sulfate Inj 500 MG/2ML (250 MG/ML)","drug_information":{"unit":2.0,"type":"ML"},"code_information":[{"code":"124712","type":"CDM"},{"code":"23155029031","type":"NDC"}],"standard_charges":[{"gross_charge":65.65,"discounted_cash":36.11,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Amikacin Sulfate Inj 500 MG/2ML (250 MG/ML)","drug_information":{"unit":2.0,"type":"ML"},"code_information":[{"code":"124712","type":"CDM"},{"code":"23155029041","type":"NDC"}],"standard_charges":[{"gross_charge":65.65,"discounted_cash":36.11,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"RimabotulinumtoxinB IM Inj 2500 Unit/0.5ML","drug_information":{"unit":0.5,"type":"ML"},"code_information":[{"code":"124768","type":"CDM"},{"code":"10454071010","type":"NDC"}],"standard_charges":[{"gross_charge":583.52,"discounted_cash":320.94,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"RimabotulinumtoxinB IM Inj 10000 Unit/2ML","drug_information":{"unit":0.5,"type":"ML"},"code_information":[{"code":"124769","type":"CDM"},{"code":"10454071210","type":"NDC"}],"standard_charges":[{"gross_charge":583.52,"discounted_cash":320.94,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Fondaparinux Sodium Subcutaneous Inj 7.5 MG/0.6ML","drug_information":{"unit":0.4,"type":"ML"},"code_information":[{"code":"124772","type":"CDM"},{"code":"55111068002","type":"NDC"}],"standard_charges":[{"gross_charge":184.91,"discounted_cash":101.70,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Fondaparinux Sodium Subcutaneous Inj 10 MG/0.8ML","drug_information":{"unit":0.8,"type":"ML"},"code_information":[{"code":"124777","type":"CDM"},{"code":"55111068102","type":"NDC"}],"standard_charges":[{"gross_charge":261.86,"discounted_cash":144.02,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Estradiol Tab 0.5 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"12491","type":"CDM"},{"code":"42806008701","type":"NDC"}],"standard_charges":[{"gross_charge":10.45,"discounted_cash":5.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Estradiol Tab 0.5 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"12491","type":"CDM"},{"code":"51862033201","type":"NDC"}],"standard_charges":[{"gross_charge":10.45,"discounted_cash":5.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Docetaxel Soln for IV Infusion 80 MG/8ML","drug_information":{"unit":8.0,"type":"ML"},"code_information":[{"code":"124981","type":"CDM"},{"code":"67457053208","type":"NDC"}],"standard_charges":[{"gross_charge":757.0,"discounted_cash":416.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Docetaxel Soln for IV Infusion 160 MG/16ML","drug_information":{"unit":16.0,"type":"ML"},"code_information":[{"code":"124982","type":"CDM"},{"code":"67457053316","type":"NDC"}],"standard_charges":[{"gross_charge":1502.0,"discounted_cash":826.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Caffeine Citrate Inj 60 MG/3ML (10 MG/ML Base Equiv)","drug_information":{"unit":3.0,"type":"ML"},"code_information":[{"code":"125108","type":"CDM"},{"code":"641616401","type":"NDC"}],"standard_charges":[{"gross_charge":77.2,"discounted_cash":42.46,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Belimumab For IV Soln 120 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"125285","type":"CDM"},{"code":"49401010101","type":"NDC"}],"standard_charges":[{"gross_charge":1157.56,"discounted_cash":636.66,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Belimumab For IV Soln 400 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"125291","type":"CDM"},{"code":"49401010201","type":"NDC"}],"standard_charges":[{"gross_charge":3934.42,"discounted_cash":2163.93,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Ertapenem Sodium For Inj 1 GM (Base Equivalent)","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"125429","type":"CDM"},{"code":"44567082001","type":"NDC"}],"standard_charges":[{"gross_charge":248.68,"discounted_cash":136.77,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Ertapenem Sodium For Inj 1 GM (Base Equivalent)","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"125429","type":"CDM"},{"code":"44567082010","type":"NDC"}],"standard_charges":[{"gross_charge":248.68,"discounted_cash":136.77,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Technetium Tc 99m Pentetate IV for Soln Kit","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"125506","type":"CDM"},{"code":"17156043904","type":"NDC"}],"standard_charges":[{"gross_charge":84.07,"discounted_cash":46.24,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Diphenhydramine HCl Liquid 12.5 MG/5ML","drug_information":{"unit":5.0,"type":"ML"},"code_information":[{"code":"12556","type":"CDM"},{"code":"81033000305","type":"NDC"}],"standard_charges":[{"gross_charge":14.68,"discounted_cash":8.07,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Diphenhydramine HCl Liquid 12.5 MG/5ML","drug_information":{"unit":5.0,"type":"ML"},"code_information":[{"code":"12556","type":"CDM"},{"code":"57237030512","type":"NDC"}],"standard_charges":[{"gross_charge":9.02,"discounted_cash":4.96,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Ipratropium Bromide Inhal Soln 0.02%","drug_information":{"unit":1.25,"type":"ML"},"code_information":[{"code":"12580","type":"CDM"},{"code":"487980101","type":"NDC"}],"standard_charges":[{"gross_charge":18.0,"discounted_cash":9.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Menthol Lozenge","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"126133","type":"CDM"},{"code":"36602019210","type":"NDC"}],"standard_charges":[{"gross_charge":8.3,"discounted_cash":4.56,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Fidaxomicin Tab 200 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"126401","type":"CDM"},{"code":"52015008001","type":"NDC"}],"standard_charges":[{"gross_charge":476.45,"discounted_cash":262.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Belatacept For IV Infusion 250 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"126685","type":"CDM"},{"code":"3037113","type":"NDC"}],"standard_charges":[{"gross_charge":1780.29,"discounted_cash":979.16,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Leuprolide Acetate (6 Month) For Inj Kit 45 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"126756","type":"CDM"},{"code":"74347303","type":"NDC"}],"standard_charges":[{"gross_charge":22438.71,"discounted_cash":12341.29,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Rivaroxaban Tab 10 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"127169","type":"CDM"},{"code":"50458058010","type":"NDC"}],"standard_charges":[{"gross_charge":73.79,"discounted_cash":40.58,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Ticagrelor Tab 90 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"127172","type":"CDM"},{"code":"186077739","type":"NDC"}],"standard_charges":[{"gross_charge":38.67,"discounted_cash":21.27,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Oseltamivir Phosphate For Susp 6 MG/ML (Base Equiv)","drug_information":{"unit":60.0,"type":"ML"},"code_information":[{"code":"127353","type":"CDM"},{"code":"68180067801","type":"NDC"}],"standard_charges":[{"gross_charge":638.4,"discounted_cash":351.12,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Barium Sulfate Susp 60%","drug_information":{"unit":355.0,"type":"ML"},"code_information":[{"code":"12748","type":"CDM"},{"code":"32909018702","type":"NDC"}],"standard_charges":[{"gross_charge":39.6,"discounted_cash":21.78,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Barium Sulfate For Susp 98%","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"12750","type":"CDM"},{"code":"32909076401","type":"NDC"}],"standard_charges":[{"gross_charge":34.21,"discounted_cash":18.82,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Barium Sulfate For Susp 98%","drug_information":{"unit":312.0,"type":"GM"},"code_information":[{"code":"12750","type":"CDM"},{"code":"68240012808","type":"NDC"}],"standard_charges":[{"gross_charge":38.54,"discounted_cash":21.20,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Iodine Solution Strong (Lugol's) (Bulk)","drug_information":{"unit":0.1,"type":"ML"},"code_information":[{"code":"127869","type":"CDM"},{"code":"51552019404","type":"NDC"}],"standard_charges":[{"gross_charge":8.19,"discounted_cash":4.50,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Hydroxocobalamin (Antidote) For IV Soln 5 GM","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"128277","type":"CDM"},{"code":"50633031011","type":"NDC"}],"standard_charges":[{"gross_charge":1854.52,"discounted_cash":1019.99,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Zoledronic Acid IV Soln 4 MG/100ML","drug_information":{"unit":100.0,"type":"ML"},"code_information":[{"code":"128304","type":"CDM"},{"code":"25021082682","type":"NDC"}],"standard_charges":[{"gross_charge":862.6,"discounted_cash":474.43,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Peginterferon alfa-2a Soln Prefilled Syr 180 MCG/0.5ML","drug_information":{"unit":0.5,"type":"ML"},"code_information":[{"code":"128599","type":"CDM"},{"code":"4035730","type":"NDC"}],"standard_charges":[{"gross_charge":1808.39,"discounted_cash":994.61,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Docusate Sodium Enema 283 MG/5ML","drug_information":{"unit":5.0,"type":"ML"},"code_information":[{"code":"12887","type":"CDM"},{"code":"17433987603","type":"NDC"}],"standard_charges":[{"gross_charge":34.42,"discounted_cash":18.93,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Docusate Sodium Enema 283 MG/5ML","drug_information":{"unit":5.0,"type":"ML"},"code_information":[{"code":"12887","type":"CDM"},{"code":"904692093","type":"NDC"}],"standard_charges":[{"gross_charge":30.55,"discounted_cash":16.80,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Clobazam Tab 10 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"129143","type":"CDM"},{"code":"16714088701","type":"NDC"}],"standard_charges":[{"gross_charge":61.89,"discounted_cash":34.04,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Bupivacaine Liposome Inj 1.3% (13.3 MG/ML)","drug_information":{"unit":10.0,"type":"ML"},"code_information":[{"code":"129185","type":"CDM"},{"code":"65250026609","type":"NDC"}],"standard_charges":[{"gross_charge":688.83,"discounted_cash":378.86,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Rivaroxaban Tab 15 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"129238","type":"CDM"},{"code":"50458057801","type":"NDC"}],"standard_charges":[{"gross_charge":73.81,"discounted_cash":40.60,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Rivaroxaban Tab 20 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"129239","type":"CDM"},{"code":"50458057930","type":"NDC"}],"standard_charges":[{"gross_charge":73.79,"discounted_cash":40.58,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Levothyroxine Sodium For IV Inj 100 MCG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"129397","type":"CDM"},{"code":"70860045110","type":"NDC"}],"standard_charges":[{"gross_charge":245.83,"discounted_cash":135.21,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Pentetate Indium Disodium In 111 Intrathecal Inj","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"129709","type":"CDM"},{"code":"17156025108","type":"NDC"}],"standard_charges":[{"gross_charge":3706.59,"discounted_cash":2038.62,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Potassium Iodide Tab 130 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"13024","type":"CDM"},{"code":"51803000101","type":"NDC"}],"standard_charges":[{"gross_charge":15.57,"discounted_cash":8.56,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Barium Sulfate For Susp 96%","drug_information":{"unit":176.0,"type":"GM"},"code_information":[{"code":"13031","type":"CDM"},{"code":"32909075003","type":"NDC"}],"standard_charges":[{"gross_charge":33.85,"discounted_cash":18.62,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Calcium Chloride Inj 10%","drug_information":{"unit":10.0,"type":"ML"},"code_information":[{"code":"1306","type":"CDM"},{"code":"76329330401","type":"NDC"}],"standard_charges":[{"gross_charge":79.51,"discounted_cash":43.73,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Calcium Chloride Inj 10%","drug_information":{"unit":10.0,"type":"ML"},"code_information":[{"code":"1306","type":"CDM"},{"code":"64253090030","type":"NDC"}],"standard_charges":[{"gross_charge":71.05,"discounted_cash":39.08,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Calcium Chloride Inj 10%","drug_information":{"unit":10.0,"type":"ML"},"code_information":[{"code":"1306","type":"CDM"},{"code":"64253090091","type":"NDC"}],"standard_charges":[{"gross_charge":77.2,"discounted_cash":42.46,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Lisinopril Tab 2.5 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"13089","type":"CDM"},{"code":"68180051201","type":"NDC"}],"standard_charges":[{"gross_charge":10.88,"discounted_cash":5.98,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Lisinopril Tab 2.5 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"13089","type":"CDM"},{"code":"60687065611","type":"NDC"}],"standard_charges":[{"gross_charge":11.04,"discounted_cash":6.07,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Lisinopril Tab 2.5 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"13089","type":"CDM"},{"code":"60687065621","type":"NDC"}],"standard_charges":[{"gross_charge":11.04,"discounted_cash":6.07,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Calcium Gluconate Inj 10%","drug_information":{"unit":10.0,"type":"ML"},"code_information":[{"code":"1312","type":"CDM"},{"code":"63323036059","type":"NDC"}],"standard_charges":[{"gross_charge":59.84,"discounted_cash":32.91,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Calcium Gluconate Inj 10%","drug_information":{"unit":10.0,"type":"ML"},"code_information":[{"code":"1312","type":"CDM"},{"code":"70069072820","type":"NDC"}],"standard_charges":[{"gross_charge":59.79,"discounted_cash":32.88,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Calcium Gluconate Inj 10%","drug_information":{"unit":10.0,"type":"ML"},"code_information":[{"code":"1312","type":"CDM"},{"code":"143918025","type":"NDC"}],"standard_charges":[{"gross_charge":77.28,"discounted_cash":42.50,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Racepinephrine HCl Soln Nebu 2.25% (Base Equivalent)","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"131323","type":"CDM"},{"code":"487590199","type":"NDC"}],"standard_charges":[{"gross_charge":17.63,"discounted_cash":9.70,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Varicella Virus Vac Live For Inj 1350 PFU/0.5ML","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"131324","type":"CDM"},{"code":"6482700","type":"NDC"}],"standard_charges":[{"gross_charge":437.68,"discounted_cash":240.72,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Valacyclovir HCl Tab 500 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"13133","type":"CDM"},{"code":"378427593","type":"NDC"}],"standard_charges":[{"gross_charge":31.84,"discounted_cash":17.51,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Verapamil HCl Tab ER 120 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"13184","type":"CDM"},{"code":"68462029201","type":"NDC"}],"standard_charges":[{"gross_charge":12.13,"discounted_cash":6.67,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Pancrelipase (Lip-Prot-Amyl) Tab 10440-39150-39150 Unit","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"134108","type":"CDM"},{"code":"73562010410","type":"NDC"}],"standard_charges":[{"gross_charge":24.73,"discounted_cash":13.60,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Mirabegron Tab ER 24 HR 25 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"134110","type":"CDM"},{"code":"70710115903","type":"NDC"}],"standard_charges":[{"gross_charge":53.57,"discounted_cash":29.46,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Morphine Sulfate Oral Soln 100 MG/5ML (20 MG/ML)","drug_information":{"unit":0.25,"type":"ML"},"code_information":[{"code":"134329","type":"CDM"},{"code":"54051744","type":"NDC"}],"standard_charges":[{"gross_charge":18.0,"discounted_cash":9.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Morphine Sulfate Oral Soln 100 MG/5ML (20 MG/ML)","drug_information":{"unit":0.25,"type":"ML"},"code_information":[{"code":"134329","type":"CDM"},{"code":"8813432905","type":"NDC"}],"standard_charges":[{"gross_charge":18.0,"discounted_cash":9.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Hydromorphone HCl Preservative Free (PF) Inj 2 MG/ML","drug_information":{"unit":0.1,"type":"ML"},"code_information":[{"code":"134613","type":"CDM"},{"code":"63323085325","type":"NDC"}],"standard_charges":[{"gross_charge":32.71,"discounted_cash":17.99,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Hydromorphone HCl Preservative Free (PF) Inj 10 MG/ML","drug_information":{"unit":50.0,"type":"ML"},"code_information":[{"code":"134615","type":"CDM"},{"code":"703001801","type":"NDC"}],"standard_charges":[{"gross_charge":509.17,"discounted_cash":280.04,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Hydromorphone HCl Preservative Free (PF) Inj 10 MG/ML","drug_information":{"unit":5.0,"type":"ML"},"code_information":[{"code":"134615","type":"CDM"},{"code":"703011301","type":"NDC"}],"standard_charges":[{"gross_charge":74.52,"discounted_cash":40.99,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Hydromorphone HCl Preservative Free (PF) Inj 10 MG/ML","drug_information":{"unit":1.0,"type":"ML"},"code_information":[{"code":"134615","type":"CDM"},{"code":"17478054001","type":"NDC"}],"standard_charges":[{"gross_charge":42.53,"discounted_cash":23.39,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Morphine Sulfate IV Soln PF 4 MG/ML","drug_information":{"unit":1.0,"type":"ML"},"code_information":[{"code":"134666","type":"CDM"},{"code":"409189113","type":"NDC"}],"standard_charges":[{"gross_charge":51.72,"discounted_cash":28.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Morphine Sulfate IV Soln PF 10 MG/ML","drug_information":{"unit":0.5,"type":"ML"},"code_information":[{"code":"134668","type":"CDM"},{"code":"409189323","type":"NDC"}],"standard_charges":[{"gross_charge":43.17,"discounted_cash":23.74,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Morphine Sulfate IV Soln PF 10 MG/ML","drug_information":{"unit":0.5,"type":"ML"},"code_information":[{"code":"134668","type":"CDM"},{"code":"409189313","type":"NDC"}],"standard_charges":[{"gross_charge":43.16,"discounted_cash":23.74,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Morphine Sulfate IV Soln PF 10 MG/ML","drug_information":{"unit":0.5,"type":"ML"},"code_information":[{"code":"134668","type":"CDM"},{"code":"641612701","type":"NDC"}],"standard_charges":[{"gross_charge":36.89,"discounted_cash":20.29,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Morphine Sulfate IV Soln PF 10 MG/ML","drug_information":{"unit":0.5,"type":"ML"},"code_information":[{"code":"134668","type":"CDM"},{"code":"409189301","type":"NDC"}],"standard_charges":[{"gross_charge":36.33,"discounted_cash":19.98,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Hydromorphone HCl Preservative Free (PF) Inj 10 MG/ML","drug_information":{"unit":5.0,"type":"ML"},"code_information":[{"code":"134847","type":"CDM"},{"code":"703011303","type":"NDC"}],"standard_charges":[{"gross_charge":74.52,"discounted_cash":40.99,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Capsaicin Cream 0.025%","drug_information":{"unit":60.0,"type":"GM"},"code_information":[{"code":"1350","type":"CDM"},{"code":"536252525","type":"NDC"}],"standard_charges":[{"gross_charge":61.32,"discounted_cash":33.73,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Phytonadione Inj 1 MG/0.5ML (2 MG/ML)","drug_information":{"unit":0.5,"type":"ML"},"code_information":[{"code":"135166","type":"CDM"},{"code":"76329124001","type":"NDC"}],"standard_charges":[{"gross_charge":57.05,"discounted_cash":31.38,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Indium In-111 Pentetreotide Kit","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"13545","type":"CDM"},{"code":"19905040","type":"NDC"}],"standard_charges":[{"gross_charge":3498.9,"discounted_cash":1924.40,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Carbamazepine Chew Tab 100 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"1355","type":"CDM"},{"code":"904385461","type":"NDC"}],"standard_charges":[{"gross_charge":10.84,"discounted_cash":5.96,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Carbamazepine Tab 200 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"1357","type":"CDM"},{"code":"904617261","type":"NDC"}],"standard_charges":[{"gross_charge":12.31,"discounted_cash":6.77,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Fluconazole Tab 150 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"13577","type":"CDM"},{"code":"16714069210","type":"NDC"}],"standard_charges":[{"gross_charge":34.53,"discounted_cash":18.99,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Carbamide Peroxide 6.5% Otic Soln","drug_information":{"unit":15.0,"type":"ML"},"code_information":[{"code":"1359","type":"CDM"},{"code":"904662735","type":"NDC"}],"standard_charges":[{"gross_charge":27.08,"discounted_cash":14.89,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Carbamide Peroxide 6.5% Otic Soln","drug_information":{"unit":15.0,"type":"ML"},"code_information":[{"code":"1359","type":"CDM"},{"code":"70677115301","type":"NDC"}],"standard_charges":[{"gross_charge":35.09,"discounted_cash":19.30,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Carbamide Peroxide 6.5% Otic Soln","drug_information":{"unit":15.0,"type":"ML"},"code_information":[{"code":"1359","type":"CDM"},{"code":"904747835","type":"NDC"}],"standard_charges":[{"gross_charge":27.08,"discounted_cash":14.89,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Apixaban Tab 2.5 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"136584","type":"CDM"},{"code":"3089321","type":"NDC"}],"standard_charges":[{"gross_charge":32.48,"discounted_cash":17.86,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Apixaban Tab 2.5 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"136584","type":"CDM"},{"code":"3089331","type":"NDC"}],"standard_charges":[{"gross_charge":32.48,"discounted_cash":17.86,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Apixaban Tab 5 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"136617","type":"CDM"},{"code":"3089431","type":"NDC"}],"standard_charges":[{"gross_charge":32.48,"discounted_cash":17.86,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Morphine Sulfate Tab ER 30 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"137383","type":"CDM"},{"code":"68084040411","type":"NDC"}],"standard_charges":[{"gross_charge":20.82,"discounted_cash":11.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Morphine Sulfate Tab ER 30 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"137383","type":"CDM"},{"code":"68084015811","type":"NDC"}],"standard_charges":[{"gross_charge":20.82,"discounted_cash":11.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Glycopyrrolate Inj 0.4 MG/2ML (0.2 MG/ML)","drug_information":{"unit":0.5,"type":"ML"},"code_information":[{"code":"137396","type":"CDM"},{"code":"43547054401","type":"NDC"}],"standard_charges":[{"gross_charge":41.84,"discounted_cash":23.01,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Glycopyrrolate Inj 0.4 MG/2ML (0.2 MG/ML)","drug_information":{"unit":0.5,"type":"ML"},"code_information":[{"code":"137396","type":"CDM"},{"code":"43547054425","type":"NDC"}],"standard_charges":[{"gross_charge":41.84,"discounted_cash":23.01,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Morphine Sulfate IV Soln PF 2 MG/ML","drug_information":{"unit":0.5,"type":"ML"},"code_information":[{"code":"137405","type":"CDM"},{"code":"63323045200","type":"NDC"}],"standard_charges":[{"gross_charge":37.62,"discounted_cash":20.69,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Morphine Sulfate Tab ER 15 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"137407","type":"CDM"},{"code":"904655761","type":"NDC"}],"standard_charges":[{"gross_charge":13.29,"discounted_cash":7.31,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Ferric Subsulfate Soln","drug_information":{"unit":8.0,"type":"ML"},"code_information":[{"code":"137701","type":"CDM"},{"code":"10481011208","type":"NDC"}],"standard_charges":[{"gross_charge":73.15,"discounted_cash":40.23,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Dexmedetomidine HCl in NaCl 0.9% IV Soln 400 MCG/100ML","drug_information":{"unit":100.0,"type":"ML"},"code_information":[{"code":"138058","type":"CDM"},{"code":"8813805800","type":"NDC"}],"standard_charges":[{"gross_charge":359.5,"discounted_cash":197.72,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Desvenlafaxine Tab ER 24HR 50 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"138076","type":"CDM"},{"code":"63304019130","type":"NDC"}],"standard_charges":[{"gross_charge":27.16,"discounted_cash":14.94,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Bismuth Subsalicylate Tab 262 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"13810","type":"CDM"},{"code":"70000059401","type":"NDC"}],"standard_charges":[{"gross_charge":9.0,"discounted_cash":4.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Prothrombin Complex Conc Human For Inj Kit 500 Unit","drug_information":{"unit":500.0,"type":"UN"},"code_information":[{"code":"138712","type":"CDM"},{"code":"63833038602","type":"NDC"}],"standard_charges":[{"gross_charge":2331.0,"discounted_cash":1282.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Neostigmine Methylsulfate IV Soln 10 MG/10 ML (1 MG/ML)","drug_information":{"unit":0.5,"type":"ML"},"code_information":[{"code":"139069","type":"CDM"},{"code":"641614910","type":"NDC"}],"standard_charges":[{"gross_charge":33.08,"discounted_cash":18.19,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Neostigmine Methylsulfate IV Soln 10 MG/10 ML (1 MG/ML)","drug_information":{"unit":0.5,"type":"ML"},"code_information":[{"code":"139069","type":"CDM"},{"code":"641614901","type":"NDC"}],"standard_charges":[{"gross_charge":33.08,"discounted_cash":18.19,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Carisoprodol Tab 350 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"1395","type":"CDM"},{"code":"50228010901","type":"NDC"}],"standard_charges":[{"gross_charge":10.65,"discounted_cash":5.86,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Lamotrigine Tab 25 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"13981","type":"CDM"},{"code":"904700761","type":"NDC"}],"standard_charges":[{"gross_charge":8.91,"discounted_cash":4.90,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Lamotrigine Tab 100 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"13982","type":"CDM"},{"code":"68084031911","type":"NDC"}],"standard_charges":[{"gross_charge":9.02,"discounted_cash":4.96,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Lamotrigine Tab 100 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"13982","type":"CDM"},{"code":"68084031901","type":"NDC"}],"standard_charges":[{"gross_charge":9.02,"discounted_cash":4.96,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Dolutegravir Sodium Tab 50 MG (Base Equiv)","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"139834","type":"CDM"},{"code":"49702022813","type":"NDC"}],"standard_charges":[{"gross_charge":189.36,"discounted_cash":104.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Oxycodone HCl Tab ER 12HR Deter 20 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"140193","type":"CDM"},{"code":"69238229601","type":"NDC"}],"standard_charges":[{"gross_charge":38.93,"discounted_cash":21.41,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Oxycodone HCl Tab ER 12HR Deter 40 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"140195","type":"CDM"},{"code":"59011044020","type":"NDC"}],"standard_charges":[{"gross_charge":69.22,"discounted_cash":38.07,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Rotavirus Vaccine, Live Oral Pentavalent Soln","drug_information":{"unit":2.0,"type":"ML"},"code_information":[{"code":"140296","type":"CDM"},{"code":"6404741","type":"NDC"}],"standard_charges":[{"gross_charge":223.5,"discounted_cash":122.92,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Bupivacaine HCl Preservative Free (PF) Inj 0.75%","drug_information":{"unit":30.0,"type":"ML"},"code_information":[{"code":"140297","type":"CDM"},{"code":"71288072832","type":"NDC"}],"standard_charges":[{"gross_charge":63.0,"discounted_cash":34.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Oxycodone HCl Tab ER 12HR Deter 10 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"140309","type":"CDM"},{"code":"59011041020","type":"NDC"}],"standard_charges":[{"gross_charge":31.03,"discounted_cash":17.07,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Heparin Sodium (Porcine) Inj 10000 Unit/ML","drug_information":{"unit":0.5,"type":"ML"},"code_information":[{"code":"140312","type":"CDM"},{"code":"71288040402","type":"NDC"}],"standard_charges":[{"gross_charge":18.23,"discounted_cash":10.03,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Heparin Sodium (Porcine) Inj 10000 Unit/ML","drug_information":{"unit":0.5,"type":"ML"},"code_information":[{"code":"140312","type":"CDM"},{"code":"71288040401","type":"NDC"}],"standard_charges":[{"gross_charge":18.23,"discounted_cash":10.03,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Dexmedetomidine HCl IV Soln 200 MCG/2ML","drug_information":{"unit":2.0,"type":"ML"},"code_information":[{"code":"140374","type":"CDM"},{"code":"66794023342","type":"NDC"}],"standard_charges":[{"gross_charge":47.17,"discounted_cash":25.94,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Dexmedetomidine HCl IV Soln 200 MCG/2ML","drug_information":{"unit":2.0,"type":"ML"},"code_information":[{"code":"140374","type":"CDM"},{"code":"63323042101","type":"NDC"}],"standard_charges":[{"gross_charge":161.68,"discounted_cash":88.92,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Dexmedetomidine HCl IV Soln 200 MCG/2ML","drug_information":{"unit":2.0,"type":"ML"},"code_information":[{"code":"140374","type":"CDM"},{"code":"63323042102","type":"NDC"}],"standard_charges":[{"gross_charge":161.68,"discounted_cash":88.92,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Dexmedetomidine HCl IV Soln 200 MCG/2ML","drug_information":{"unit":2.0,"type":"ML"},"code_information":[{"code":"140374","type":"CDM"},{"code":"66794023302","type":"NDC"}],"standard_charges":[{"gross_charge":47.17,"discounted_cash":25.94,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Artificial Saliva - Solution","drug_information":{"unit":120.0,"type":"ML"},"code_information":[{"code":"140499","type":"CDM"},{"code":"59467510000","type":"NDC"}],"standard_charges":[{"gross_charge":87.62,"discounted_cash":48.19,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Tbo-Filgrastim Soln Prefilled Syringe 300 MCG/0.5ML","drug_information":{"unit":0.5,"type":"ML"},"code_information":[{"code":"140784","type":"CDM"},{"code":"63459091011","type":"NDC"}],"standard_charges":[{"gross_charge":465.75,"discounted_cash":256.16,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Dapagliflozin Propanediol Tab 5 MG (Base Equivalent)","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"141231","type":"CDM"},{"code":"66993045630","type":"NDC"}],"standard_charges":[{"gross_charge":68.84,"discounted_cash":37.86,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Umeclidinium-Vilanterol Aero Powd BA 62.5-25 MCG/ACT","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"141638","type":"CDM"},{"code":"173086906","type":"NDC"}],"standard_charges":[{"gross_charge":44.71,"discounted_cash":24.59,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Insulin Glargine Soln Pen-Injector 100 Unit/ML","drug_information":{"unit":3.0,"type":"ML"},"code_information":[{"code":"141840","type":"CDM"},{"code":"88221901","type":"NDC"}],"standard_charges":[{"gross_charge":107.36,"discounted_cash":59.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Insulin Glargine Soln Pen-Injector 100 Unit/ML","drug_information":{"unit":3.0,"type":"ML"},"code_information":[{"code":"141840","type":"CDM"},{"code":"88221905","type":"NDC"}],"standard_charges":[{"gross_charge":107.34,"discounted_cash":59.04,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Insulin Aspart Soln Pen-injector 100 Unit/ML","drug_information":{"unit":3.0,"type":"ML"},"code_information":[{"code":"141842","type":"CDM"},{"code":"169633910","type":"NDC"}],"standard_charges":[{"gross_charge":62.44,"discounted_cash":34.34,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Insulin Aspart Soln Pen-injector 100 Unit/ML","drug_information":{"unit":3.0,"type":"ML"},"code_information":[{"code":"141842","type":"CDM"},{"code":"73070010315","type":"NDC"}],"standard_charges":[{"gross_charge":62.44,"discounted_cash":34.34,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Insulin Aspart Prot & Aspart Sus Pen-inj 100 Unit/ML (70-30)","drug_information":{"unit":3.0,"type":"ML"},"code_information":[{"code":"141849","type":"CDM"},{"code":"73070020310","type":"NDC"}],"standard_charges":[{"gross_charge":123.21,"discounted_cash":67.77,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Insulin NPH & Regular Susp Pen-Inj 100 Unit/ML (70-30)","drug_information":{"unit":3.0,"type":"ML"},"code_information":[{"code":"141850","type":"CDM"},{"code":"2880359","type":"NDC"}],"standard_charges":[{"gross_charge":124.32,"discounted_cash":68.38,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Insulin NPH & Regular Susp Pen-Inj 100 Unit/ML (70-30)","drug_information":{"unit":3.0,"type":"ML"},"code_information":[{"code":"141850","type":"CDM"},{"code":"2880301","type":"NDC"}],"standard_charges":[{"gross_charge":124.33,"discounted_cash":68.38,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Insulin NPH (Human) (Isophane) Susp Pen-injector 100 Unit/ML","drug_information":{"unit":3.0,"type":"ML"},"code_information":[{"code":"141851","type":"CDM"},{"code":"2880559","type":"NDC"}],"standard_charges":[{"gross_charge":63.01,"discounted_cash":34.66,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Tobramycin Ophth Soln 0.3%","drug_information":{"unit":5.0,"type":"ML"},"code_information":[{"code":"141866","type":"CDM"},{"code":"61314064305","type":"NDC"}],"standard_charges":[{"gross_charge":129.2,"discounted_cash":71.06,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Hylan G-F 20 Intra-articular Soln Prefilled Syr 48 MG/6ML","drug_information":{"unit":6.0,"type":"ML"},"code_information":[{"code":"141870","type":"CDM"},{"code":"58468009003","type":"NDC"}],"standard_charges":[{"gross_charge":2825.01,"discounted_cash":1553.76,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Hydrocortisone Sodium Succinate PF For Inj 100 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"141874","type":"CDM"},{"code":"9082501","type":"NDC"}],"standard_charges":[{"gross_charge":94.2,"discounted_cash":51.81,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Hydrocortisone Sodium Succinate PF For Inj 100 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"141874","type":"CDM"},{"code":"9001103","type":"NDC"}],"standard_charges":[{"gross_charge":94.54,"discounted_cash":52.00,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Hydrocortisone Sodium Succinate PF For Inj 100 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"141874","type":"CDM"},{"code":"9001104","type":"NDC"}],"standard_charges":[{"gross_charge":93.37,"discounted_cash":51.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Perflutren Lipid Microsphere IV Susp 6.52 MG/ML","drug_information":{"unit":2.0,"type":"ML"},"code_information":[{"code":"141882","type":"CDM"},{"code":"11994001116","type":"NDC"}],"standard_charges":[{"gross_charge":759.58,"discounted_cash":417.77,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Perflutren Lipid Microsphere IV Susp 6.52 MG/ML","drug_information":{"unit":0.5,"type":"ML"},"code_information":[{"code":"141882","type":"CDM"},{"code":"11994001101","type":"NDC"}],"standard_charges":[{"gross_charge":187.39,"discounted_cash":103.06,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Vedolizumab For IV Solution 300 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"142941","type":"CDM"},{"code":"64764030020","type":"NDC"}],"standard_charges":[{"gross_charge":19755.81,"discounted_cash":10865.70,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Dantrolene Sodium For IV Susp 250 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"143550","type":"CDM"},{"code":"42367054032","type":"NDC"}],"standard_charges":[{"gross_charge":5797.98,"discounted_cash":3188.89,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Empagliflozin Tab 10 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"143597","type":"CDM"},{"code":"597015230","type":"NDC"}],"standard_charges":[{"gross_charge":63.39,"discounted_cash":34.86,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Empagliflozin Tab 10 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"143597","type":"CDM"},{"code":"597015237","type":"NDC"}],"standard_charges":[{"gross_charge":63.39,"discounted_cash":34.86,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Testosterone Cypionate IM Inj in Oil 200 MG/ML","drug_information":{"unit":0.25,"type":"ML"},"code_information":[{"code":"143895","type":"CDM"},{"code":"70700028922","type":"NDC"}],"standard_charges":[{"gross_charge":46.94,"discounted_cash":25.82,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Testosterone Cypionate IM Inj in Oil 200 MG/ML","drug_information":{"unit":0.25,"type":"ML"},"code_information":[{"code":"143895","type":"CDM"},{"code":"409656201","type":"NDC"}],"standard_charges":[{"gross_charge":45.51,"discounted_cash":25.03,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Phenylephrine HCl IV Soln 10 MG/ML","drug_information":{"unit":0.01,"type":"ML"},"code_information":[{"code":"144467","type":"CDM"},{"code":"71288080702","type":"NDC"}],"standard_charges":[{"gross_charge":31.09,"discounted_cash":17.10,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Phenylephrine HCl IV Soln 10 MG/ML","drug_information":{"unit":0.01,"type":"ML"},"code_information":[{"code":"144467","type":"CDM"},{"code":"71288080701","type":"NDC"}],"standard_charges":[{"gross_charge":31.09,"discounted_cash":17.10,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Cefazolin Sodium For Inj 1 GM","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"1445","type":"CDM"},{"code":"143992490","type":"NDC"}],"standard_charges":[{"gross_charge":37.32,"discounted_cash":20.53,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Cefazolin Sodium For Inj 10 GM","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"1446","type":"CDM"},{"code":"143998391","type":"NDC"}],"standard_charges":[{"gross_charge":67.47,"discounted_cash":37.11,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Cefazolin Sodium For Inj 10 GM","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"1446","type":"CDM"},{"code":"143998303","type":"NDC"}],"standard_charges":[{"gross_charge":67.47,"discounted_cash":37.11,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Saline Nasal Spray 0.65%","drug_information":{"unit":44.0,"type":"ML"},"code_information":[{"code":"14469","type":"CDM"},{"code":"904386575","type":"NDC"}],"standard_charges":[{"gross_charge":22.09,"discounted_cash":12.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Dorzolamide HCl Ophth Soln 2%","drug_information":{"unit":10.0,"type":"ML"},"code_information":[{"code":"14471","type":"CDM"},{"code":"70069050101","type":"NDC"}],"standard_charges":[{"gross_charge":317.17,"discounted_cash":174.44,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Cefazolin Sodium For Inj 500 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"1448","type":"CDM"},{"code":"781345095","type":"NDC"}],"standard_charges":[{"gross_charge":63.13,"discounted_cash":34.72,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Vasopressin IV Soln 20 Unit/ML (For IV Infusion)","drug_information":{"unit":0.25,"type":"ML"},"code_information":[{"code":"144836","type":"CDM"},{"code":"55150037025","type":"NDC"}],"standard_charges":[{"gross_charge":49.48,"discounted_cash":27.21,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Vasopressin IV Soln 20 Unit/ML (For IV Infusion)","drug_information":{"unit":0.25,"type":"ML"},"code_information":[{"code":"144836","type":"CDM"},{"code":"55150037001","type":"NDC"}],"standard_charges":[{"gross_charge":49.48,"discounted_cash":27.21,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Human Papillomavirus (HPV) 9-Valent Recomb Vac Susp Pref Syr","drug_information":{"unit":0.5,"type":"ML"},"code_information":[{"code":"145112","type":"CDM"},{"code":"6412101","type":"NDC"}],"standard_charges":[{"gross_charge":603.4,"discounted_cash":331.87,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Human Papillomavirus (HPV) 9-Valent Recomb Vac Susp Pref Syr","drug_information":{"unit":0.5,"type":"ML"},"code_information":[{"code":"145112","type":"CDM"},{"code":"6412102","type":"NDC"}],"standard_charges":[{"gross_charge":603.4,"discounted_cash":331.87,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Umeclidinium Br Aero Powd Breath Act 62.5 MCG/ACT (Base Eq)","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"145159","type":"CDM"},{"code":"173087306","type":"NDC"}],"standard_charges":[{"gross_charge":52.38,"discounted_cash":28.81,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Mometasone Furoate Inhal Aerosol Suspension 100 MCG/ACT","drug_information":{"unit":13.0,"type":"GM"},"code_information":[{"code":"145229","type":"CDM"},{"code":"78206011201","type":"NDC"}],"standard_charges":[{"gross_charge":414.47,"discounted_cash":227.96,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Meningococcal Vac B (Recomb OMV Adjuv) Inj Prefilled Syringe","drug_information":{"unit":0.5,"type":"ML"},"code_information":[{"code":"145410","type":"CDM"},{"code":"58160097620","type":"NDC"}],"standard_charges":[{"gross_charge":446.88,"discounted_cash":245.78,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Influenza Virus Vac Tiss-Cult Subunit Susp Pref Syr 0.5 ML","drug_information":{"unit":0.5,"type":"ML"},"code_information":[{"code":"146010","type":"CDM"},{"code":"70461065503","type":"NDC"}],"standard_charges":[{"gross_charge":26.0,"discounted_cash":14.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Influenza Virus Vac Tiss-Cult Subunit Susp Pref Syr 0.5 ML","drug_information":{"unit":0.5,"type":"ML"},"code_information":[{"code":"146010","type":"CDM"},{"code":"70461065504","type":"NDC"}],"standard_charges":[{"gross_charge":26.0,"discounted_cash":14.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Norepinephrine Bitartrate IV Soln 1 MG/ML (Base Equivalent)","drug_information":{"unit":4.0,"type":"ML"},"code_information":[{"code":"146011","type":"CDM"},{"code":"51991098317","type":"NDC"}],"standard_charges":[{"gross_charge":30.18,"discounted_cash":16.60,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Norepinephrine Bitartrate IV Soln 1 MG/ML (Base Equivalent)","drug_information":{"unit":4.0,"type":"ML"},"code_information":[{"code":"146011","type":"CDM"},{"code":"67457085200","type":"NDC"}],"standard_charges":[{"gross_charge":46.05,"discounted_cash":25.33,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Norepinephrine Bitartrate IV Soln 1 MG/ML (Base Equivalent)","drug_information":{"unit":4.0,"type":"ML"},"code_information":[{"code":"146011","type":"CDM"},{"code":"67457085204","type":"NDC"}],"standard_charges":[{"gross_charge":46.05,"discounted_cash":25.33,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Rho D Immune Globulin Sol Pref Syr 1500 Unt/2ML (300MCG/2ML)","drug_information":{"unit":2.0,"type":"ML"},"code_information":[{"code":"146013","type":"CDM"},{"code":"44206030001","type":"NDC"}],"standard_charges":[{"gross_charge":442.86,"discounted_cash":243.57,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Verapamil HCl Tab ER 180 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"14626","type":"CDM"},{"code":"75834015801","type":"NDC"}],"standard_charges":[{"gross_charge":13.54,"discounted_cash":7.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Tramadol HCl Tab 50 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"14632","type":"CDM"},{"code":"60219234801","type":"NDC"}],"standard_charges":[{"gross_charge":11.71,"discounted_cash":6.44,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Ceftazidime-Avibactam Sodium For IV Soln 2.5 GM (2-0.5 GM)","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"146469","type":"CDM"},{"code":"456270010","type":"NDC"}],"standard_charges":[{"gross_charge":778.66,"discounted_cash":428.26,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Desvenlafaxine Succinate Tab ER 24HR 25 MG (Base Equiv)","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"146614","type":"CDM"},{"code":"51991000633","type":"NDC"}],"standard_charges":[{"gross_charge":39.55,"discounted_cash":21.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Sacubitril-Valsartan Tab 49-51 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"147534","type":"CDM"},{"code":"78077720","type":"NDC"}],"standard_charges":[{"gross_charge":46.79,"discounted_cash":25.73,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Sacubitril-Valsartan Tab 24-26 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"147559","type":"CDM"},{"code":"43598064360","type":"NDC"}],"standard_charges":[{"gross_charge":45.46,"discounted_cash":25.00,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Sacubitril-Valsartan Tab 97-103 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"147560","type":"CDM"},{"code":"78069620","type":"NDC"}],"standard_charges":[{"gross_charge":46.79,"discounted_cash":25.73,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Cangrelor Tetrasodium For IV Soln 50 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"147588","type":"CDM"},{"code":"10122062010","type":"NDC"}],"standard_charges":[{"gross_charge":1773.09,"discounted_cash":975.20,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Cangrelor Tetrasodium For IV Soln 50 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"147588","type":"CDM"},{"code":"10122062001","type":"NDC"}],"standard_charges":[{"gross_charge":1773.09,"discounted_cash":975.20,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Tizanidine HCl Tab 2 MG (Base Equivalent)","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"14792","type":"CDM"},{"code":"68084077525","type":"NDC"}],"standard_charges":[{"gross_charge":14.73,"discounted_cash":8.10,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Losartan Potassium Tab 25 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"14823","type":"CDM"},{"code":"68084034601","type":"NDC"}],"standard_charges":[{"gross_charge":14.46,"discounted_cash":7.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Losartan Potassium Tab 25 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"14823","type":"CDM"},{"code":"68084034611","type":"NDC"}],"standard_charges":[{"gross_charge":14.46,"discounted_cash":7.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Magnesium Sulfate IV Soln 2 GM/50ML (40 MG/ML)","drug_information":{"unit":50.0,"type":"ML"},"code_information":[{"code":"148233","type":"CDM"},{"code":"44567042000","type":"NDC"}],"standard_charges":[{"gross_charge":26.91,"discounted_cash":14.80,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Magnesium Sulfate IV Soln 2 GM/50ML (40 MG/ML)","drug_information":{"unit":50.0,"type":"ML"},"code_information":[{"code":"148233","type":"CDM"},{"code":"63323010603","type":"NDC"}],"standard_charges":[{"gross_charge":21.59,"discounted_cash":11.87,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Magnesium Sulfate IV Soln 2 GM/50ML (40 MG/ML)","drug_information":{"unit":50.0,"type":"ML"},"code_information":[{"code":"148233","type":"CDM"},{"code":"63323010605","type":"NDC"}],"standard_charges":[{"gross_charge":37.06,"discounted_cash":20.38,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Magnesium Sulfate IV Soln 2 GM/50ML (40 MG/ML)","drug_information":{"unit":50.0,"type":"ML"},"code_information":[{"code":"148233","type":"CDM"},{"code":"47335099201","type":"NDC"}],"standard_charges":[{"gross_charge":37.55,"discounted_cash":20.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Magnesium Sulfate IV Soln 4 GM/100ML (40 MG/ML)","drug_information":{"unit":100.0,"type":"ML"},"code_information":[{"code":"148235","type":"CDM"},{"code":"63323010600","type":"NDC"}],"standard_charges":[{"gross_charge":79.51,"discounted_cash":43.73,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Magnesium Sulfate IV Soln 4 GM/100ML (40 MG/ML)","drug_information":{"unit":100.0,"type":"ML"},"code_information":[{"code":"148235","type":"CDM"},{"code":"63323010601","type":"NDC"}],"standard_charges":[{"gross_charge":79.51,"discounted_cash":43.73,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Magnesium Sulfate IV Soln 20 GM/500ML (40 MG/ML)","drug_information":{"unit":500.0,"type":"ML"},"code_information":[{"code":"148236","type":"CDM"},{"code":"63323010615","type":"NDC"}],"standard_charges":[{"gross_charge":26.0,"discounted_cash":14.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Pegfilgrastim Soln Prefilled Syringe 6 MG/0.6ML","drug_information":{"unit":0.6,"type":"ML"},"code_information":[{"code":"148242","type":"CDM"},{"code":"55513019001","type":"NDC"}],"standard_charges":[{"gross_charge":11198.31,"discounted_cash":6159.07,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Fosfomycin Tromethamine Powd Pack 3 GM (Base Equivalent)","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"14825","type":"CDM"},{"code":"70700026899","type":"NDC"}],"standard_charges":[{"gross_charge":203.78,"discounted_cash":112.08,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Fosfomycin Tromethamine Powd Pack 3 GM (Base Equivalent)","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"14825","type":"CDM"},{"code":"70700026894","type":"NDC"}],"standard_charges":[{"gross_charge":203.78,"discounted_cash":112.08,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Chlorpromazine HCl Inj 50 MG/2ML","drug_information":{"unit":1.0,"type":"ML"},"code_information":[{"code":"148251","type":"CDM"},{"code":"641139835","type":"NDC"}],"standard_charges":[{"gross_charge":85.62,"discounted_cash":47.09,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Darbepoetin Alfa Soln Prefilled Syringe 25 MCG/0.42ML","drug_information":{"unit":0.42,"type":"ML"},"code_information":[{"code":"148260","type":"CDM"},{"code":"55513005701","type":"NDC"}],"standard_charges":[{"gross_charge":367.69,"discounted_cash":202.23,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Darbepoetin Alfa Soln Prefilled Syringe 25 MCG/0.42ML","drug_information":{"unit":0.42,"type":"ML"},"code_information":[{"code":"148260","type":"CDM"},{"code":"55513005704","type":"NDC"}],"standard_charges":[{"gross_charge":367.69,"discounted_cash":202.23,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Darbepoetin Alfa Soln Inj 40 MCG/ML","drug_information":{"unit":1.0,"type":"ML"},"code_information":[{"code":"148261","type":"CDM"},{"code":"55513000304","type":"NDC"}],"standard_charges":[{"gross_charge":588.28,"discounted_cash":323.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Darbepoetin Alfa Soln Prefilled Syringe 40 MCG/0.4ML","drug_information":{"unit":0.4,"type":"ML"},"code_information":[{"code":"148262","type":"CDM"},{"code":"55513002104","type":"NDC"}],"standard_charges":[{"gross_charge":569.7,"discounted_cash":313.34,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Darbepoetin Alfa Soln Prefilled Syringe 40 MCG/0.4ML","drug_information":{"unit":0.4,"type":"ML"},"code_information":[{"code":"148262","type":"CDM"},{"code":"55513002101","type":"NDC"}],"standard_charges":[{"gross_charge":569.7,"discounted_cash":313.34,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Darbepoetin Alfa Soln Prefilled Syringe 60 MCG/0.3ML","drug_information":{"unit":0.3,"type":"ML"},"code_information":[{"code":"148264","type":"CDM"},{"code":"55513002304","type":"NDC"}],"standard_charges":[{"gross_charge":839.06,"discounted_cash":461.48,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Darbepoetin Alfa Soln Prefilled Syringe 60 MCG/0.3ML","drug_information":{"unit":0.3,"type":"ML"},"code_information":[{"code":"148264","type":"CDM"},{"code":"55513002301","type":"NDC"}],"standard_charges":[{"gross_charge":839.06,"discounted_cash":461.48,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Darbepoetin Alfa Soln Prefilled Syringe 100 MCG/0.5ML","drug_information":{"unit":0.5,"type":"ML"},"code_information":[{"code":"148267","type":"CDM"},{"code":"55513002501","type":"NDC"}],"standard_charges":[{"gross_charge":1377.76,"discounted_cash":757.77,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Darbepoetin Alfa Soln Prefilled Syringe 100 MCG/0.5ML","drug_information":{"unit":0.5,"type":"ML"},"code_information":[{"code":"148267","type":"CDM"},{"code":"55513002504","type":"NDC"}],"standard_charges":[{"gross_charge":1377.76,"discounted_cash":757.77,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Darbepoetin Alfa Soln Prefilled Syringe 150 MCG/0.3ML","drug_information":{"unit":0.3,"type":"ML"},"code_information":[{"code":"148270","type":"CDM"},{"code":"55513002704","type":"NDC"}],"standard_charges":[{"gross_charge":2051.14,"discounted_cash":1128.13,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Darbepoetin Alfa Soln Prefilled Syringe 200 MCG/0.4ML","drug_information":{"unit":0.4,"type":"ML"},"code_information":[{"code":"148271","type":"CDM"},{"code":"55513002801","type":"NDC"}],"standard_charges":[{"gross_charge":2724.52,"discounted_cash":1498.49,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Darbepoetin Alfa Soln Prefilled Syringe 300 MCG/0.6ML","drug_information":{"unit":0.6,"type":"ML"},"code_information":[{"code":"148272","type":"CDM"},{"code":"55513011101","type":"NDC"}],"standard_charges":[{"gross_charge":4071.28,"discounted_cash":2239.20,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Neostigmine Methylsulfate Soln Pref Syr 5 MG/5ML (1 MG/ML)","drug_information":{"unit":0.5,"type":"ML"},"code_information":[{"code":"148274","type":"CDM"},{"code":"8888900329","type":"NDC"}],"standard_charges":[{"gross_charge":32.87,"discounted_cash":18.08,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Ephedrine Sulf-NaCl Soln Pref Syr 50 MG/10ML-0.9% (5 MG/ML)","drug_information":{"unit":10.0,"type":"ML"},"code_information":[{"code":"148299","type":"CDM"},{"code":"70004060012","type":"NDC"}],"standard_charges":[{"gross_charge":122.44,"discounted_cash":67.34,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Filgrastim-sndz Soln Prefilled Syringe 300 MCG/0.5ML","drug_information":{"unit":0.5,"type":"ML"},"code_information":[{"code":"148382","type":"CDM"},{"code":"61314031801","type":"NDC"}],"standard_charges":[{"gross_charge":508.38,"discounted_cash":279.61,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Filgrastim-sndz Soln Prefilled Syringe 480 MCG/0.8ML","drug_information":{"unit":0.8,"type":"ML"},"code_information":[{"code":"148385","type":"CDM"},{"code":"61314032601","type":"NDC"}],"standard_charges":[{"gross_charge":794.83,"discounted_cash":437.16,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Dopamine in Dextrose 5% Inj 1.6 MG/ML","drug_information":{"unit":250.0,"type":"ML"},"code_information":[{"code":"14845","type":"CDM"},{"code":"338100702","type":"NDC"}],"standard_charges":[{"gross_charge":106.65,"discounted_cash":58.66,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Ticagrelor Tab 60 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"148465","type":"CDM"},{"code":"480268806","type":"NDC"}],"standard_charges":[{"gross_charge":37.14,"discounted_cash":20.43,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Lidocaine IV Infusion in D5W Inj 8 MG/ML","drug_information":{"unit":250.0,"type":"ML"},"code_information":[{"code":"14869","type":"CDM"},{"code":"264959820","type":"NDC"}],"standard_charges":[{"gross_charge":74.68,"discounted_cash":41.07,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Idarucizumab IV Soln 2.5 GM/50ML","drug_information":{"unit":100.0,"type":"ML"},"code_information":[{"code":"148710","type":"CDM"},{"code":"597019705","type":"NDC"}],"standard_charges":[{"gross_charge":11987.66,"discounted_cash":6593.21,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Calcium Acetate (Phosphate Binder) Cap 667 MG (169 MG Ca)","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"148913","type":"CDM"},{"code":"23155053102","type":"NDC"}],"standard_charges":[{"gross_charge":11.95,"discounted_cash":6.57,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Patiromer Sorbitex Calcium For Susp Packet 8.4 GM (Base Eq)","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"149269","type":"CDM"},{"code":"53436008401","type":"NDC"}],"standard_charges":[{"gross_charge":101.72,"discounted_cash":55.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Sulfur Hexafluoride Lipid-Type A Micros For Susp 60.7-25 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"149625","type":"CDM"},{"code":"270709973","type":"NDC"}],"standard_charges":[{"gross_charge":326.8,"discounted_cash":179.74,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Sulfur Hexafluoride Lipid-Type A Micros For Susp 60.7-25 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"149625","type":"CDM"},{"code":"270709707","type":"NDC"}],"standard_charges":[{"gross_charge":327.31,"discounted_cash":180.02,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Sugammadex Sodium IV 200 MG/2ML (Base Equivalent)","drug_information":{"unit":2.0,"type":"ML"},"code_information":[{"code":"149637","type":"CDM"},{"code":"6542312","type":"NDC"}],"standard_charges":[{"gross_charge":361.24,"discounted_cash":198.68,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Sugammadex Sodium IV 200 MG/2ML (Base Equivalent)","drug_information":{"unit":2.0,"type":"ML"},"code_information":[{"code":"149637","type":"CDM"},{"code":"6542302","type":"NDC"}],"standard_charges":[{"gross_charge":361.24,"discounted_cash":198.68,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Sugammadex Sodium IV 500 MG/5ML (Base Equivalent)","drug_information":{"unit":5.0,"type":"ML"},"code_information":[{"code":"149641","type":"CDM"},{"code":"6542505","type":"NDC"}],"standard_charges":[{"gross_charge":632.94,"discounted_cash":348.12,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Water For Inject, Bacteriostatic Benzyl Alcohol","drug_information":{"unit":30.0,"type":"ML"},"code_information":[{"code":"14979","type":"CDM"},{"code":"409397703","type":"NDC"}],"standard_charges":[{"gross_charge":64.51,"discounted_cash":35.48,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Water For Inject, Bacteriostatic Benzyl Alcohol","drug_information":{"unit":30.0,"type":"ML"},"code_information":[{"code":"14979","type":"CDM"},{"code":"409397701","type":"NDC"}],"standard_charges":[{"gross_charge":64.51,"discounted_cash":35.48,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Phenylephrine-Mineral Oil-Petrolatum Oint 0.25-14-74.9%","drug_information":{"unit":57.0,"type":"GM"},"code_information":[{"code":"150257","type":"CDM"},{"code":"536128806","type":"NDC"}],"standard_charges":[{"gross_charge":30.19,"discounted_cash":16.60,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Fentanyl Citrate Preservative Free (PF) Inj 100 MCG/2ML","drug_information":{"unit":0.5,"type":"ML"},"code_information":[{"code":"150521","type":"CDM"},{"code":"641602701","type":"NDC"}],"standard_charges":[{"gross_charge":33.44,"discounted_cash":18.39,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Fentanyl Citrate Preservative Free (PF) Inj 100 MCG/2ML","drug_information":{"unit":0.5,"type":"ML"},"code_information":[{"code":"150521","type":"CDM"},{"code":"641602725","type":"NDC"}],"standard_charges":[{"gross_charge":33.45,"discounted_cash":18.40,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Propofol IV Emul 200 MG/20ML (10 MG/ML)","drug_information":{"unit":2.0,"type":"ML"},"code_information":[{"code":"150522","type":"CDM"},{"code":"72572059001","type":"NDC"}],"standard_charges":[{"gross_charge":35.74,"discounted_cash":19.66,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Propofol IV Emul 200 MG/20ML (10 MG/ML)","drug_information":{"unit":2.0,"type":"ML"},"code_information":[{"code":"150522","type":"CDM"},{"code":"72572059010","type":"NDC"}],"standard_charges":[{"gross_charge":35.74,"discounted_cash":19.66,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Lidocaine HCl Local Preservative Free (PF) Inj 4%","drug_information":{"unit":5.0,"type":"ML"},"code_information":[{"code":"150524","type":"CDM"},{"code":"409428301","type":"NDC"}],"standard_charges":[{"gross_charge":53.33,"discounted_cash":29.33,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Lidocaine HCl Local Preservative Free (PF) Inj 4%","drug_information":{"unit":5.0,"type":"ML"},"code_information":[{"code":"150524","type":"CDM"},{"code":"409428311","type":"NDC"}],"standard_charges":[{"gross_charge":53.33,"discounted_cash":29.33,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Tranexamic Acid IV Soln 1000 MG/10ML (100 MG/ML)","drug_information":{"unit":10.0,"type":"ML"},"code_information":[{"code":"150527","type":"CDM"},{"code":"23155016631","type":"NDC"}],"standard_charges":[{"gross_charge":52.89,"discounted_cash":29.09,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Tranexamic Acid IV Soln 1000 MG/10ML (100 MG/ML)","drug_information":{"unit":10.0,"type":"ML"},"code_information":[{"code":"150527","type":"CDM"},{"code":"23155016641","type":"NDC"}],"standard_charges":[{"gross_charge":52.89,"discounted_cash":29.09,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Divalproex Sodium Cap Delayed Release Sprinkle 125 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"150530","type":"CDM"},{"code":"68084031365","type":"NDC"}],"standard_charges":[{"gross_charge":12.28,"discounted_cash":6.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Linezolid IV Soln 600 MG/300ML (2 MG/ML)","drug_information":{"unit":300.0,"type":"ML"},"code_information":[{"code":"150531","type":"CDM"},{"code":"781343346","type":"NDC"}],"standard_charges":[{"gross_charge":124.7,"discounted_cash":68.58,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Linezolid IV Soln 600 MG/300ML (2 MG/ML)","drug_information":{"unit":300.0,"type":"ML"},"code_information":[{"code":"150531","type":"CDM"},{"code":"781343395","type":"NDC"}],"standard_charges":[{"gross_charge":124.7,"discounted_cash":68.58,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Acetylcholine Chloride Intraocular For Soln 20 MG (1:100)","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"150533","type":"CDM"},{"code":"24208053920","type":"NDC"}],"standard_charges":[{"gross_charge":274.36,"discounted_cash":150.90,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Fentanyl Citrate Preservative Free (PF) Inj 250 MCG/5ML","drug_information":{"unit":0.5,"type":"ML"},"code_information":[{"code":"150548","type":"CDM"},{"code":"63323080605","type":"NDC"}],"standard_charges":[{"gross_charge":32.52,"discounted_cash":17.89,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Fentanyl Citrate Preservative Free (PF) Inj 250 MCG/5ML","drug_information":{"unit":0.5,"type":"ML"},"code_information":[{"code":"150548","type":"CDM"},{"code":"63323080613","type":"NDC"}],"standard_charges":[{"gross_charge":32.52,"discounted_cash":17.89,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Propofol IV Emul 100 MG/10ML (10 MG/ML)","drug_information":{"unit":10.0,"type":"ML"},"code_information":[{"code":"150574","type":"CDM"},{"code":"63323026910","type":"NDC"}],"standard_charges":[{"gross_charge":47.02,"discounted_cash":25.86,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Propofol IV Emul 100 MG/10ML (10 MG/ML)","drug_information":{"unit":10.0,"type":"ML"},"code_information":[{"code":"150574","type":"CDM"},{"code":"63323026906","type":"NDC"}],"standard_charges":[{"gross_charge":37.41,"discounted_cash":20.58,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Propofol IV Emul 500 MG/50ML (10 MG/ML)","drug_information":{"unit":2.5,"type":"ML"},"code_information":[{"code":"150575","type":"CDM"},{"code":"25021060850","type":"NDC"}],"standard_charges":[{"gross_charge":34.9,"discounted_cash":19.20,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Propofol IV Emul 1000 MG/100ML (10 MG/ML)","drug_information":{"unit":100.0,"type":"ML"},"code_information":[{"code":"150576","type":"CDM"},{"code":"409469954","type":"NDC"}],"standard_charges":[{"gross_charge":146.26,"discounted_cash":80.44,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Propofol IV Emul 1000 MG/100ML (10 MG/ML)","drug_information":{"unit":100.0,"type":"ML"},"code_information":[{"code":"150576","type":"CDM"},{"code":"409469924","type":"NDC"}],"standard_charges":[{"gross_charge":146.26,"discounted_cash":80.44,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Propofol IV Emul 1000 MG/100ML (10 MG/ML)","drug_information":{"unit":100.0,"type":"ML"},"code_information":[{"code":"150576","type":"CDM"},{"code":"69024801","type":"NDC"}],"standard_charges":[{"gross_charge":146.26,"discounted_cash":80.44,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Propofol IV Emul 1000 MG/100ML (10 MG/ML)","drug_information":{"unit":100.0,"type":"ML"},"code_information":[{"code":"150576","type":"CDM"},{"code":"69024810","type":"NDC"}],"standard_charges":[{"gross_charge":146.26,"discounted_cash":80.44,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Fentanyl Citrate Preservative Free (PF) Inj 2500 MCG/50ML","drug_information":{"unit":50.0,"type":"ML"},"code_information":[{"code":"150580","type":"CDM"},{"code":"409909441","type":"NDC"}],"standard_charges":[{"gross_charge":198.32,"discounted_cash":109.08,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Fentanyl Citrate Preservative Free (PF) Inj 2500 MCG/50ML","drug_information":{"unit":50.0,"type":"ML"},"code_information":[{"code":"150580","type":"CDM"},{"code":"409909461","type":"NDC"}],"standard_charges":[{"gross_charge":198.32,"discounted_cash":109.08,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Fentanyl Citrate Preservative Free (PF) Inj 2500 MCG/50ML","drug_information":{"unit":50.0,"type":"ML"},"code_information":[{"code":"150580","type":"CDM"},{"code":"641603001","type":"NDC"}],"standard_charges":[{"gross_charge":164.5,"discounted_cash":90.48,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Fentanyl Citrate Preservative Free (PF) Inj 2500 MCG/50ML","drug_information":{"unit":50.0,"type":"ML"},"code_information":[{"code":"150580","type":"CDM"},{"code":"8883000440","type":"NDC"}],"standard_charges":[{"gross_charge":164.5,"discounted_cash":90.48,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Famotidine Tab 10 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"15065","type":"CDM"},{"code":"904552952","type":"NDC"}],"standard_charges":[{"gross_charge":9.19,"discounted_cash":5.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Phenylephrine-NaCl Pref Syr 0.5 MG/5ML-0.9% (100 MCG/ML)","drug_information":{"unit":5.0,"type":"ML"},"code_information":[{"code":"151107","type":"CDM"},{"code":"70092132844","type":"NDC"}],"standard_charges":[{"gross_charge":55.02,"discounted_cash":30.26,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Insulin Regular (Human) Soln Pen-Injector 500 Unit/ML","drug_information":{"unit":3.0,"type":"ML"},"code_information":[{"code":"151112","type":"CDM"},{"code":"2882427","type":"NDC"}],"standard_charges":[{"gross_charge":702.81,"discounted_cash":386.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Mycophenolate Mofetil Cap 250 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"15113","type":"CDM"},{"code":"51079072101","type":"NDC"}],"standard_charges":[{"gross_charge":23.26,"discounted_cash":12.79,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Mycophenolate Mofetil Cap 250 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"15113","type":"CDM"},{"code":"51079072120","type":"NDC"}],"standard_charges":[{"gross_charge":23.26,"discounted_cash":12.79,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Mycophenolate Mofetil Cap 250 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"15113","type":"CDM"},{"code":"31722087801","type":"NDC"}],"standard_charges":[{"gross_charge":23.27,"discounted_cash":12.80,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Succinylcholine Chloride Sol Pref Syr 200 MG/10ML (20 MG/ML)","drug_information":{"unit":10.0,"type":"ML"},"code_information":[{"code":"151151","type":"CDM"},{"code":"69374091910","type":"NDC"}],"standard_charges":[{"gross_charge":122.25,"discounted_cash":67.24,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Sevoflurane Inhal Soln","drug_information":{"unit":250.0,"type":"ML"},"code_information":[{"code":"15119","type":"CDM"},{"code":"66794001525","type":"NDC"}],"standard_charges":[{"gross_charge":598.84,"discounted_cash":329.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Emtricitabine-Tenofovir Alafenamide Fumarate Tab 200-25 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"151195","type":"CDM"},{"code":"61958200202","type":"NDC"}],"standard_charges":[{"gross_charge":179.78,"discounted_cash":98.88,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Radium Ra 223 Dichloride Inj 30 microcurie/ML (1100 kBq/ML)","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"151399","type":"CDM"},{"code":"50419020801","type":"NDC"}],"standard_charges":[{"gross_charge":39912.94,"discounted_cash":21952.12,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Fentanyl Cit 0.2 MG/100ML-Ropiv 0.2%-NaCl 0.9% Epidural Inj","drug_information":{"unit":100.0,"type":"ML"},"code_information":[{"code":"151664","type":"CDM"},{"code":"70092110836","type":"NDC"}],"standard_charges":[{"gross_charge":273.97,"discounted_cash":150.68,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Influenza Vac Type A&B Surface Ant Adj Susp Pref Syr 0.5 ML","drug_information":{"unit":0.5,"type":"ML"},"code_information":[{"code":"152026","type":"CDM"},{"code":"70461002404","type":"NDC"}],"standard_charges":[{"gross_charge":65.0,"discounted_cash":35.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Influenza Vac Type A&B Surface Ant Adj Susp Pref Syr 0.5 ML","drug_information":{"unit":0.5,"type":"ML"},"code_information":[{"code":"152026","type":"CDM"},{"code":"70461002504","type":"NDC"}],"standard_charges":[{"gross_charge":65.0,"discounted_cash":35.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Influenza Vac Type A&B Surface Ant Adj Susp Pref Syr 0.5 ML","drug_information":{"unit":0.5,"type":"ML"},"code_information":[{"code":"152026","type":"CDM"},{"code":"70461002503","type":"NDC"}],"standard_charges":[{"gross_charge":65.0,"discounted_cash":35.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Methylene Blue IV Soln 50 MG/10ML (5 MG/ML)","drug_information":{"unit":10.0,"type":"ML"},"code_information":[{"code":"152675","type":"CDM"},{"code":"517037405","type":"NDC"}],"standard_charges":[{"gross_charge":649.79,"discounted_cash":357.38,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Methylene Blue IV Soln 50 MG/10ML (5 MG/ML)","drug_information":{"unit":10.0,"type":"ML"},"code_information":[{"code":"152675","type":"CDM"},{"code":"517037401","type":"NDC"}],"standard_charges":[{"gross_charge":649.79,"discounted_cash":357.38,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Technetium Tc 99m Sestamibi IV for Soln Kit","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"152755","type":"CDM"},{"code":"65857050020","type":"NDC"}],"standard_charges":[{"gross_charge":600.99,"discounted_cash":330.54,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Chloroprocaine HCl Preservative Free (PF) Inj 3%","drug_information":{"unit":20.0,"type":"ML"},"code_information":[{"code":"152878","type":"CDM"},{"code":"63323047827","type":"NDC"}],"standard_charges":[{"gross_charge":134.41,"discounted_cash":73.93,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Chloroprocaine HCl Preservative Free (PF) Inj 3%","drug_information":{"unit":20.0,"type":"ML"},"code_information":[{"code":"152878","type":"CDM"},{"code":"143921001","type":"NDC"}],"standard_charges":[{"gross_charge":134.41,"discounted_cash":73.93,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Chloroprocaine HCl Preservative Free (PF) Inj 3%","drug_information":{"unit":20.0,"type":"ML"},"code_information":[{"code":"152878","type":"CDM"},{"code":"63323047801","type":"NDC"}],"standard_charges":[{"gross_charge":134.41,"discounted_cash":73.93,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Chloroprocaine HCl Preservative Free (PF) Inj 3%","drug_information":{"unit":20.0,"type":"ML"},"code_information":[{"code":"152878","type":"CDM"},{"code":"143921010","type":"NDC"}],"standard_charges":[{"gross_charge":134.41,"discounted_cash":73.93,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Naloxone HCl Inj 0.4 MG/ML,Naloxone HCl Inj 4 MG/10ML,Naloxone HCl Soln Cartridge 0.4 MG/ML","drug_information":{"unit":0.5,"type":"ML"},"code_information":[{"code":"152879","type":"CDM"},{"code":"67457029202","type":"NDC"}],"standard_charges":[{"gross_charge":63.62,"discounted_cash":34.99,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Tirofiban HCl in NaCl 0.9% IV Soln 5 MG/100ML (Base Equiv),Tirofiban HCl in NaCl 0.9% IV Soln 12.5 MG/250ML (Base Eq)","drug_information":{"unit":250.0,"type":"ML"},"code_information":[{"code":"152881","type":"CDM"},{"code":"25208090202","type":"NDC"}],"standard_charges":[{"gross_charge":601.71,"discounted_cash":330.94,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Medroxyprogesterone Acetate IM Susp Prefilled Syr 150 MG/ML","drug_information":{"unit":1.0,"type":"ML"},"code_information":[{"code":"152912","type":"CDM"},{"code":"548570100","type":"NDC"}],"standard_charges":[{"gross_charge":97.0,"discounted_cash":53.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Medroxyprogesterone Acetate IM Susp Prefilled Syr 150 MG/ML","drug_information":{"unit":1.0,"type":"ML"},"code_information":[{"code":"152912","type":"CDM"},{"code":"70121148001","type":"NDC"}],"standard_charges":[{"gross_charge":255.64,"discounted_cash":140.60,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Naloxone HCl Soln Prefilled Syringe 2 MG/2ML","drug_information":{"unit":0.2,"type":"ML"},"code_information":[{"code":"152918","type":"CDM"},{"code":"76329336901","type":"NDC"}],"standard_charges":[{"gross_charge":41.89,"discounted_cash":23.04,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Sumatriptan Succinate Tab 50 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"15328","type":"CDM"},{"code":"65862014736","type":"NDC"}],"standard_charges":[{"gross_charge":63.31,"discounted_cash":34.82,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Adenosine IV Soln 3 MG/ML (Diagnostic)","drug_information":{"unit":30.0,"type":"ML"},"code_information":[{"code":"15330","type":"CDM"},{"code":"55150019301","type":"NDC"}],"standard_charges":[{"gross_charge":738.85,"discounted_cash":406.37,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Ustekinumab IV Soln 130 MG/26ML (5 MG/ML) (For IV Infusion)","drug_information":{"unit":26.0,"type":"ML"},"code_information":[{"code":"153398","type":"CDM"},{"code":"57894005427","type":"NDC"}],"standard_charges":[{"gross_charge":4551.27,"discounted_cash":2503.20,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Infliximab-dyyb For IV Inj 100 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"153464","type":"CDM"},{"code":"69080901","type":"NDC"}],"standard_charges":[{"gross_charge":1737.81,"discounted_cash":955.80,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Tenofovir Alafenamide Fumarate Tab 25 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"154057","type":"CDM"},{"code":"61958230101","type":"NDC"}],"standard_charges":[{"gross_charge":127.08,"discounted_cash":69.89,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Bezlotoxumab IV Soln 1000 MG/40ML (25 MG/ML)","drug_information":{"unit":40.0,"type":"ML"},"code_information":[{"code":"154135","type":"CDM"},{"code":"6302500","type":"NDC"}],"standard_charges":[{"gross_charge":8923.0,"discounted_cash":4907.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Valproate Sodium Oral Soln 250 MG/5ML (Base Equiv)","drug_information":{"unit":5.0,"type":"ML"},"code_information":[{"code":"155154","type":"CDM"},{"code":"121467540","type":"NDC"}],"standard_charges":[{"gross_charge":29.02,"discounted_cash":15.96,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Valproate Sodium Oral Soln 250 MG/5ML (Base Equiv)","drug_information":{"unit":5.0,"type":"ML"},"code_information":[{"code":"155154","type":"CDM"},{"code":"121467505","type":"NDC"}],"standard_charges":[{"gross_charge":24.63,"discounted_cash":13.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Fluorescein Sodium IV Soln 10%","drug_information":{"unit":0.25,"type":"ML"},"code_information":[{"code":"155157","type":"CDM"},{"code":"17478025310","type":"NDC"}],"standard_charges":[{"gross_charge":42.88,"discounted_cash":23.58,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Magnesium Sulfate in Dextrose 5% IV Soln 1 GM/100ML","drug_information":{"unit":100.0,"type":"ML"},"code_information":[{"code":"155158","type":"CDM"},{"code":"44567041024","type":"NDC"}],"standard_charges":[{"gross_charge":47.91,"discounted_cash":26.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Magnesium Sulfate in Dextrose 5% IV Soln 1 GM/100ML","drug_information":{"unit":100.0,"type":"ML"},"code_information":[{"code":"155158","type":"CDM"},{"code":"63323010800","type":"NDC"}],"standard_charges":[{"gross_charge":80.4,"discounted_cash":44.22,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Milrinone Lactate in Dextrose 5% IV Soln 20 MG/100ML","drug_information":{"unit":100.0,"type":"ML"},"code_information":[{"code":"155162","type":"CDM"},{"code":"143971901","type":"NDC"}],"standard_charges":[{"gross_charge":86.85,"discounted_cash":47.77,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Milrinone Lactate in Dextrose 5% IV Soln 20 MG/100ML","drug_information":{"unit":100.0,"type":"ML"},"code_information":[{"code":"155162","type":"CDM"},{"code":"143971910","type":"NDC"}],"standard_charges":[{"gross_charge":86.85,"discounted_cash":47.77,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Poractant Alfa Intratracheal Susp 240 MG/3ML","drug_information":{"unit":3.0,"type":"ML"},"code_information":[{"code":"155320","type":"CDM"},{"code":"10122051003","type":"NDC"}],"standard_charges":[{"gross_charge":2133.95,"discounted_cash":1173.67,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Ocrelizumab Soln For IV Infusion 300 MG/10ML","drug_information":{"unit":10.0,"type":"ML"},"code_information":[{"code":"155563","type":"CDM"},{"code":"50242015001","type":"NDC"}],"standard_charges":[{"gross_charge":43446.01,"discounted_cash":23895.31,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Infliximab-abda For IV Inj 100 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"156995","type":"CDM"},{"code":"78206016201","type":"NDC"}],"standard_charges":[{"gross_charge":1390.61,"discounted_cash":764.84,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Sotalol HCl Tab 120 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"15723","type":"CDM"},{"code":"69584084210","type":"NDC"}],"standard_charges":[{"gross_charge":20.05,"discounted_cash":11.03,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Calcitonin (Salmon) Nasal Soln 200 Unit/ACT","drug_information":{"unit":3.7,"type":"ML"},"code_information":[{"code":"15738","type":"CDM"},{"code":"60505082306","type":"NDC"}],"standard_charges":[{"gross_charge":277.79,"discounted_cash":152.78,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Bicalutamide Tab 50 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"15746","type":"CDM"},{"code":"47335048583","type":"NDC"}],"standard_charges":[{"gross_charge":58.97,"discounted_cash":32.43,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Carvedilol Tab 12.5 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"15749","type":"CDM"},{"code":"68382009401","type":"NDC"}],"standard_charges":[{"gross_charge":16.23,"discounted_cash":8.93,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Epinephrine Soln Prefilled Syringe 1 MG/10ML (0.1 MG/ML)","drug_information":{"unit":10.0,"type":"ML"},"code_information":[{"code":"157705","type":"CDM"},{"code":"76329331601","type":"NDC"}],"standard_charges":[{"gross_charge":76.51,"discounted_cash":42.08,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Azithromycin For Susp 200 MG/5ML","drug_information":{"unit":15.0,"type":"ML"},"code_information":[{"code":"15797","type":"CDM"},{"code":"42806014932","type":"NDC"}],"standard_charges":[{"gross_charge":64.33,"discounted_cash":35.38,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Dextromethorphan-Guaifenesin Syrup 10-100 MG/5ML","drug_information":{"unit":5.0,"type":"ML"},"code_information":[{"code":"15816","type":"CDM"},{"code":"121127600","type":"NDC"}],"standard_charges":[{"gross_charge":4.39,"discounted_cash":2.41,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Dextromethorphan-Guaifenesin Syrup 10-100 MG/5ML","drug_information":{"unit":5.0,"type":"ML"},"code_information":[{"code":"15816","type":"CDM"},{"code":"121127610","type":"NDC"}],"standard_charges":[{"gross_charge":4.39,"discounted_cash":2.41,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Zoster Vac Recombinant Adjuvanted for IM Inj 50 MCG/0.5ML","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"158279","type":"CDM"},{"code":"58160082311","type":"NDC"}],"standard_charges":[{"gross_charge":487.07,"discounted_cash":267.89,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Zoster Vac Recombinant Adjuvanted for IM Inj 50 MCG/0.5ML","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"158279","type":"CDM"},{"code":"58160081912","type":"NDC"}],"standard_charges":[{"gross_charge":487.07,"discounted_cash":267.89,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Morphine Sulfate Inj PF 1 MG/ML","drug_information":{"unit":10.0,"type":"ML"},"code_information":[{"code":"15852","type":"CDM"},{"code":"641601910","type":"NDC"}],"standard_charges":[{"gross_charge":164.79,"discounted_cash":90.63,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Nitroglycerin IV Soln 200 MCG/ML in D5W","drug_information":{"unit":250.0,"type":"ML"},"code_information":[{"code":"15859","type":"CDM"},{"code":"338104902","type":"NDC"}],"standard_charges":[{"gross_charge":151.15,"discounted_cash":83.13,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Dextrose 5% w/ Sodium Chloride 0.45%","drug_information":{"unit":1000.0,"type":"ML"},"code_information":[{"code":"15861","type":"CDM"},{"code":"264761200","type":"NDC"}],"standard_charges":[{"gross_charge":21.1,"discounted_cash":11.60,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Dextrose 5% w/ Sodium Chloride 0.2%","drug_information":{"unit":1000.0,"type":"ML"},"code_information":[{"code":"15863","type":"CDM"},{"code":"264761600","type":"NDC"}],"standard_charges":[{"gross_charge":23.9,"discounted_cash":13.14,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Dextrose 10% w/ Sodium Chloride 0.2%","drug_information":{"unit":250.0,"type":"ML"},"code_information":[{"code":"15865","type":"CDM"},{"code":"264762320","type":"NDC"}],"standard_charges":[{"gross_charge":66.27,"discounted_cash":36.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Lamivudine Tab 150 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"15880","type":"CDM"},{"code":"64380071003","type":"NDC"}],"standard_charges":[{"gross_charge":31.6,"discounted_cash":17.38,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Lamivudine Oral Soln 10 MG/ML","drug_information":{"unit":240.0,"type":"ML"},"code_information":[{"code":"15881","type":"CDM"},{"code":"57237027424","type":"NDC"}],"standard_charges":[{"gross_charge":540.93,"discounted_cash":297.51,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Dextrose 5% w/ Sodium Chloride 0.9%","drug_information":{"unit":1000.0,"type":"ML"},"code_information":[{"code":"15882","type":"CDM"},{"code":"264761000","type":"NDC"}],"standard_charges":[{"gross_charge":22.5,"discounted_cash":12.38,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Acarbose Tab 50 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"15895","type":"CDM"},{"code":"64380075906","type":"NDC"}],"standard_charges":[{"gross_charge":12.31,"discounted_cash":6.77,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Alpha1-Proteinase Inhibitor (Human) Inj 1000 MG/20ML","drug_information":{"unit":1000.0,"type":"ME"},"code_information":[{"code":"158982","type":"CDM"},{"code":"13533070501","type":"NDC"}],"standard_charges":[{"gross_charge":3235.0,"discounted_cash":1779.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Gentamicin in Saline Inj 2 MG/ML","drug_information":{"unit":50.0,"type":"ML"},"code_information":[{"code":"15912","type":"CDM"},{"code":"338051141","type":"NDC"}],"standard_charges":[{"gross_charge":70.25,"discounted_cash":38.64,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Bictegravir-Emtricitabine-Tenofovir AF Tab 50-200-25 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"159339","type":"CDM"},{"code":"61958250103","type":"NDC"}],"standard_charges":[{"gross_charge":294.69,"discounted_cash":162.08,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Dobutamine in Dextrose 5% Inj 4 MG/ML","drug_information":{"unit":250.0,"type":"ML"},"code_information":[{"code":"15982","type":"CDM"},{"code":"338107702","type":"NDC"}],"standard_charges":[{"gross_charge":186.75,"discounted_cash":102.71,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Bivalirudin Trifluoroacetate For IV Soln 250 MG (Base Equiv)","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"159897","type":"CDM"},{"code":"72572003510","type":"NDC"}],"standard_charges":[{"gross_charge":218.74,"discounted_cash":120.31,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Methadone HCl Conc 10 MG/ML","drug_information":{"unit":0.5,"type":"ML"},"code_information":[{"code":"15996","type":"CDM"},{"code":"527192736","type":"NDC"}],"standard_charges":[{"gross_charge":9.88,"discounted_cash":5.43,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Nafcillin Sodium For IV Soln 10 GM","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"160080","type":"CDM"},{"code":"55150012499","type":"NDC"}],"standard_charges":[{"gross_charge":183.4,"discounted_cash":100.87,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Talc Intrapleural Powder 4 GM","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"160479","type":"CDM"},{"code":"62327044444","type":"NDC"}],"standard_charges":[{"gross_charge":415.82,"discounted_cash":228.70,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Talc Intrapleural Powder 4 GM","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"160479","type":"CDM"},{"code":"62327044404","type":"NDC"}],"standard_charges":[{"gross_charge":415.82,"discounted_cash":228.70,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Desmopressin Acetate Tab 0.1 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"16052","type":"CDM"},{"code":"23155048901","type":"NDC"}],"standard_charges":[{"gross_charge":25.44,"discounted_cash":13.99,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Desmopressin Acetate Tab 0.2 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"16053","type":"CDM"},{"code":"16714088401","type":"NDC"}],"standard_charges":[{"gross_charge":26.46,"discounted_cash":14.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Baclofen Tab 5 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"160636","type":"CDM"},{"code":"70710160901","type":"NDC"}],"standard_charges":[{"gross_charge":12.76,"discounted_cash":7.02,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Epoetin Alfa-epbx Inj 4000 Unit/ML","drug_information":{"unit":1.0,"type":"ML"},"code_information":[{"code":"160704","type":"CDM"},{"code":"69130701","type":"NDC"}],"standard_charges":[{"gross_charge":134.24,"discounted_cash":73.83,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Epoetin Alfa-epbx Inj 10000 Unit/ML","drug_information":{"unit":1.0,"type":"ML"},"code_information":[{"code":"160705","type":"CDM"},{"code":"69130810","type":"NDC"}],"standard_charges":[{"gross_charge":289.1,"discounted_cash":159.00,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Baricitinib Tab 2 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"161090","type":"CDM"},{"code":"2418230","type":"NDC"}],"standard_charges":[{"gross_charge":223.86,"discounted_cash":123.12,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Pegfilgrastim-jmdb Soln Prefilled Syringe 6 MG/0.6ML","drug_information":{"unit":0.6,"type":"ML"},"code_information":[{"code":"161758","type":"CDM"},{"code":"83257000541","type":"NDC"}],"standard_charges":[{"gross_charge":3663.25,"discounted_cash":2014.79,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Anastrozole Tab 1 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"16205","type":"CDM"},{"code":"16729003510","type":"NDC"}],"standard_charges":[{"gross_charge":44.59,"discounted_cash":24.52,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Sodium Zirconium Cyclosilicate For Susp Packet 10 GM","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"162118","type":"CDM"},{"code":"310111001","type":"NDC"}],"standard_charges":[{"gross_charge":83.81,"discounted_cash":46.10,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Sodium Zirconium Cyclosilicate For Susp Packet 10 GM","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"162118","type":"CDM"},{"code":"310111039","type":"NDC"}],"standard_charges":[{"gross_charge":83.81,"discounted_cash":46.10,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Chlordiazepoxide HCl Cap 25 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"1623","type":"CDM"},{"code":"555015902","type":"NDC"}],"standard_charges":[{"gross_charge":9.9,"discounted_cash":5.44,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Chlordiazepoxide HCl Cap 5 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"1624","type":"CDM"},{"code":"555015802","type":"NDC"}],"standard_charges":[{"gross_charge":9.57,"discounted_cash":5.26,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Clonidine TD Patch Weekly 0.1 MG/24HR","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"162585","type":"CDM"},{"code":"378087199","type":"NDC"}],"standard_charges":[{"gross_charge":80.87,"discounted_cash":44.48,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Measles-Mumps-Rubella-Varicella Virus Vaccines For Susp","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"162588","type":"CDM"},{"code":"6417100","type":"NDC"}],"standard_charges":[{"gross_charge":475.64,"discounted_cash":261.60,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Measles-Mumps-Rubella-Varicella Virus Vaccines For Susp","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"162588","type":"CDM"},{"code":"6417101","type":"NDC"}],"standard_charges":[{"gross_charge":475.64,"discounted_cash":261.60,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Vancomycin HCl For IV Soln 1 GM (Base Equivalent)","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"162589","type":"CDM"},{"code":"71288002321","type":"NDC"}],"standard_charges":[{"gross_charge":25.58,"discounted_cash":14.07,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Vancomycin HCl For IV Soln 1 GM (Base Equivalent)","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"162589","type":"CDM"},{"code":"409653359","type":"NDC"}],"standard_charges":[{"gross_charge":20.04,"discounted_cash":11.02,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Vancomycin HCl For IV Soln 1 GM (Base Equivalent)","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"162589","type":"CDM"},{"code":"71288002320","type":"NDC"}],"standard_charges":[{"gross_charge":25.58,"discounted_cash":14.07,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Vancomycin HCl For IV Soln 1 GM (Base Equivalent)","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"162589","type":"CDM"},{"code":"409653321","type":"NDC"}],"standard_charges":[{"gross_charge":42.85,"discounted_cash":23.57,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Vancomycin HCl For IV Soln 5 GM (Base Equivalent)","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"162590","type":"CDM"},{"code":"72572080301","type":"NDC"}],"standard_charges":[{"gross_charge":85.23,"discounted_cash":46.88,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Na Nitrite Inj 300 MG/10ML &Na Thiosulf Inj 12.5 GM/50ML Kit","drug_information":{"unit":60.0,"type":"ML"},"code_information":[{"code":"162717","type":"CDM"},{"code":"60267081200","type":"NDC"}],"standard_charges":[{"gross_charge":935.83,"discounted_cash":514.71,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Rivaroxaban Tab 2.5 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"162859","type":"CDM"},{"code":"50458057760","type":"NDC"}],"standard_charges":[{"gross_charge":40.89,"discounted_cash":22.49,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Omalizumab Subcutaneous Soln Prefilled Syringe 150 MG/ML","drug_information":{"unit":1.0,"type":"ML"},"code_information":[{"code":"163276","type":"CDM"},{"code":"50242021503","type":"NDC"}],"standard_charges":[{"gross_charge":2593.6,"discounted_cash":1426.48,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Tbo-Filgrastim Subcutaneous Inj 480 MCG/1.6ML (300 MCG/ML)","drug_information":{"unit":1.6,"type":"ML"},"code_information":[{"code":"163284","type":"CDM"},{"code":"63459092053","type":"NDC"}],"standard_charges":[{"gross_charge":846.77,"discounted_cash":465.72,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Glimepiride Tab 1 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"16355","type":"CDM"},{"code":"50268035815","type":"NDC"}],"standard_charges":[{"gross_charge":11.88,"discounted_cash":6.53,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Glimepiride Tab 1 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"16355","type":"CDM"},{"code":"50268035811","type":"NDC"}],"standard_charges":[{"gross_charge":11.88,"discounted_cash":6.53,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Pegfilgrastim-cbqv Soln Prefilled Syringe 6 MG/0.6ML","drug_information":{"unit":0.6,"type":"ML"},"code_information":[{"code":"163616","type":"CDM"},{"code":"70114010101","type":"NDC"}],"standard_charges":[{"gross_charge":7295.5,"discounted_cash":4012.52,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Vancomycin HCl For IV Soln 1.5 GM (Base Equivalent)","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"163679","type":"CDM"},{"code":"409351501","type":"NDC"}],"standard_charges":[{"gross_charge":95.29,"discounted_cash":52.41,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Cefepime HCl For Inj 1 GM","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"16369","type":"CDM"},{"code":"60505614600","type":"NDC"}],"standard_charges":[{"gross_charge":43.96,"discounted_cash":24.18,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Cefepime HCl For Inj 1 GM","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"16369","type":"CDM"},{"code":"60505614604","type":"NDC"}],"standard_charges":[{"gross_charge":43.97,"discounted_cash":24.18,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Cefepime HCl For IV Soln 2 GM","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"16371","type":"CDM"},{"code":"60505614704","type":"NDC"}],"standard_charges":[{"gross_charge":72.0,"discounted_cash":39.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Calcium Gluconate-NaCl IV Soln 1 GM/50ML-0.675% (20 MG/ML)","drug_information":{"unit":50.0,"type":"ML"},"code_information":[{"code":"163938","type":"CDM"},{"code":"44567062001","type":"NDC"}],"standard_charges":[{"gross_charge":136.47,"discounted_cash":75.06,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Calcium Gluconate-NaCl IV Soln 1 GM/50ML-0.675% (20 MG/ML)","drug_information":{"unit":50.0,"type":"ML"},"code_information":[{"code":"163938","type":"CDM"},{"code":"44567062024","type":"NDC"}],"standard_charges":[{"gross_charge":136.47,"discounted_cash":75.06,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Dehydrated Alcohol Intra-arterial Soln","drug_information":{"unit":1.0,"type":"ML"},"code_information":[{"code":"164289","type":"CDM"},{"code":"54288010515","type":"NDC"}],"standard_charges":[{"gross_charge":370.83,"discounted_cash":203.96,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Denosumab Inj Soln Prefilled Syringe 60 MG/ML","drug_information":{"unit":1.0,"type":"ML"},"code_information":[{"code":"164547","type":"CDM"},{"code":"55513071021","type":"NDC"}],"standard_charges":[{"gross_charge":3166.23,"discounted_cash":1741.43,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Denosumab Inj Soln Prefilled Syringe 60 MG/ML","drug_information":{"unit":1.0,"type":"ML"},"code_information":[{"code":"164547","type":"CDM"},{"code":"55513071001","type":"NDC"}],"standard_charges":[{"gross_charge":3166.23,"discounted_cash":1741.43,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Lidocaine HCl Urethral/Mucosal Gel 2%","drug_information":{"unit":6.0,"type":"ML"},"code_information":[{"code":"164556","type":"CDM"},{"code":"25021067376","type":"NDC"}],"standard_charges":[{"gross_charge":63.06,"discounted_cash":34.68,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Lidocaine HCl Urethral/Mucosal Gel 2%","drug_information":{"unit":5.0,"type":"ML"},"code_information":[{"code":"164556","type":"CDM"},{"code":"17478071110","type":"NDC"}],"standard_charges":[{"gross_charge":68.1,"discounted_cash":37.46,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Lidocaine HCl Urethral/Mucosal Gel 2%","drug_information":{"unit":30.0,"type":"ML"},"code_information":[{"code":"164556","type":"CDM"},{"code":"17478071130","type":"NDC"}],"standard_charges":[{"gross_charge":547.86,"discounted_cash":301.32,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Morphine Sulf For Microinfusion PF Inj 500 MG/20ML (25MG/ML)","drug_information":{"unit":20.0,"type":"ML"},"code_information":[{"code":"164697","type":"CDM"},{"code":"641604001","type":"NDC"}],"standard_charges":[{"gross_charge":1198.05,"discounted_cash":658.93,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Romosozumab-aqqg Inj Soln Prefilled Syringe 105 MG/1.17ML","drug_information":{"unit":2.34,"type":"ML"},"code_information":[{"code":"165123","type":"CDM"},{"code":"55513099802","type":"NDC"}],"standard_charges":[{"gross_charge":4605.31,"discounted_cash":2532.92,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Romosozumab-aqqg Inj Soln Prefilled Syringe 105 MG/1.17ML","drug_information":{"unit":2.34,"type":"ML"},"code_information":[{"code":"165123","type":"CDM"},{"code":"55513099801","type":"NDC"}],"standard_charges":[{"gross_charge":4605.31,"discounted_cash":2532.92,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Romosozumab-aqqg Inj Soln Prefilled Syringe 105 MG/1.17ML","drug_information":{"unit":2.34,"type":"ML"},"code_information":[{"code":"165123","type":"CDM"},{"code":"55513088002","type":"NDC"}],"standard_charges":[{"gross_charge":4605.31,"discounted_cash":2532.92,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Romosozumab-aqqg Inj Soln Prefilled Syringe 105 MG/1.17ML","drug_information":{"unit":2.34,"type":"ML"},"code_information":[{"code":"165123","type":"CDM"},{"code":"55513088001","type":"NDC"}],"standard_charges":[{"gross_charge":4605.31,"discounted_cash":2532.92,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Levothyroxine Sodium IV Soln 100 MCG/5ML (20 MCG/ML)","drug_information":{"unit":1.25,"type":"ML"},"code_information":[{"code":"165379","type":"CDM"},{"code":"63323088510","type":"NDC"}],"standard_charges":[{"gross_charge":104.17,"discounted_cash":57.29,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Chlorpromazine HCl Tab 25 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"1656","type":"CDM"},{"code":"50268016311","type":"NDC"}],"standard_charges":[{"gross_charge":32.7,"discounted_cash":17.98,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Chlorthalidone Tab 25 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"1661","type":"CDM"},{"code":"50268016711","type":"NDC"}],"standard_charges":[{"gross_charge":16.84,"discounted_cash":9.26,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Chlorthalidone Tab 25 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"1661","type":"CDM"},{"code":"50268016715","type":"NDC"}],"standard_charges":[{"gross_charge":16.84,"discounted_cash":9.26,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Calcium Gluconate-NaCl IV Soln 2 GM/100ML-0.675% (20 MG/ML)","drug_information":{"unit":100.0,"type":"ML"},"code_information":[{"code":"166109","type":"CDM"},{"code":"44567062101","type":"NDC"}],"standard_charges":[{"gross_charge":241.93,"discounted_cash":133.06,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Calcium Gluconate-NaCl IV Soln 2 GM/100ML-0.675% (20 MG/ML)","drug_information":{"unit":100.0,"type":"ML"},"code_information":[{"code":"166109","type":"CDM"},{"code":"44567062124","type":"NDC"}],"standard_charges":[{"gross_charge":241.93,"discounted_cash":133.06,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Paroxetine HCl Tab 10 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"16632","type":"CDM"},{"code":"13107015430","type":"NDC"}],"standard_charges":[{"gross_charge":18.08,"discounted_cash":9.94,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Tranexamic Acid-Sodium Chloride IV Soln 1000 MG/100ML-0.7%","drug_information":{"unit":100.0,"type":"ML"},"code_information":[{"code":"166480","type":"CDM"},{"code":"25021041882","type":"NDC"}],"standard_charges":[{"gross_charge":157.47,"discounted_cash":86.61,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Sodium Chloride Preservative Free (PF) Inj 0.9%","drug_information":{"unit":2.5,"type":"ML"},"code_information":[{"code":"166691","type":"CDM"},{"code":"409488806","type":"NDC"}],"standard_charges":[{"gross_charge":31.95,"discounted_cash":17.57,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Sodium Chloride Preservative Free (PF) Inj 0.9%","drug_information":{"unit":2.5,"type":"ML"},"code_information":[{"code":"166691","type":"CDM"},{"code":"63323018601","type":"NDC"}],"standard_charges":[{"gross_charge":32.55,"discounted_cash":17.90,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Sodium Chloride Preservative Free (PF) Inj 0.9%","drug_information":{"unit":2.5,"type":"ML"},"code_information":[{"code":"166691","type":"CDM"},{"code":"409488820","type":"NDC"}],"standard_charges":[{"gross_charge":32.6,"discounted_cash":17.93,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Sodium Chloride Preservative Free (PF) Inj 0.9%","drug_information":{"unit":2.5,"type":"ML"},"code_information":[{"code":"166691","type":"CDM"},{"code":"63323018610","type":"NDC"}],"standard_charges":[{"gross_charge":32.55,"discounted_cash":17.90,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Lidocaine HCl Urethral/Mucosal Gel Prefilled Syringe 2%","drug_information":{"unit":10.0,"type":"ML"},"code_information":[{"code":"166883","type":"CDM"},{"code":"76329301305","type":"NDC"}],"standard_charges":[{"gross_charge":68.6,"discounted_cash":37.73,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Rituximab-abbs IV Soln 500 MG/50ML (10 MG/ML)","drug_information":{"unit":50.0,"type":"ML"},"code_information":[{"code":"167592","type":"CDM"},{"code":"63459010450","type":"NDC"}],"standard_charges":[{"gross_charge":9942.94,"discounted_cash":5468.62,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Pegfilgrastim-bmez Soln Prefilled Syringe 6 MG/0.6ML","drug_information":{"unit":0.6,"type":"ML"},"code_information":[{"code":"167611","type":"CDM"},{"code":"61314086601","type":"NDC"}],"standard_charges":[{"gross_charge":6861.43,"discounted_cash":3773.79,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Insulin Aspart Soln Pen-injector 100 Unit/ML","drug_information":{"unit":3.0,"type":"ML"},"code_information":[{"code":"168031","type":"CDM"},{"code":"73070010310","type":"NDC"}],"standard_charges":[{"gross_charge":123.21,"discounted_cash":67.77,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Anticoagulant Citrate Dextrose Solution A","drug_information":{"unit":1000.0,"type":"ML"},"code_information":[{"code":"16825","type":"CDM"},{"code":"942064104","type":"NDC"}],"standard_charges":[{"gross_charge":84.4,"discounted_cash":46.42,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Melatonin Tab 3 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"16830","type":"CDM"},{"code":"20555003600","type":"NDC"}],"standard_charges":[{"gross_charge":8.76,"discounted_cash":4.82,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Cefiderocol Sulfate Tosylate For IV Soln 1 GM","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"168666","type":"CDM"},{"code":"59630026610","type":"NDC"}],"standard_charges":[{"gross_charge":505.99,"discounted_cash":278.29,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Eptinezumab-jjmr IV Soln 100 MG/ML","drug_information":{"unit":1.0,"type":"ML"},"code_information":[{"code":"168851","type":"CDM"},{"code":"67386013051","type":"NDC"}],"standard_charges":[{"gross_charge":3406.72,"discounted_cash":1873.70,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Trastuzumab-pkrb For IV Soln 150 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"169114","type":"CDM"},{"code":"63459030343","type":"NDC"}],"standard_charges":[{"gross_charge":2013.35,"discounted_cash":1107.34,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Sodium Hypochlorite Soln 0.125%","drug_information":{"unit":473.0,"type":"ML"},"code_information":[{"code":"169118","type":"CDM"},{"code":"436067216","type":"NDC"}],"standard_charges":[{"gross_charge":78.04,"discounted_cash":42.92,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Sodium Hypochlorite Soln 0.25%","drug_information":{"unit":473.0,"type":"ML"},"code_information":[{"code":"169119","type":"CDM"},{"code":"39328006325","type":"NDC"}],"standard_charges":[{"gross_charge":99.09,"discounted_cash":54.50,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Hepatitis A Vaccine Inj Susp 50 Unit/ML","drug_information":{"unit":1.0,"type":"ML"},"code_information":[{"code":"16967","type":"CDM"},{"code":"6409601","type":"NDC"}],"standard_charges":[{"gross_charge":235.16,"discounted_cash":129.34,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Hepatitis A Vaccine Inj Susp 50 Unit/ML","drug_information":{"unit":1.0,"type":"ML"},"code_information":[{"code":"16967","type":"CDM"},{"code":"6409602","type":"NDC"}],"standard_charges":[{"gross_charge":235.16,"discounted_cash":129.34,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Remdesivir for IV Soln 100 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"169692","type":"CDM"},{"code":"61958290102","type":"NDC"}],"standard_charges":[{"gross_charge":1163.25,"discounted_cash":639.79,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Nicardipine HCl IV Soln 20 MG/200ML in Sodium Chloride 0.9%","drug_information":{"unit":200.0,"type":"ML"},"code_information":[{"code":"169718","type":"CDM"},{"code":"143963410","type":"NDC"}],"standard_charges":[{"gross_charge":465.32,"discounted_cash":255.93,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Nicardipine HCl IV Soln 20 MG/200ML in Sodium Chloride 0.9%","drug_information":{"unit":200.0,"type":"ML"},"code_information":[{"code":"169718","type":"CDM"},{"code":"69097000722","type":"NDC"}],"standard_charges":[{"gross_charge":298.0,"discounted_cash":163.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Nicardipine HCl IV Soln 20 MG/200ML in Sodium Chloride 0.9%","drug_information":{"unit":200.0,"type":"ML"},"code_information":[{"code":"169718","type":"CDM"},{"code":"69097000745","type":"NDC"}],"standard_charges":[{"gross_charge":298.0,"discounted_cash":163.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Nicardipine HCl IV Soln 20 MG/200ML in Sodium Chloride 0.9%","drug_information":{"unit":200.0,"type":"ML"},"code_information":[{"code":"169718","type":"CDM"},{"code":"143963401","type":"NDC"}],"standard_charges":[{"gross_charge":465.32,"discounted_cash":255.93,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Ephedrine Sulfate IV Soln 5 MG/ML","drug_information":{"unit":1.0,"type":"ML"},"code_information":[{"code":"169792","type":"CDM"},{"code":"42023024301","type":"NDC"}],"standard_charges":[{"gross_charge":44.4,"discounted_cash":24.42,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Infliximab-axxq For IV Inj 100 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"169974","type":"CDM"},{"code":"55513067001","type":"NDC"}],"standard_charges":[{"gross_charge":934.5,"discounted_cash":513.98,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Hyoscyamine Sulfate Tab ER 12HR 0.375 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"17010","type":"CDM"},{"code":"51525011501","type":"NDC"}],"standard_charges":[{"gross_charge":12.4,"discounted_cash":6.82,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Hyoscyamine Sulfate SL Tab 0.125 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"17023","type":"CDM"},{"code":"63629103101","type":"NDC"}],"standard_charges":[{"gross_charge":10.54,"discounted_cash":5.80,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Epinephrine Soln Prefilled Syringe 0.1 MG/10ML (10 MCG/ML)","drug_information":{"unit":10.0,"type":"ML"},"code_information":[{"code":"170778","type":"CDM"},{"code":"69374054410","type":"NDC"}],"standard_charges":[{"gross_charge":55.03,"discounted_cash":30.27,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Trace Min (Cu-Mn-Se-Zn) Inj 300-55-60-3000 MCG/ML","drug_information":{"unit":1.0,"type":"ML"},"code_information":[{"code":"171064","type":"CDM"},{"code":"517930525","type":"NDC"}],"standard_charges":[{"gross_charge":105.42,"discounted_cash":57.98,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Trace Min (Cu-Mn-Se-Zn) Inj 300-55-60-3000 MCG/ML","drug_information":{"unit":1.0,"type":"ML"},"code_information":[{"code":"171064","type":"CDM"},{"code":"517930501","type":"NDC"}],"standard_charges":[{"gross_charge":105.43,"discounted_cash":57.99,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Cyclophosphamide IV Soln 1 GM/5ML (200 MG/ML)","drug_information":{"unit":5.0,"type":"ML"},"code_information":[{"code":"171079","type":"CDM"},{"code":"55150027199","type":"NDC"}],"standard_charges":[{"gross_charge":635.0,"discounted_cash":349.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Gemcitabine HCl For Inj 1 GM","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"17122","type":"CDM"},{"code":"16714093001","type":"NDC"}],"standard_charges":[{"gross_charge":166.73,"discounted_cash":91.70,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Tropicamide-Cyclopent-PE-Ketor-Propar Ophth Sol Pref Syr","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"171407","type":"CDM"},{"code":"71226822101","type":"NDC"}],"standard_charges":[{"gross_charge":51.93,"discounted_cash":28.56,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Pegfilgrastim-apgf Soln Prefilled Syringe 6 MG/0.6ML","drug_information":{"unit":0.6,"type":"ML"},"code_information":[{"code":"172756","type":"CDM"},{"code":"69032401","type":"NDC"}],"standard_charges":[{"gross_charge":6860.5,"discounted_cash":3773.28,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Meropenem IV For Soln 500 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"17379","type":"CDM"},{"code":"63323050720","type":"NDC"}],"standard_charges":[{"gross_charge":44.86,"discounted_cash":24.67,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Meropenem IV For Soln 1 GM","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"17380","type":"CDM"},{"code":"63323050845","type":"NDC"}],"standard_charges":[{"gross_charge":13.2,"discounted_cash":7.26,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Meropenem IV For Soln 1 GM","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"17380","type":"CDM"},{"code":"63323050830","type":"NDC"}],"standard_charges":[{"gross_charge":13.2,"discounted_cash":7.26,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Epinephrine-Dextrose IV Soln Pref Syr 100 MCG/10ML-5%","drug_information":{"unit":10.0,"type":"ML"},"code_information":[{"code":"173904","type":"CDM"},{"code":"70092168846","type":"NDC"}],"standard_charges":[{"gross_charge":74.2,"discounted_cash":40.81,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Clindamycin HCl Cap 150 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"1740","type":"CDM"},{"code":"904595961","type":"NDC"}],"standard_charges":[{"gross_charge":11.25,"discounted_cash":6.19,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Clindamycin HCl Cap 150 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"1740","type":"CDM"},{"code":"63304069201","type":"NDC"}],"standard_charges":[{"gross_charge":12.59,"discounted_cash":6.92,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Sevelamer Carbonate Tab 800 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"174129","type":"CDM"},{"code":"50268072015","type":"NDC"}],"standard_charges":[{"gross_charge":37.36,"discounted_cash":20.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Sevelamer Carbonate Tab 800 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"174129","type":"CDM"},{"code":"50268072011","type":"NDC"}],"standard_charges":[{"gross_charge":37.36,"discounted_cash":20.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Mirtazapine Tab 15 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"17466","type":"CDM"},{"code":"68084011911","type":"NDC"}],"standard_charges":[{"gross_charge":12.0,"discounted_cash":6.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Mirtazapine Tab 15 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"17466","type":"CDM"},{"code":"68084011901","type":"NDC"}],"standard_charges":[{"gross_charge":12.02,"discounted_cash":6.61,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Lisdexamfetamine Dimesylate Cap 20 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"175233","type":"CDM"},{"code":"527466237","type":"NDC"}],"standard_charges":[{"gross_charge":44.52,"discounted_cash":24.49,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Clomipramine HCl Cap 50 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"1754","type":"CDM"},{"code":"42571034330","type":"NDC"}],"standard_charges":[{"gross_charge":38.92,"discounted_cash":21.41,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Clomipramine HCl Cap 50 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"1754","type":"CDM"},{"code":"42571034301","type":"NDC"}],"standard_charges":[{"gross_charge":38.92,"discounted_cash":21.41,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Clonidine HCl Tab 0.1 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"1755","type":"CDM"},{"code":"60687011301","type":"NDC"}],"standard_charges":[{"gross_charge":9.62,"discounted_cash":5.29,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Clonidine HCl Tab 0.1 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"1755","type":"CDM"},{"code":"60687011311","type":"NDC"}],"standard_charges":[{"gross_charge":9.65,"discounted_cash":5.31,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Diclofenac Sodium Gel 1% (1.16% Diethylamine Equiv)","drug_information":{"unit":100.0,"type":"GM"},"code_information":[{"code":"175562","type":"CDM"},{"code":"69097072044","type":"NDC"}],"standard_charges":[{"gross_charge":97.1,"discounted_cash":53.40,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Diclofenac Sodium Gel 1% (1.16% Diethylamine Equiv)","drug_information":{"unit":50.0,"type":"GM"},"code_information":[{"code":"175562","type":"CDM"},{"code":"70000055501","type":"NDC"}],"standard_charges":[{"gross_charge":61.5,"discounted_cash":33.82,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Hepatitis A Vaccine Inj Susp 720 EL Unit/0.5ML","drug_information":{"unit":0.5,"type":"ML"},"code_information":[{"code":"175568","type":"CDM"},{"code":"58160082552","type":"NDC"}],"standard_charges":[{"gross_charge":122.26,"discounted_cash":67.24,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Hepatitis A Vaccine Inj Susp 1440 EL Unit/ML","drug_information":{"unit":1.0,"type":"ML"},"code_information":[{"code":"175569","type":"CDM"},{"code":"58160082643","type":"NDC"}],"standard_charges":[{"gross_charge":240.96,"discounted_cash":132.53,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Hepatitis A Vaccine Inj Susp 1440 EL Unit/ML","drug_information":{"unit":1.0,"type":"ML"},"code_information":[{"code":"175569","type":"CDM"},{"code":"58160082652","type":"NDC"}],"standard_charges":[{"gross_charge":240.96,"discounted_cash":132.53,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Hepatitis A Vaccine Inj Susp 25 Unit/0.5ML","drug_information":{"unit":0.5,"type":"ML"},"code_information":[{"code":"175578","type":"CDM"},{"code":"6483101","type":"NDC"}],"standard_charges":[{"gross_charge":154.09,"discounted_cash":84.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Hepatitis A Vaccine Inj Susp 25 Unit/0.5ML","drug_information":{"unit":0.5,"type":"ML"},"code_information":[{"code":"175578","type":"CDM"},{"code":"6483141","type":"NDC"}],"standard_charges":[{"gross_charge":154.09,"discounted_cash":84.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Ciprofloxacin 200 MG/100ML in D5W","drug_information":{"unit":100.0,"type":"ML"},"code_information":[{"code":"175759","type":"CDM"},{"code":"25021019282","type":"NDC"}],"standard_charges":[{"gross_charge":47.02,"discounted_cash":25.86,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Ciprofloxacin 400 MG/200ML in D5W","drug_information":{"unit":200.0,"type":"ML"},"code_information":[{"code":"175760","type":"CDM"},{"code":"25021011487","type":"NDC"}],"standard_charges":[{"gross_charge":68.38,"discounted_cash":37.61,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Ciprofloxacin 400 MG/200ML in D5W","drug_information":{"unit":200.0,"type":"ML"},"code_information":[{"code":"175760","type":"CDM"},{"code":"25021019287","type":"NDC"}],"standard_charges":[{"gross_charge":68.38,"discounted_cash":37.61,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Clorazepate Dipotassium Tab 3.75 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"1759","type":"CDM"},{"code":"60505475401","type":"NDC"}],"standard_charges":[{"gross_charge":23.53,"discounted_cash":12.94,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Clotrimazole Cream 1%","drug_information":{"unit":30.0,"type":"GM"},"code_information":[{"code":"1767","type":"CDM"},{"code":"45802043411","type":"NDC"}],"standard_charges":[{"gross_charge":55.18,"discounted_cash":30.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Clotrimazole Cream 1%","drug_information":{"unit":30.0,"type":"GM"},"code_information":[{"code":"1767","type":"CDM"},{"code":"51672200202","type":"NDC"}],"standard_charges":[{"gross_charge":65.99,"discounted_cash":36.29,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Piflufolastat F 18 IV Solution Prefilled Syringe 9 mCi","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"176839","type":"CDM"},{"code":"71258002200","type":"NDC"}],"standard_charges":[{"gross_charge":7506.88,"discounted_cash":4128.78,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Pneumococcal 20-Valent Conjugate Vaccine Sus Pref Syr 0.5 ML","drug_information":{"unit":0.5,"type":"ML"},"code_information":[{"code":"177391","type":"CDM"},{"code":"5200010","type":"NDC"}],"standard_charges":[{"gross_charge":452.65,"discounted_cash":248.96,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Gadopiclenol IV Soln 0.5 MMOL/ML","drug_information":{"unit":7.5,"type":"ML"},"code_information":[{"code":"177790","type":"CDM"},{"code":"270702540","type":"NDC"}],"standard_charges":[{"gross_charge":308.53,"discounted_cash":169.69,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Gadopiclenol IV Soln 0.5 MMOL/ML","drug_information":{"unit":3.0,"type":"ML"},"code_information":[{"code":"177790","type":"CDM"},{"code":"270702038","type":"NDC"}],"standard_charges":[{"gross_charge":142.86,"discounted_cash":78.57,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Gadopiclenol IV Soln 0.5 MMOL/ML","drug_information":{"unit":30.0,"type":"ML"},"code_information":[{"code":"177790","type":"CDM"},{"code":"270701546","type":"NDC"}],"standard_charges":[{"gross_charge":1136.09,"discounted_cash":624.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Gadopiclenol IV Soln 0.5 MMOL/ML","drug_information":{"unit":10.0,"type":"ML"},"code_information":[{"code":"177790","type":"CDM"},{"code":"270703042","type":"NDC"}],"standard_charges":[{"gross_charge":399.39,"discounted_cash":219.66,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Ethiodized Inj Oil 480 MG/ML (Iodine Equivalent)","drug_information":{"unit":10.0,"type":"ML"},"code_information":[{"code":"178234","type":"CDM"},{"code":"67684190102","type":"NDC"}],"standard_charges":[{"gross_charge":2895.16,"discounted_cash":1592.34,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Hepatitis B Immune Globulin (Human) IM Soln 312 Unit/ML","drug_information":{"unit":0.5,"type":"ML"},"code_information":[{"code":"178258","type":"CDM"},{"code":"59730420201","type":"NDC"}],"standard_charges":[{"gross_charge":196.26,"discounted_cash":107.94,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Albuterol Sulfate Inhal Aero 108 MCG/ACT (90MCG Base Equiv)","drug_information":{"unit":6.7,"type":"GM"},"code_information":[{"code":"17837","type":"CDM"},{"code":"69097014260","type":"NDC"}],"standard_charges":[{"gross_charge":119.13,"discounted_cash":65.52,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Albuterol Sulfate Inhal Aero 108 MCG/ACT (90MCG Base Equiv)","drug_information":{"unit":8.5,"type":"GM"},"code_information":[{"code":"17837","type":"CDM"},{"code":"93317431","type":"NDC"}],"standard_charges":[{"gross_charge":119.13,"discounted_cash":65.52,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Albuterol Sulfate Inhal Aero 108 MCG/ACT (90MCG Base Equiv)","drug_information":{"unit":8.0,"type":"GM"},"code_information":[{"code":"17837","type":"CDM"},{"code":"173068224","type":"NDC"}],"standard_charges":[{"gross_charge":53.67,"discounted_cash":29.52,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Albuterol Sulfate Inhal Aero 108 MCG/ACT (90MCG Base Equiv)","drug_information":{"unit":6.7,"type":"GM"},"code_information":[{"code":"17837","type":"CDM"},{"code":"54074287","type":"NDC"}],"standard_charges":[{"gross_charge":142.76,"discounted_cash":78.52,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Alcohol Nasal Swab Kit","drug_information":{"unit":12.0,"type":"ML"},"code_information":[{"code":"178590","type":"CDM"},{"code":"56923001177","type":"NDC"}],"standard_charges":[{"gross_charge":87.88,"discounted_cash":48.33,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Brimonidine Tartrate Ophth Soln 0.2%","drug_information":{"unit":5.0,"type":"ML"},"code_information":[{"code":"17881","type":"CDM"},{"code":"70069023101","type":"NDC"}],"standard_charges":[{"gross_charge":65.13,"discounted_cash":35.82,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Olanzapine Tab 5 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"17936","type":"CDM"},{"code":"60505311100","type":"NDC"}],"standard_charges":[{"gross_charge":44.34,"discounted_cash":24.39,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Olanzapine Tab 10 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"17937","type":"CDM"},{"code":"43598016630","type":"NDC"}],"standard_charges":[{"gross_charge":62.77,"discounted_cash":34.52,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Efgartigimod alfa-fcab IV Soln 400 MG/20ML","drug_information":{"unit":20.0,"type":"ML"},"code_information":[{"code":"179501","type":"CDM"},{"code":"73475304105","type":"NDC"}],"standard_charges":[{"gross_charge":11173.69,"discounted_cash":6145.53,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Zidovudine Tab 300 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"17961","type":"CDM"},{"code":"65862002460","type":"NDC"}],"standard_charges":[{"gross_charge":27.85,"discounted_cash":15.32,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Cefazolin Sodium For Inj 2 GM","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"180185","type":"CDM"},{"code":"60505623105","type":"NDC"}],"standard_charges":[{"gross_charge":55.13,"discounted_cash":30.32,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Typhoid VI Polysaccharide Vacc IM Soln Pref Syr 25 MCG/0.5ML","drug_information":{"unit":0.5,"type":"ML"},"code_information":[{"code":"180246","type":"CDM"},{"code":"49281079051","type":"NDC"}],"standard_charges":[{"gross_charge":257.32,"discounted_cash":141.53,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Risankizumab-rzaa IV Soln 600 MG/10ML (60 MG/ML)","drug_information":{"unit":10.0,"type":"ML"},"code_information":[{"code":"181342","type":"CDM"},{"code":"74501501","type":"NDC"}],"standard_charges":[{"gross_charge":18530.71,"discounted_cash":10191.89,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Sennosides Tab 8.6 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"18138","type":"CDM"},{"code":"904725261","type":"NDC"}],"standard_charges":[{"gross_charge":8.22,"discounted_cash":4.52,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Ropivacaine HCl Inj 2 MG/ML","drug_information":{"unit":5.0,"type":"ML"},"code_information":[{"code":"18192","type":"CDM"},{"code":"70069006201","type":"NDC"}],"standard_charges":[{"gross_charge":47.35,"discounted_cash":26.04,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Ropivacaine HCl Inj 2 MG/ML","drug_information":{"unit":5.0,"type":"ML"},"code_information":[{"code":"18192","type":"CDM"},{"code":"70069006210","type":"NDC"}],"standard_charges":[{"gross_charge":47.35,"discounted_cash":26.04,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Ropivacaine HCl Inj 5 MG/ML","drug_information":{"unit":1.0,"type":"ML"},"code_information":[{"code":"18195","type":"CDM"},{"code":"72572070710","type":"NDC"}],"standard_charges":[{"gross_charge":35.27,"discounted_cash":19.40,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Ropivacaine HCl Inj 5 MG/ML","drug_information":{"unit":1.0,"type":"ML"},"code_information":[{"code":"18195","type":"CDM"},{"code":"72572070701","type":"NDC"}],"standard_charges":[{"gross_charge":35.27,"discounted_cash":19.40,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Ropivacaine HCl Inj 5 MG/ML","drug_information":{"unit":1.0,"type":"ML"},"code_information":[{"code":"18195","type":"CDM"},{"code":"63323028601","type":"NDC"}],"standard_charges":[{"gross_charge":38.63,"discounted_cash":21.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Ropivacaine HCl Inj 5 MG/ML","drug_information":{"unit":1.0,"type":"ML"},"code_information":[{"code":"18195","type":"CDM"},{"code":"63323028627","type":"NDC"}],"standard_charges":[{"gross_charge":35.57,"discounted_cash":19.56,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Ropivacaine HCl Inj 5 MG/ML","drug_information":{"unit":1.0,"type":"ML"},"code_information":[{"code":"18195","type":"CDM"},{"code":"63323028635","type":"NDC"}],"standard_charges":[{"gross_charge":38.79,"discounted_cash":21.33,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Colchicine Tab 0.6 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"1821","type":"CDM"},{"code":"904712004","type":"NDC"}],"standard_charges":[{"gross_charge":27.0,"discounted_cash":14.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Hepatitis B Vaccine (Recombinant) Susp Pref Syr 10 MCG/0.5ML","drug_information":{"unit":0.5,"type":"ML"},"code_information":[{"code":"182230","type":"CDM"},{"code":"58160082052","type":"NDC"}],"standard_charges":[{"gross_charge":69.17,"discounted_cash":38.04,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Hepatitis B Vaccine (Recombinant) Susp Pref Syr 10 MCG/0.5ML","drug_information":{"unit":0.5,"type":"ML"},"code_information":[{"code":"182230","type":"CDM"},{"code":"58160082043","type":"NDC"}],"standard_charges":[{"gross_charge":69.17,"discounted_cash":38.04,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Bisoprolol Fumarate Tab 5 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"18288","type":"CDM"},{"code":"70954045520","type":"NDC"}],"standard_charges":[{"gross_charge":16.67,"discounted_cash":9.17,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Torsemide Tab 20 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"18293","type":"CDM"},{"code":"50268075615","type":"NDC"}],"standard_charges":[{"gross_charge":11.69,"discounted_cash":6.43,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Torsemide Tab 20 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"18293","type":"CDM"},{"code":"50268075611","type":"NDC"}],"standard_charges":[{"gross_charge":11.69,"discounted_cash":6.43,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Torsemide Tab 5 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"18295","type":"CDM"},{"code":"50268075411","type":"NDC"}],"standard_charges":[{"gross_charge":10.79,"discounted_cash":5.93,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Barium Sulfate Susp 2%","drug_information":{"unit":450.0,"type":"ML"},"code_information":[{"code":"18299","type":"CDM"},{"code":"32909074103","type":"NDC"}],"standard_charges":[{"gross_charge":32.03,"discounted_cash":17.62,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Piperacillin Sod-Tazobactam Sod For Inj 4.5 GM (4-0.5 GM)","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"18302","type":"CDM"},{"code":"72485040410","type":"NDC"}],"standard_charges":[{"gross_charge":45.88,"discounted_cash":25.23,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Piperacillin Sod-Tazobactam Sod For Inj 4.5 GM (4-0.5 GM)","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"18302","type":"CDM"},{"code":"72485040401","type":"NDC"}],"standard_charges":[{"gross_charge":45.88,"discounted_cash":25.23,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Piperacillin Sod-Tazobactam Sod For Inj 4.5 GM (4-0.5 GM)","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"18302","type":"CDM"},{"code":"60505615904","type":"NDC"}],"standard_charges":[{"gross_charge":45.95,"discounted_cash":25.27,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Piperacillin Sod-Tazobactam Sod For Inj 4.5 GM (4-0.5 GM)","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"18302","type":"CDM"},{"code":"60505615900","type":"NDC"}],"standard_charges":[{"gross_charge":45.95,"discounted_cash":25.27,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Piperacillin Sod-Tazobactam Sod For Inj 4.5 GM (4-0.5 GM)","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"18302","type":"CDM"},{"code":"55150012150","type":"NDC"}],"standard_charges":[{"gross_charge":26.42,"discounted_cash":14.53,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Piperacillin Sod-Tazobactam Sod For Inj 4.5 GM (4-0.5 GM)","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"18302","type":"CDM"},{"code":"781311495","type":"NDC"}],"standard_charges":[{"gross_charge":48.24,"discounted_cash":26.53,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Piperacillin Sod-Tazobactam Na For Inj 3.375 GM (3-0.375 GM)","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"18303","type":"CDM"},{"code":"781921390","type":"NDC"}],"standard_charges":[{"gross_charge":41.35,"discounted_cash":22.74,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Piperacillin Sod-Tazobactam Na For Inj 3.375 GM (3-0.375 GM)","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"18303","type":"CDM"},{"code":"781311395","type":"NDC"}],"standard_charges":[{"gross_charge":41.35,"discounted_cash":22.74,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Piperacillin Sod-Tazobactam Sod For Inj 2.25 GM (2-0.25 GM)","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"18304","type":"CDM"},{"code":"55150011930","type":"NDC"}],"standard_charges":[{"gross_charge":20.54,"discounted_cash":11.30,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Gabapentin Cap 400 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"18307","type":"CDM"},{"code":"60687060201","type":"NDC"}],"standard_charges":[{"gross_charge":12.7,"discounted_cash":6.98,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Gabapentin Cap 300 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"18308","type":"CDM"},{"code":"904666661","type":"NDC"}],"standard_charges":[{"gross_charge":8.87,"discounted_cash":4.88,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Gabapentin Cap 100 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"18309","type":"CDM"},{"code":"67877022201","type":"NDC"}],"standard_charges":[{"gross_charge":10.39,"discounted_cash":5.71,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Risperidone Tab 2 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"18311","type":"CDM"},{"code":"68382011514","type":"NDC"}],"standard_charges":[{"gross_charge":33.1,"discounted_cash":18.20,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Risperidone Tab 1 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"18313","type":"CDM"},{"code":"68084027201","type":"NDC"}],"standard_charges":[{"gross_charge":25.48,"discounted_cash":14.01,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Risperidone Tab 1 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"18313","type":"CDM"},{"code":"68084027211","type":"NDC"}],"standard_charges":[{"gross_charge":25.48,"discounted_cash":14.01,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Risperidone Tab 1 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"18313","type":"CDM"},{"code":"27241000150","type":"NDC"}],"standard_charges":[{"gross_charge":25.53,"discounted_cash":14.04,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Cefazolin Sodium For IV Soln 3 GM","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"183721","type":"CDM"},{"code":"44567084501","type":"NDC"}],"standard_charges":[{"gross_charge":54.36,"discounted_cash":29.90,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Cefazolin Sodium For IV Soln 3 GM","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"183721","type":"CDM"},{"code":"44567084525","type":"NDC"}],"standard_charges":[{"gross_charge":54.36,"discounted_cash":29.90,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Bupropion HCl Tab ER 12HR 100 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"18385","type":"CDM"},{"code":"591354060","type":"NDC"}],"standard_charges":[{"gross_charge":14.49,"discounted_cash":7.97,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Bupropion HCl Tab ER 12HR 150 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"18386","type":"CDM"},{"code":"43547028910","type":"NDC"}],"standard_charges":[{"gross_charge":15.47,"discounted_cash":8.51,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Remifentanil HCl For IV Soln 1 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"18398","type":"CDM"},{"code":"63323072301","type":"NDC"}],"standard_charges":[{"gross_charge":202.54,"discounted_cash":111.40,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Remifentanil HCl For IV Soln 1 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"18398","type":"CDM"},{"code":"63323072303","type":"NDC"}],"standard_charges":[{"gross_charge":202.55,"discounted_cash":111.40,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"RSV Pre-Fusion F A&B Vac Recomb For IM Soln 120 MCG/0.5ML","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"185215","type":"CDM"},{"code":"69034405","type":"NDC"}],"standard_charges":[{"gross_charge":586.74,"discounted_cash":322.71,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Carvedilol Tab 3.125 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"18551","type":"CDM"},{"code":"68382009201","type":"NDC"}],"standard_charges":[{"gross_charge":16.23,"discounted_cash":8.93,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Nirsevimab-alip IM Soln Prefilled Syringe 50 MG/0.5ML","drug_information":{"unit":0.5,"type":"ML"},"code_information":[{"code":"185845","type":"CDM"},{"code":"49281057500","type":"NDC"}],"standard_charges":[{"gross_charge":998.67,"discounted_cash":549.27,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Nirsevimab-alip IM Soln Prefilled Syringe 50 MG/0.5ML","drug_information":{"unit":0.5,"type":"ML"},"code_information":[{"code":"185845","type":"CDM"},{"code":"49281057515","type":"NDC"}],"standard_charges":[{"gross_charge":998.67,"discounted_cash":549.27,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Nirsevimab-alip IM Soln Prefilled Syringe 100 MG/ML","drug_information":{"unit":0.5,"type":"ML"},"code_information":[{"code":"185846","type":"CDM"},{"code":"49281057488","type":"NDC"}],"standard_charges":[{"gross_charge":514.84,"discounted_cash":283.16,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Nirsevimab-alip IM Soln Prefilled Syringe 100 MG/ML","drug_information":{"unit":0.5,"type":"ML"},"code_information":[{"code":"185846","type":"CDM"},{"code":"49281057415","type":"NDC"}],"standard_charges":[{"gross_charge":514.83,"discounted_cash":283.16,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Lidocaine HCl-Racepinephrine-Tetracaine HCl Gel 4-0.05-0.5%","drug_information":{"unit":3.0,"type":"ML"},"code_information":[{"code":"185905","type":"CDM"},{"code":"70092161144","type":"NDC"}],"standard_charges":[{"gross_charge":80.98,"discounted_cash":44.54,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Latanoprost Ophth Soln 0.005%","drug_information":{"unit":2.5,"type":"ML"},"code_information":[{"code":"18621","type":"CDM"},{"code":"70069042101","type":"NDC"}],"standard_charges":[{"gross_charge":127.5,"discounted_cash":70.12,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Latanoprost Ophth Soln 0.005%","drug_information":{"unit":2.5,"type":"ML"},"code_information":[{"code":"18621","type":"CDM"},{"code":"61314054701","type":"NDC"}],"standard_charges":[{"gross_charge":127.5,"discounted_cash":70.12,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Fluorescein Sodium IV Soln 10%","drug_information":{"unit":5.0,"type":"ML"},"code_information":[{"code":"186557","type":"CDM"},{"code":"14789012205","type":"NDC"}],"standard_charges":[{"gross_charge":721.3,"discounted_cash":396.72,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Secukinumab IV Soln 125 MG/5ML","drug_information":{"unit":5.0,"type":"ML"},"code_information":[{"code":"186606","type":"CDM"},{"code":"78116861","type":"NDC"}],"standard_charges":[{"gross_charge":3860.15,"discounted_cash":2123.08,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Sitagliptin Tab 25 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"187072","type":"CDM"},{"code":"70710189903","type":"NDC"}],"standard_charges":[{"gross_charge":39.22,"discounted_cash":21.57,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Methylene Blue IV Soln 50 MG/10ML (5 MG/ML)","drug_information":{"unit":10.0,"type":"ML"},"code_information":[{"code":"187098","type":"CDM"},{"code":"70710183805","type":"NDC"}],"standard_charges":[{"gross_charge":649.79,"discounted_cash":357.38,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Methylene Blue IV Soln 50 MG/10ML (5 MG/ML)","drug_information":{"unit":10.0,"type":"ML"},"code_information":[{"code":"187098","type":"CDM"},{"code":"70710183801","type":"NDC"}],"standard_charges":[{"gross_charge":649.79,"discounted_cash":357.38,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Pegfilgrastim-cbqv Soln Prefill Syr/Infusion Dev 6 MG/0.6ML","drug_information":{"unit":0.6,"type":"ML"},"code_information":[{"code":"187543","type":"CDM"},{"code":"70114013001","type":"NDC"}],"standard_charges":[{"gross_charge":7295.5,"discounted_cash":4012.52,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Donepezil Hydrochloride Tab 5 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"18786","type":"CDM"},{"code":"60687029211","type":"NDC"}],"standard_charges":[{"gross_charge":11.45,"discounted_cash":6.30,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Donepezil Hydrochloride Tab 10 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"18787","type":"CDM"},{"code":"904647861","type":"NDC"}],"standard_charges":[{"gross_charge":8.73,"discounted_cash":4.80,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Donepezil Hydrochloride Tab 10 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"18787","type":"CDM"},{"code":"60687030311","type":"NDC"}],"standard_charges":[{"gross_charge":11.45,"discounted_cash":6.30,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Certolizumab Pegol Prefilled Syringe Kit 200 MG/ML","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"188194","type":"CDM"},{"code":"50474071079","type":"NDC"}],"standard_charges":[{"gross_charge":9363.12,"discounted_cash":5149.72,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Tocilizumab-aazg IV Inj 80 MG/4ML","drug_information":{"unit":4.0,"type":"ML"},"code_information":[{"code":"188585","type":"CDM"},{"code":"65219059004","type":"NDC"}],"standard_charges":[{"gross_charge":947.54,"discounted_cash":521.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Tocilizumab-aazg IV Inj 200 MG/10ML","drug_information":{"unit":10.0,"type":"ML"},"code_information":[{"code":"188586","type":"CDM"},{"code":"65219059210","type":"NDC"}],"standard_charges":[{"gross_charge":2322.33,"discounted_cash":1277.28,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Tocilizumab-aazg IV Inj 400 MG/20ML","drug_information":{"unit":20.0,"type":"ML"},"code_information":[{"code":"188587","type":"CDM"},{"code":"65219059420","type":"NDC"}],"standard_charges":[{"gross_charge":4613.66,"discounted_cash":2537.51,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Ondansetron HCl Oral Soln 4 MG/5ML","drug_information":{"unit":5.0,"type":"ML"},"code_information":[{"code":"18877","type":"CDM"},{"code":"65162069179","type":"NDC"}],"standard_charges":[{"gross_charge":130.44,"discounted_cash":71.74,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Nitroprusside Sodium IV Soln 25 MG/ML","drug_information":{"unit":2.0,"type":"ML"},"code_information":[{"code":"18908","type":"CDM"},{"code":"72485010501","type":"NDC"}],"standard_charges":[{"gross_charge":97.0,"discounted_cash":53.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Levofloxacin Tab 250 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"18918","type":"CDM"},{"code":"904635161","type":"NDC"}],"standard_charges":[{"gross_charge":36.12,"discounted_cash":19.87,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Topiramate Tab 25 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"18920","type":"CDM"},{"code":"68084034201","type":"NDC"}],"standard_charges":[{"gross_charge":16.09,"discounted_cash":8.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Topiramate Tab 25 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"18920","type":"CDM"},{"code":"68084034211","type":"NDC"}],"standard_charges":[{"gross_charge":16.09,"discounted_cash":8.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Topiramate Tab 100 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"18922","type":"CDM"},{"code":"68084034411","type":"NDC"}],"standard_charges":[{"gross_charge":28.46,"discounted_cash":15.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Topiramate Tab 100 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"18922","type":"CDM"},{"code":"68084034401","type":"NDC"}],"standard_charges":[{"gross_charge":28.46,"discounted_cash":15.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Cupric Chloride Inj 0.4 MG/ML (Elemental)","drug_information":{"unit":10.0,"type":"ML"},"code_information":[{"code":"1900","type":"CDM"},{"code":"409409201","type":"NDC"}],"standard_charges":[{"gross_charge":177.49,"discounted_cash":97.62,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Atorvastatin Calcium Tab 10 MG (Base Equivalent)","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"19176","type":"CDM"},{"code":"904629061","type":"NDC"}],"standard_charges":[{"gross_charge":4.65,"discounted_cash":2.56,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Atorvastatin Calcium Tab 40 MG (Base Equivalent)","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"19177","type":"CDM"},{"code":"378395277","type":"NDC"}],"standard_charges":[{"gross_charge":23.57,"discounted_cash":12.96,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Clonidine HCl Inj (For Epidural Infusion) 100 MCG/ML","drug_information":{"unit":0.5,"type":"ML"},"code_information":[{"code":"19333","type":"CDM"},{"code":"39822200001","type":"NDC"}],"standard_charges":[{"gross_charge":37.02,"discounted_cash":20.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Warfarin Sodium Tab 3 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"19433","type":"CDM"},{"code":"93171501","type":"NDC"}],"standard_charges":[{"gross_charge":10.95,"discounted_cash":6.02,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Diph, Acellular Pert & Tet Tox Inj 25 LF-58 MCG-10 LF/0.5ML","drug_information":{"unit":0.5,"type":"ML"},"code_information":[{"code":"19451","type":"CDM"},{"code":"58160081052","type":"NDC"}],"standard_charges":[{"gross_charge":69.35,"discounted_cash":38.14,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Phenylephrine HCl Ophth Soln 10%","drug_information":{"unit":5.0,"type":"ML"},"code_information":[{"code":"19636","type":"CDM"},{"code":"17478020605","type":"NDC"}],"standard_charges":[{"gross_charge":154.5,"discounted_cash":84.98,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Benzocaine Dental Gel 20%","drug_information":{"unit":11.9,"type":"GM"},"code_information":[{"code":"19691","type":"CDM"},{"code":"10310028313","type":"NDC"}],"standard_charges":[{"gross_charge":48.4,"discounted_cash":26.62,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Benzocaine Dental Soln 20%","drug_information":{"unit":30.0,"type":"ML"},"code_information":[{"code":"19696","type":"CDM"},{"code":"283056931","type":"NDC"}],"standard_charges":[{"gross_charge":58.65,"discounted_cash":32.26,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Carbachol Intraocular Inj 0.01%","drug_information":{"unit":0.5,"type":"ML"},"code_information":[{"code":"19704","type":"CDM"},{"code":"65002315","type":"NDC"}],"standard_charges":[{"gross_charge":57.89,"discounted_cash":31.84,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Ketorolac Tromethamine Ophth Soln 0.5%","drug_information":{"unit":10.0,"type":"ML"},"code_information":[{"code":"19733","type":"CDM"},{"code":"60505100302","type":"NDC"}],"standard_charges":[{"gross_charge":675.69,"discounted_cash":371.63,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Ketorolac Tromethamine Ophth Soln 0.5%","drug_information":{"unit":5.0,"type":"ML"},"code_information":[{"code":"19733","type":"CDM"},{"code":"61314012605","type":"NDC"}],"standard_charges":[{"gross_charge":351.0,"discounted_cash":193.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Methylcellulose Powder Laxative","drug_information":{"unit":454.0,"type":"GM"},"code_information":[{"code":"19739","type":"CDM"},{"code":"904567516","type":"NDC"}],"standard_charges":[{"gross_charge":51.35,"discounted_cash":28.24,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Ofloxacin Ophth Soln 0.3%","drug_information":{"unit":5.0,"type":"ML"},"code_information":[{"code":"19746","type":"CDM"},{"code":"70756060730","type":"NDC"}],"standard_charges":[{"gross_charge":210.46,"discounted_cash":115.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Ofloxacin Ophth Soln 0.3%","drug_information":{"unit":5.0,"type":"ML"},"code_information":[{"code":"19746","type":"CDM"},{"code":"72485061310","type":"NDC"}],"standard_charges":[{"gross_charge":86.65,"discounted_cash":47.66,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Metronidazole Cream 0.75%","drug_information":{"unit":45.0,"type":"GM"},"code_information":[{"code":"19805","type":"CDM"},{"code":"168032346","type":"NDC"}],"standard_charges":[{"gross_charge":346.69,"discounted_cash":190.68,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Sertraline HCl Tab 25 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"19882","type":"CDM"},{"code":"60687023111","type":"NDC"}],"standard_charges":[{"gross_charge":9.79,"discounted_cash":5.38,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Sertraline HCl Tab 25 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"19882","type":"CDM"},{"code":"60687023101","type":"NDC"}],"standard_charges":[{"gross_charge":9.79,"discounted_cash":5.38,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Itraconazole Oral Soln 10 MG/ML","drug_information":{"unit":20.0,"type":"ML"},"code_information":[{"code":"19928","type":"CDM"},{"code":"65162008774","type":"NDC"}],"standard_charges":[{"gross_charge":196.5,"discounted_cash":108.08,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Itraconazole Oral Soln 10 MG/ML","drug_information":{"unit":20.0,"type":"ML"},"code_information":[{"code":"19928","type":"CDM"},{"code":"10147015001","type":"NDC"}],"standard_charges":[{"gross_charge":186.18,"discounted_cash":102.40,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Cyanocobalamin Inj 1000 MCG/ML","drug_information":{"unit":0.1,"type":"ML"},"code_information":[{"code":"2007","type":"CDM"},{"code":"71288030301","type":"NDC"}],"standard_charges":[{"gross_charge":15.8,"discounted_cash":8.69,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Cyanocobalamin Inj 1000 MCG/ML","drug_information":{"unit":0.1,"type":"ML"},"code_information":[{"code":"2007","type":"CDM"},{"code":"71288030302","type":"NDC"}],"standard_charges":[{"gross_charge":15.8,"discounted_cash":8.69,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Cyclobenzaprine HCl Tab 10 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"2017","type":"CDM"},{"code":"93342201","type":"NDC"}],"standard_charges":[{"gross_charge":12.42,"discounted_cash":6.83,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Cyclobenzaprine HCl Tab 10 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"2017","type":"CDM"},{"code":"60687055801","type":"NDC"}],"standard_charges":[{"gross_charge":8.95,"discounted_cash":4.92,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Cyclobenzaprine HCl Tab 10 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"2017","type":"CDM"},{"code":"60687055811","type":"NDC"}],"standard_charges":[{"gross_charge":8.95,"discounted_cash":4.92,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Cyproheptadine HCl Tab 4 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"2033","type":"CDM"},{"code":"70752010710","type":"NDC"}],"standard_charges":[{"gross_charge":12.11,"discounted_cash":6.66,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Cyproheptadine HCl Tab 4 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"2033","type":"CDM"},{"code":"50268018915","type":"NDC"}],"standard_charges":[{"gross_charge":12.12,"discounted_cash":6.67,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Cyproheptadine HCl Tab 4 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"2033","type":"CDM"},{"code":"50268018911","type":"NDC"}],"standard_charges":[{"gross_charge":12.12,"discounted_cash":6.67,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Etomidate IV Soln 2 MG/ML","drug_information":{"unit":10.0,"type":"ML"},"code_information":[{"code":"20472","type":"CDM"},{"code":"72485050810","type":"NDC"}],"standard_charges":[{"gross_charge":55.16,"discounted_cash":30.34,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Meloxicam Tab 7.5 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"20566","type":"CDM"},{"code":"68382005001","type":"NDC"}],"standard_charges":[{"gross_charge":20.2,"discounted_cash":11.11,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Fluvoxamine Maleate Tab 25 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"20634","type":"CDM"},{"code":"60505016401","type":"NDC"}],"standard_charges":[{"gross_charge":16.87,"discounted_cash":9.28,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Valproate Sodium Inj 100 MG/ML","drug_information":{"unit":5.0,"type":"ML"},"code_information":[{"code":"20887","type":"CDM"},{"code":"143978510","type":"NDC"}],"standard_charges":[{"gross_charge":63.34,"discounted_cash":34.84,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Valproate Sodium Inj 100 MG/ML","drug_information":{"unit":5.0,"type":"ML"},"code_information":[{"code":"20887","type":"CDM"},{"code":"143978501","type":"NDC"}],"standard_charges":[{"gross_charge":63.34,"discounted_cash":34.84,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Azithromycin Tab 250 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"20943","type":"CDM"},{"code":"50268007415","type":"NDC"}],"standard_charges":[{"gross_charge":17.57,"discounted_cash":9.66,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Levocarnitine Inj 200 MG/ML","drug_information":{"unit":5.0,"type":"ML"},"code_information":[{"code":"20954","type":"CDM"},{"code":"54482014701","type":"NDC"}],"standard_charges":[{"gross_charge":184.95,"discounted_cash":101.72,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Olanzapine Tab 2.5 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"21057","type":"CDM"},{"code":"60505311000","type":"NDC"}],"standard_charges":[{"gross_charge":38.79,"discounted_cash":21.33,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Citalopram Hydrobromide Tab 20 MG (Base Equiv)","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"21062","type":"CDM"},{"code":"904608561","type":"NDC"}],"standard_charges":[{"gross_charge":19.27,"discounted_cash":10.60,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Azithromycin IV For Soln 500 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"21063","type":"CDM"},{"code":"55150017410","type":"NDC"}],"standard_charges":[{"gross_charge":30.9,"discounted_cash":17.00,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Azithromycin IV For Soln 500 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"21063","type":"CDM"},{"code":"70436001982","type":"NDC"}],"standard_charges":[{"gross_charge":39.72,"discounted_cash":21.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Pramipexole Dihydrochloride Tab 0.25 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"21290","type":"CDM"},{"code":"13668009290","type":"NDC"}],"standard_charges":[{"gross_charge":19.32,"discounted_cash":10.63,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Dapsone Tab 100 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"2131","type":"CDM"},{"code":"70954013610","type":"NDC"}],"standard_charges":[{"gross_charge":19.64,"discounted_cash":10.80,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Dapsone Tab 25 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"2132","type":"CDM"},{"code":"70954013510","type":"NDC"}],"standard_charges":[{"gross_charge":17.49,"discounted_cash":9.62,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"BCG Live Intravesical For Susp 50 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"21570","type":"CDM"},{"code":"52060202","type":"NDC"}],"standard_charges":[{"gross_charge":391.4,"discounted_cash":215.27,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Ropinirole Hydrochloride Tab 0.25 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"21688","type":"CDM"},{"code":"50268074115","type":"NDC"}],"standard_charges":[{"gross_charge":10.63,"discounted_cash":5.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Ropinirole Hydrochloride Tab 1 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"21689","type":"CDM"},{"code":"50268074311","type":"NDC"}],"standard_charges":[{"gross_charge":11.03,"discounted_cash":6.07,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Ropinirole Hydrochloride Tab 1 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"21689","type":"CDM"},{"code":"50268074315","type":"NDC"}],"standard_charges":[{"gross_charge":11.03,"discounted_cash":6.07,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Quetiapine Fumarate Tab 25 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"21823","type":"CDM"},{"code":"50268063011","type":"NDC"}],"standard_charges":[{"gross_charge":20.7,"discounted_cash":11.38,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Quetiapine Fumarate Tab 25 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"21823","type":"CDM"},{"code":"50268063015","type":"NDC"}],"standard_charges":[{"gross_charge":20.7,"discounted_cash":11.38,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Quetiapine Fumarate Tab 100 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"21824","type":"CDM"},{"code":"60687034911","type":"NDC"}],"standard_charges":[{"gross_charge":24.57,"discounted_cash":13.51,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Quetiapine Fumarate Tab 100 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"21824","type":"CDM"},{"code":"60687034901","type":"NDC"}],"standard_charges":[{"gross_charge":24.57,"discounted_cash":13.51,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Quetiapine Fumarate Tab 200 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"21825","type":"CDM"},{"code":"904664161","type":"NDC"}],"standard_charges":[{"gross_charge":17.1,"discounted_cash":9.40,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Amphotericin B Liposome IV For Susp 50 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"21900","type":"CDM"},{"code":"469305130","type":"NDC"}],"standard_charges":[{"gross_charge":603.96,"discounted_cash":332.18,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Amphotericin B Liposome IV For Susp 50 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"21900","type":"CDM"},{"code":"62756023301","type":"NDC"}],"standard_charges":[{"gross_charge":489.54,"discounted_cash":269.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Rabies Vaccine, PCEC For Inj","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"22120","type":"CDM"},{"code":"50632001001","type":"NDC"}],"standard_charges":[{"gross_charge":816.8,"discounted_cash":449.24,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Clopidogrel Bisulfate Tab 75 MG (Base Equiv)","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"22142","type":"CDM"},{"code":"68084053601","type":"NDC"}],"standard_charges":[{"gross_charge":25.04,"discounted_cash":13.77,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Clopidogrel Bisulfate Tab 75 MG (Base Equiv)","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"22142","type":"CDM"},{"code":"68084053611","type":"NDC"}],"standard_charges":[{"gross_charge":25.04,"discounted_cash":13.77,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Acarbose Tab 25 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"22148","type":"CDM"},{"code":"54014025","type":"NDC"}],"standard_charges":[{"gross_charge":12.05,"discounted_cash":6.63,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Fomepizole Inj 1 GM/ML (For IV Infusion)","drug_information":{"unit":1.5,"type":"ML"},"code_information":[{"code":"22185","type":"CDM"},{"code":"517071001","type":"NDC"}],"standard_charges":[{"gross_charge":3044.0,"discounted_cash":1674.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Tobramycin Nebu Soln 300 MG/5ML","drug_information":{"unit":5.0,"type":"ML"},"code_information":[{"code":"22240","type":"CDM"},{"code":"65162091446","type":"NDC"}],"standard_charges":[{"gross_charge":318.99,"discounted_cash":175.44,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Ofloxacin Otic Soln 0.3%","drug_information":{"unit":5.0,"type":"ML"},"code_information":[{"code":"22257","type":"CDM"},{"code":"60505036301","type":"NDC"}],"standard_charges":[{"gross_charge":356.42,"discounted_cash":196.03,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Ofloxacin Otic Soln 0.3%","drug_information":{"unit":5.0,"type":"ML"},"code_information":[{"code":"22257","type":"CDM"},{"code":"70756060915","type":"NDC"}],"standard_charges":[{"gross_charge":363.15,"discounted_cash":199.73,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Cefdinir Cap 300 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"22289","type":"CDM"},{"code":"68180071160","type":"NDC"}],"standard_charges":[{"gross_charge":24.88,"discounted_cash":13.68,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Lactase Tab 3000 Unit","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"22469","type":"CDM"},{"code":"77333043050","type":"NDC"}],"standard_charges":[{"gross_charge":10.45,"discounted_cash":5.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Lactase Tab 3000 Unit","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"22469","type":"CDM"},{"code":"77333043025","type":"NDC"}],"standard_charges":[{"gross_charge":10.45,"discounted_cash":5.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Ketorolac Tromethamine Inj 15 MG/ML","drug_information":{"unit":1.0,"type":"ML"},"code_information":[{"code":"22472","type":"CDM"},{"code":"25021070001","type":"NDC"}],"standard_charges":[{"gross_charge":52.45,"discounted_cash":28.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Ketorolac Tromethamine Inj 15 MG/ML","drug_information":{"unit":1.0,"type":"ML"},"code_information":[{"code":"22472","type":"CDM"},{"code":"72266023401","type":"NDC"}],"standard_charges":[{"gross_charge":39.35,"discounted_cash":21.64,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Ketorolac Tromethamine Inj 15 MG/ML","drug_information":{"unit":1.0,"type":"ML"},"code_information":[{"code":"22472","type":"CDM"},{"code":"72266023425","type":"NDC"}],"standard_charges":[{"gross_charge":39.35,"discounted_cash":21.64,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Ketorolac Tromethamine Inj 30 MG/ML","drug_information":{"unit":0.333333333333333,"type":"ML"},"code_information":[{"code":"22473","type":"CDM"},{"code":"72572035501","type":"NDC"}],"standard_charges":[{"gross_charge":35.97,"discounted_cash":19.78,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Ketorolac Tromethamine Inj 30 MG/ML","drug_information":{"unit":0.333333333333333,"type":"ML"},"code_information":[{"code":"22473","type":"CDM"},{"code":"72572035525","type":"NDC"}],"standard_charges":[{"gross_charge":35.97,"discounted_cash":19.78,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Montelukast Sodium Tab 10 MG (Base Equiv)","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"22509","type":"CDM"},{"code":"904680861","type":"NDC"}],"standard_charges":[{"gross_charge":9.76,"discounted_cash":5.37,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Sulfamethoxazole-Trimethoprim Susp 200-40 MG/5ML","drug_information":{"unit":473.0,"type":"ML"},"code_information":[{"code":"22560","type":"CDM"},{"code":"65862049647","type":"NDC"}],"standard_charges":[{"gross_charge":974.71,"discounted_cash":536.09,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Losartan Potassium Tab 100 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"22588","type":"CDM"},{"code":"50268050615","type":"NDC"}],"standard_charges":[{"gross_charge":11.4,"discounted_cash":6.27,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Losartan Potassium Tab 100 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"22588","type":"CDM"},{"code":"50268050611","type":"NDC"}],"standard_charges":[{"gross_charge":11.4,"discounted_cash":6.27,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Pramipexole Dihydrochloride Tab 0.5 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"22719","type":"CDM"},{"code":"57237018290","type":"NDC"}],"standard_charges":[{"gross_charge":19.36,"discounted_cash":10.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Pramipexole Dihydrochloride Tab 0.5 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"22719","type":"CDM"},{"code":"13668009390","type":"NDC"}],"standard_charges":[{"gross_charge":19.36,"discounted_cash":10.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Tolterodine Tartrate Tab 1 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"22782","type":"CDM"},{"code":"59762017006","type":"NDC"}],"standard_charges":[{"gross_charge":20.74,"discounted_cash":11.41,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Tolterodine Tartrate Tab 2 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"22783","type":"CDM"},{"code":"33342009809","type":"NDC"}],"standard_charges":[{"gross_charge":21.08,"discounted_cash":11.59,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Tolterodine Tartrate Tab 2 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"22783","type":"CDM"},{"code":"16571012706","type":"NDC"}],"standard_charges":[{"gross_charge":21.08,"discounted_cash":11.59,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Dorzolamide HCl-Timolol Maleate Ophth Soln 2-0.5%","drug_information":{"unit":10.0,"type":"ML"},"code_information":[{"code":"22982","type":"CDM"},{"code":"24208048610","type":"NDC"}],"standard_charges":[{"gross_charge":239.72,"discounted_cash":131.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Acyclovir Sodium IV Soln 50 MG/ML","drug_information":{"unit":10.0,"type":"ML"},"code_information":[{"code":"23128","type":"CDM"},{"code":"55150015410","type":"NDC"}],"standard_charges":[{"gross_charge":92.6,"discounted_cash":50.93,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Acyclovir Sodium IV Soln 50 MG/ML","drug_information":{"unit":10.0,"type":"ML"},"code_information":[{"code":"23128","type":"CDM"},{"code":"65219062202","type":"NDC"}],"standard_charges":[{"gross_charge":101.92,"discounted_cash":56.06,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Acyclovir Sodium IV Soln 50 MG/ML","drug_information":{"unit":10.0,"type":"ML"},"code_information":[{"code":"23128","type":"CDM"},{"code":"65219062210","type":"NDC"}],"standard_charges":[{"gross_charge":101.92,"discounted_cash":56.06,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Dexamethasone Tab 0.5 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"2322","type":"CDM"},{"code":"54417925","type":"NDC"}],"standard_charges":[{"gross_charge":35.16,"discounted_cash":19.34,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Dexamethasone Tab 2 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"2326","type":"CDM"},{"code":"54418325","type":"NDC"}],"standard_charges":[{"gross_charge":37.33,"discounted_cash":20.53,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Dexamethasone Tab 4 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"2327","type":"CDM"},{"code":"60687071801","type":"NDC"}],"standard_charges":[{"gross_charge":12.64,"discounted_cash":6.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Dexamethasone Tab 4 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"2327","type":"CDM"},{"code":"60687071811","type":"NDC"}],"standard_charges":[{"gross_charge":12.64,"discounted_cash":6.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Dexamethasone Sodium Phosphate Inj 4 MG/ML","drug_information":{"unit":1.0,"type":"ML"},"code_information":[{"code":"2332","type":"CDM"},{"code":"641614501","type":"NDC"}],"standard_charges":[{"gross_charge":39.14,"discounted_cash":21.53,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Dexamethasone Sodium Phosphate Inj 4 MG/ML","drug_information":{"unit":1.0,"type":"ML"},"code_information":[{"code":"2332","type":"CDM"},{"code":"641614525","type":"NDC"}],"standard_charges":[{"gross_charge":39.14,"discounted_cash":21.53,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Rizatriptan Benzoate Tab 10 MG (Base Equivalent)","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"23377","type":"CDM"},{"code":"65862060003","type":"NDC"}],"standard_charges":[{"gross_charge":111.14,"discounted_cash":61.13,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Rizatriptan Benzoate Tab 10 MG (Base Equivalent)","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"23377","type":"CDM"},{"code":"65862060012","type":"NDC"}],"standard_charges":[{"gross_charge":111.14,"discounted_cash":61.13,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Lidocaine Cream 4%","drug_information":{"unit":5.0,"type":"GM"},"code_information":[{"code":"23461","type":"CDM"},{"code":"24357070106","type":"NDC"}],"standard_charges":[{"gross_charge":54.45,"discounted_cash":29.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Citalopram Hydrobromide Tab 40 MG (Base Equiv)","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"23490","type":"CDM"},{"code":"378623301","type":"NDC"}],"standard_charges":[{"gross_charge":19.22,"discounted_cash":10.57,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Dextrose Inj 10%","drug_information":{"unit":1000.0,"type":"ML"},"code_information":[{"code":"2357","type":"CDM"},{"code":"264752000","type":"NDC"}],"standard_charges":[{"gross_charge":25.3,"discounted_cash":13.92,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Dextrose Inj 10%","drug_information":{"unit":250.0,"type":"ML"},"code_information":[{"code":"2357","type":"CDM"},{"code":"264752020","type":"NDC"}],"standard_charges":[{"gross_charge":22.85,"discounted_cash":12.57,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Dextrose Inj 10%","drug_information":{"unit":1000.0,"type":"ML"},"code_information":[{"code":"2357","type":"CDM"},{"code":"338002304","type":"NDC"}],"standard_charges":[{"gross_charge":28.1,"discounted_cash":15.46,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Dextrose Inj 20%","drug_information":{"unit":500.0,"type":"ML"},"code_information":[{"code":"2359","type":"CDM"},{"code":"990793519","type":"NDC"}],"standard_charges":[{"gross_charge":106.65,"discounted_cash":58.66,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Dextrose Inj 25%","drug_information":{"unit":10.0,"type":"ML"},"code_information":[{"code":"2360","type":"CDM"},{"code":"409177510","type":"NDC"}],"standard_charges":[{"gross_charge":126.1,"discounted_cash":69.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Dextrose Inj 5%","drug_information":{"unit":1000.0,"type":"ML"},"code_information":[{"code":"2364","type":"CDM"},{"code":"65219046205","type":"NDC"}],"standard_charges":[{"gross_charge":22.5,"discounted_cash":12.38,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Dextrose Inj 5%","drug_information":{"unit":500.0,"type":"ML"},"code_information":[{"code":"2364","type":"CDM"},{"code":"338001703","type":"NDC"}],"standard_charges":[{"gross_charge":23.2,"discounted_cash":12.76,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Dextrose Inj 5%","drug_information":{"unit":250.0,"type":"ML"},"code_information":[{"code":"2364","type":"CDM"},{"code":"338001702","type":"NDC"}],"standard_charges":[{"gross_charge":22.85,"discounted_cash":12.57,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Dextrose Inj 5%","drug_information":{"unit":250.0,"type":"ML"},"code_information":[{"code":"2364","type":"CDM"},{"code":"264751020","type":"NDC"}],"standard_charges":[{"gross_charge":21.8,"discounted_cash":11.99,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Dextrose Inj 5%","drug_information":{"unit":100.0,"type":"ML"},"code_information":[{"code":"2364","type":"CDM"},{"code":"264151032","type":"NDC"}],"standard_charges":[{"gross_charge":61.35,"discounted_cash":33.74,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Dextrose Inj 5%","drug_information":{"unit":50.0,"type":"ML"},"code_information":[{"code":"2364","type":"CDM"},{"code":"264151031","type":"NDC"}],"standard_charges":[{"gross_charge":61.13,"discounted_cash":33.62,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Dextrose Inj 50%","drug_information":{"unit":50.0,"type":"ML"},"code_information":[{"code":"2365","type":"CDM"},{"code":"70092147550","type":"NDC"}],"standard_charges":[{"gross_charge":91.67,"discounted_cash":50.42,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Dextrose Inj 50%","drug_information":{"unit":50.0,"type":"ML"},"code_information":[{"code":"2365","type":"CDM"},{"code":"409664816","type":"NDC"}],"standard_charges":[{"gross_charge":68.56,"discounted_cash":37.71,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Dextrose Inj 70%","drug_information":{"unit":2000.0,"type":"ML"},"code_information":[{"code":"2367","type":"CDM"},{"code":"338071906","type":"NDC"}],"standard_charges":[{"gross_charge":49.1,"discounted_cash":27.00,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Infliximab For IV Inj 100 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"23796","type":"CDM"},{"code":"57894016001","type":"NDC"}],"standard_charges":[{"gross_charge":889.5,"discounted_cash":489.22,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Diazepam Inj 5 MG/ML","drug_information":{"unit":10.0,"type":"ML"},"code_information":[{"code":"2401","type":"CDM"},{"code":"409321312","type":"NDC"}],"standard_charges":[{"gross_charge":260.19,"discounted_cash":143.10,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Diazepam Inj 5 MG/ML","drug_information":{"unit":2.0,"type":"ML"},"code_information":[{"code":"2401","type":"CDM"},{"code":"69339013603","type":"NDC"}],"standard_charges":[{"gross_charge":112.24,"discounted_cash":61.73,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Diazepam Inj 5 MG/ML","drug_information":{"unit":2.0,"type":"ML"},"code_information":[{"code":"2401","type":"CDM"},{"code":"69339013634","type":"NDC"}],"standard_charges":[{"gross_charge":112.23,"discounted_cash":61.73,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Diazepam Inj 5 MG/ML","drug_information":{"unit":2.0,"type":"ML"},"code_information":[{"code":"2401","type":"CDM"},{"code":"69339013693","type":"NDC"}],"standard_charges":[{"gross_charge":112.23,"discounted_cash":61.73,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Diazepam Inj 5 MG/ML","drug_information":{"unit":2.0,"type":"ML"},"code_information":[{"code":"2401","type":"CDM"},{"code":"69339013697","type":"NDC"}],"standard_charges":[{"gross_charge":112.23,"discounted_cash":61.73,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Diazepam Inj 5 MG/ML","drug_information":{"unit":2.0,"type":"ML"},"code_information":[{"code":"2401","type":"CDM"},{"code":"409127332","type":"NDC"}],"standard_charges":[{"gross_charge":142.08,"discounted_cash":78.14,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Diazepam Inj 5 MG/ML","drug_information":{"unit":2.0,"type":"ML"},"code_information":[{"code":"2401","type":"CDM"},{"code":"409127303","type":"NDC"}],"standard_charges":[{"gross_charge":142.07,"discounted_cash":78.14,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Diazepam Tab 2 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"2404","type":"CDM"},{"code":"51079028401","type":"NDC"}],"standard_charges":[{"gross_charge":9.07,"discounted_cash":4.99,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Diazepam Tab 2 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"2404","type":"CDM"},{"code":"51079028420","type":"NDC"}],"standard_charges":[{"gross_charge":9.08,"discounted_cash":4.99,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Diazepam Tab 5 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"2405","type":"CDM"},{"code":"378034501","type":"NDC"}],"standard_charges":[{"gross_charge":8.73,"discounted_cash":4.80,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Diazepam Tab 5 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"2405","type":"CDM"},{"code":"51079028501","type":"NDC"}],"standard_charges":[{"gross_charge":9.42,"discounted_cash":5.18,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Nevirapine Susp 50 MG/5ML","drug_information":{"unit":20.0,"type":"ML"},"code_information":[{"code":"24119","type":"CDM"},{"code":"65862005724","type":"NDC"}],"standard_charges":[{"gross_charge":78.22,"discounted_cash":43.02,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Midazolam HCl Syrup 2 MG/ML (Base Equivalent)","drug_information":{"unit":118.0,"type":"ML"},"code_information":[{"code":"24176","type":"CDM"},{"code":"54356699","type":"NDC"}],"standard_charges":[{"gross_charge":987.02,"discounted_cash":542.86,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Midazolam HCl Syrup 2 MG/ML (Base Equivalent)","drug_information":{"unit":5.0,"type":"ML"},"code_information":[{"code":"24176","type":"CDM"},{"code":"8882417605","type":"NDC"}],"standard_charges":[{"gross_charge":49.48,"discounted_cash":27.21,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Midazolam HCl Syrup 2 MG/ML (Base Equivalent)","drug_information":{"unit":5.0,"type":"ML"},"code_information":[{"code":"24176","type":"CDM"},{"code":"60687057640","type":"NDC"}],"standard_charges":[{"gross_charge":36.49,"discounted_cash":20.07,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Dicyclomine HCl Cap 10 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"2418","type":"CDM"},{"code":"527058601","type":"NDC"}],"standard_charges":[{"gross_charge":10.0,"discounted_cash":5.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Dicyclomine HCl Cap 10 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"2418","type":"CDM"},{"code":"60687036911","type":"NDC"}],"standard_charges":[{"gross_charge":10.93,"discounted_cash":6.01,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Dicyclomine HCl Tab 20 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"2420","type":"CDM"},{"code":"527128201","type":"NDC"}],"standard_charges":[{"gross_charge":10.59,"discounted_cash":5.82,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Sennosides-Docusate Sodium Tab 8.6-50 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"24216","type":"CDM"},{"code":"536124801","type":"NDC"}],"standard_charges":[{"gross_charge":8.12,"discounted_cash":4.47,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Sennosides-Docusate Sodium Tab 8.6-50 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"24216","type":"CDM"},{"code":"904744061","type":"NDC"}],"standard_charges":[{"gross_charge":8.86,"discounted_cash":4.87,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Heparin Sodium (Porcine) 100 Unit/ML in D5W","drug_information":{"unit":250.0,"type":"ML"},"code_information":[{"code":"24329","type":"CDM"},{"code":"409452030","type":"NDC"}],"standard_charges":[{"gross_charge":89.96,"discounted_cash":49.48,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Heparin Sodium (Porcine) 100 Unit/ML in D5W","drug_information":{"unit":250.0,"type":"ML"},"code_information":[{"code":"24329","type":"CDM"},{"code":"264958720","type":"NDC"}],"standard_charges":[{"gross_charge":114.44,"discounted_cash":62.94,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Lamivudine Tab 100 MG (HBV)","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"24419","type":"CDM"},{"code":"60505325006","type":"NDC"}],"standard_charges":[{"gross_charge":52.31,"discounted_cash":28.77,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Digoxin Inj 0.25 MG/ML","drug_information":{"unit":0.5,"type":"ML"},"code_information":[{"code":"2442","type":"CDM"},{"code":"781305972","type":"NDC"}],"standard_charges":[{"gross_charge":38.2,"discounted_cash":21.01,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Octreotide Acetate For IM Inj Kit 20 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"24435","type":"CDM"},{"code":"78081881","type":"NDC"}],"standard_charges":[{"gross_charge":8063.36,"discounted_cash":4434.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Digoxin Tab 125 MCG (0.125 MG)","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"2444","type":"CDM"},{"code":"70954020110","type":"NDC"}],"standard_charges":[{"gross_charge":16.86,"discounted_cash":9.27,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Cilostazol Tab 50 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"24473","type":"CDM"},{"code":"60505252101","type":"NDC"}],"standard_charges":[{"gross_charge":15.03,"discounted_cash":8.27,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Celecoxib Cap 100 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"24500","type":"CDM"},{"code":"50268016811","type":"NDC"}],"standard_charges":[{"gross_charge":24.81,"discounted_cash":13.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Celecoxib Cap 100 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"24500","type":"CDM"},{"code":"50268016815","type":"NDC"}],"standard_charges":[{"gross_charge":24.81,"discounted_cash":13.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Celecoxib Cap 200 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"24501","type":"CDM"},{"code":"69097042107","type":"NDC"}],"standard_charges":[{"gross_charge":33.01,"discounted_cash":18.16,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Metronidazole IV Soln 500 MG/100ML","drug_information":{"unit":50.0,"type":"ML"},"code_information":[{"code":"24502","type":"CDM"},{"code":"338105548","type":"NDC"}],"standard_charges":[{"gross_charge":54.23,"discounted_cash":29.83,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Isosorbide Mononitrate Tab ER 24HR 30 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"24521","type":"CDM"},{"code":"904644961","type":"NDC"}],"standard_charges":[{"gross_charge":14.39,"discounted_cash":7.91,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Timolol Maleate Ophth Gel Forming Soln 0.25%","drug_information":{"unit":5.0,"type":"ML"},"code_information":[{"code":"24575","type":"CDM"},{"code":"61314022405","type":"NDC"}],"standard_charges":[{"gross_charge":453.15,"discounted_cash":249.23,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Neomycin-Bacitracin-Polymyxin Oint","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"24696","type":"CDM"},{"code":"45802014370","type":"NDC"}],"standard_charges":[{"gross_charge":4.36,"discounted_cash":2.40,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Modafinil Tab 100 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"24702","type":"CDM"},{"code":"904679104","type":"NDC"}],"standard_charges":[{"gross_charge":38.77,"discounted_cash":21.32,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Diltiazem HCl Tab 30 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"2475","type":"CDM"},{"code":"60687071711","type":"NDC"}],"standard_charges":[{"gross_charge":10.34,"discounted_cash":5.69,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Diltiazem HCl Tab 30 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"2475","type":"CDM"},{"code":"60687071701","type":"NDC"}],"standard_charges":[{"gross_charge":10.34,"discounted_cash":5.69,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Tacrolimus Cap 0.5 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"24914","type":"CDM"},{"code":"68084044911","type":"NDC"}],"standard_charges":[{"gross_charge":16.59,"discounted_cash":9.12,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Tacrolimus Cap 0.5 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"24914","type":"CDM"},{"code":"68084044901","type":"NDC"}],"standard_charges":[{"gross_charge":16.59,"discounted_cash":9.12,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Levalbuterol HCl Soln Nebu 0.63 MG/3ML (Base Equiv)","drug_information":{"unit":1.47619047619048,"type":"ML"},"code_information":[{"code":"24915","type":"CDM"},{"code":"93414656","type":"NDC"}],"standard_charges":[{"gross_charge":8.29,"discounted_cash":4.56,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Levalbuterol HCl Soln Nebu 1.25 MG/3ML (Base Equiv)","drug_information":{"unit":3.0,"type":"ML"},"code_information":[{"code":"24916","type":"CDM"},{"code":"76204090011","type":"NDC"}],"standard_charges":[{"gross_charge":6.6,"discounted_cash":3.63,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Levalbuterol HCl Soln Nebu 1.25 MG/3ML (Base Equiv)","drug_information":{"unit":3.0,"type":"ML"},"code_information":[{"code":"24916","type":"CDM"},{"code":"76204090001","type":"NDC"}],"standard_charges":[{"gross_charge":6.6,"discounted_cash":3.63,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Sod Ferric Gluc Cmplx in Sucrose IV Soln 12.5 MG/ML (Fe Eq)","drug_information":{"unit":5.0,"type":"ML"},"code_information":[{"code":"24932","type":"CDM"},{"code":"143957010","type":"NDC"}],"standard_charges":[{"gross_charge":156.93,"discounted_cash":86.31,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Sod Ferric Gluc Cmplx in Sucrose IV Soln 12.5 MG/ML (Fe Eq)","drug_information":{"unit":5.0,"type":"ML"},"code_information":[{"code":"24932","type":"CDM"},{"code":"143957001","type":"NDC"}],"standard_charges":[{"gross_charge":156.93,"discounted_cash":86.31,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Albuterol Sulfate Soln Nebu 0.083% (2.5 MG/3ML)","drug_information":{"unit":3.0,"type":"ML"},"code_information":[{"code":"250","type":"CDM"},{"code":"76204020001","type":"NDC"}],"standard_charges":[{"gross_charge":14.22,"discounted_cash":7.82,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Diphenhydramine HCl Inj 50 MG/ML","drug_information":{"unit":0.25,"type":"ML"},"code_information":[{"code":"2508","type":"CDM"},{"code":"641037621","type":"NDC"}],"standard_charges":[{"gross_charge":32.35,"discounted_cash":17.79,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Diphenhydramine HCl Inj 50 MG/ML","drug_information":{"unit":0.25,"type":"ML"},"code_information":[{"code":"2508","type":"CDM"},{"code":"641037625","type":"NDC"}],"standard_charges":[{"gross_charge":32.35,"discounted_cash":17.79,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Diphenhydramine HCl Cap 25 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"2509","type":"CDM"},{"code":"71399102701","type":"NDC"}],"standard_charges":[{"gross_charge":8.09,"discounted_cash":4.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Albuterol Sulfate Soln Nebu 0.5% (5 MG/ML)","drug_information":{"unit":0.5,"type":"ML"},"code_information":[{"code":"251","type":"CDM"},{"code":"487990130","type":"NDC"}],"standard_charges":[{"gross_charge":19.0,"discounted_cash":10.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Diphenhydramine HCl Cap 50 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"2510","type":"CDM"},{"code":"904530760","type":"NDC"}],"standard_charges":[{"gross_charge":3.03,"discounted_cash":1.67,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Diphenhydramine HCl Elixir 12.5 MG/5ML","drug_information":{"unit":5.0,"type":"ML"},"code_information":[{"code":"2511","type":"CDM"},{"code":"121048905","type":"NDC"}],"standard_charges":[{"gross_charge":55.34,"discounted_cash":30.44,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Diphenhydramine HCl Elixir 12.5 MG/5ML","drug_information":{"unit":5.0,"type":"ML"},"code_information":[{"code":"2511","type":"CDM"},{"code":"121048900","type":"NDC"}],"standard_charges":[{"gross_charge":55.34,"discounted_cash":30.44,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Ciprofloxacin HCl Tab 250 MG (Base Equiv)","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"25118","type":"CDM"},{"code":"59651086601","type":"NDC"}],"standard_charges":[{"gross_charge":25.64,"discounted_cash":14.10,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Ciprofloxacin HCl Tab 500 MG (Base Equiv)","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"25119","type":"CDM"},{"code":"60687086001","type":"NDC"}],"standard_charges":[{"gross_charge":9.95,"discounted_cash":5.47,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Ciprofloxacin HCl Tab 500 MG (Base Equiv)","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"25119","type":"CDM"},{"code":"60687086011","type":"NDC"}],"standard_charges":[{"gross_charge":9.95,"discounted_cash":5.47,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Diphenoxylate w/ Atropine Tab 2.5-0.025 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"2516","type":"CDM"},{"code":"406123601","type":"NDC"}],"standard_charges":[{"gross_charge":11.12,"discounted_cash":6.12,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Amoxicillin (Trihydrate) For Susp 400 MG/5ML","drug_information":{"unit":6.25,"type":"ML"},"code_information":[{"code":"25246","type":"CDM"},{"code":"143988750","type":"NDC"}],"standard_charges":[{"gross_charge":10.73,"discounted_cash":5.90,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Disulfiram Tab 250 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"2540","type":"CDM"},{"code":"47781060730","type":"NDC"}],"standard_charges":[{"gross_charge":23.55,"discounted_cash":12.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Polyethylene Glycol 3350 Oral Packet 17 GM","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"25424","type":"CDM"},{"code":"60687043198","type":"NDC"}],"standard_charges":[{"gross_charge":18.71,"discounted_cash":10.29,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Polyethylene Glycol 3350 Oral Packet 17 GM","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"25424","type":"CDM"},{"code":"60687043127","type":"NDC"}],"standard_charges":[{"gross_charge":14.76,"discounted_cash":8.12,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Divalproex Sodium Tab Delayed Release 125 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"2551","type":"CDM"},{"code":"74732513","type":"NDC"}],"standard_charges":[{"gross_charge":17.5,"discounted_cash":9.62,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Risperidone Tab 0.25 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"25519","type":"CDM"},{"code":"68084027011","type":"NDC"}],"standard_charges":[{"gross_charge":22.99,"discounted_cash":12.64,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Divalproex Sodium Tab Delayed Release 250 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"2552","type":"CDM"},{"code":"832712301","type":"NDC"}],"standard_charges":[{"gross_charge":12.13,"discounted_cash":6.67,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Risperidone Tab 0.5 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"25520","type":"CDM"},{"code":"27241000306","type":"NDC"}],"standard_charges":[{"gross_charge":24.49,"discounted_cash":13.47,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Pioglitazone HCl Tab 15 MG (Base Equiv)","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"25528","type":"CDM"},{"code":"65862051290","type":"NDC"}],"standard_charges":[{"gross_charge":31.13,"discounted_cash":17.12,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Docusate Sodium Cap 100 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"2566","type":"CDM"},{"code":"904728060","type":"NDC"}],"standard_charges":[{"gross_charge":3.03,"discounted_cash":1.67,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Docusate Sodium Cap 100 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"2566","type":"CDM"},{"code":"904718361","type":"NDC"}],"standard_charges":[{"gross_charge":3.06,"discounted_cash":1.68,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Ivermectin Tab 3 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"25820","type":"CDM"},{"code":"42799080601","type":"NDC"}],"standard_charges":[{"gross_charge":27.13,"discounted_cash":14.92,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Dopamine HCl Inj 40 MG/ML","drug_information":{"unit":5.0,"type":"ML"},"code_information":[{"code":"2595","type":"CDM"},{"code":"143925225","type":"NDC"}],"standard_charges":[{"gross_charge":46.62,"discounted_cash":25.64,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Doxepin HCl Cap 10 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"2608","type":"CDM"},{"code":"51079043620","type":"NDC"}],"standard_charges":[{"gross_charge":10.84,"discounted_cash":5.96,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Doxepin HCl Cap 10 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"2608","type":"CDM"},{"code":"51079043601","type":"NDC"}],"standard_charges":[{"gross_charge":10.85,"discounted_cash":5.97,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Doxepin HCl Cap 25 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"2611","type":"CDM"},{"code":"49884021801","type":"NDC"}],"standard_charges":[{"gross_charge":11.66,"discounted_cash":6.41,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Doxepin HCl Cap 25 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"2611","type":"CDM"},{"code":"51079043701","type":"NDC"}],"standard_charges":[{"gross_charge":11.74,"discounted_cash":6.46,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Doxorubicin HCl For Inj 50 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"2619","type":"CDM"},{"code":"143927701","type":"NDC"}],"standard_charges":[{"gross_charge":523.46,"discounted_cash":287.90,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Doxycycline Hyclate For Inj 100 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"2622","type":"CDM"},{"code":"70436003282","type":"NDC"}],"standard_charges":[{"gross_charge":97.44,"discounted_cash":53.59,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Doxycycline Hyclate For Inj 100 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"2622","type":"CDM"},{"code":"70436003235","type":"NDC"}],"standard_charges":[{"gross_charge":97.44,"discounted_cash":53.59,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Pantoprazole Sodium EC Tab 40 MG (Base Equiv)","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"26225","type":"CDM"},{"code":"50268063915","type":"NDC"}],"standard_charges":[{"gross_charge":21.14,"discounted_cash":11.63,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Pantoprazole Sodium For IV Soln 40 MG (Base Equiv)","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"26226","type":"CDM"},{"code":"70095002402","type":"NDC"}],"standard_charges":[{"gross_charge":27.4,"discounted_cash":15.07,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Pantoprazole Sodium For IV Soln 40 MG (Base Equiv)","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"26226","type":"CDM"},{"code":"70095002401","type":"NDC"}],"standard_charges":[{"gross_charge":27.4,"discounted_cash":15.07,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Droperidol Inj 2.5 MG/ML","drug_information":{"unit":2.0,"type":"ML"},"code_information":[{"code":"2654","type":"CDM"},{"code":"517970225","type":"NDC"}],"standard_charges":[{"gross_charge":73.09,"discounted_cash":40.20,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Oseltamivir Phosphate Cap 75 MG (Base Equiv)","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"26546","type":"CDM"},{"code":"68180067711","type":"NDC"}],"standard_charges":[{"gross_charge":50.51,"discounted_cash":27.78,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Levetiracetam Tab 250 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"26816","type":"CDM"},{"code":"68084085911","type":"NDC"}],"standard_charges":[{"gross_charge":10.67,"discounted_cash":5.87,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Levetiracetam Tab 500 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"26817","type":"CDM"},{"code":"60687065701","type":"NDC"}],"standard_charges":[{"gross_charge":11.2,"discounted_cash":6.16,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Dofetilide Cap 125 MCG (0.125 MG)","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"26965","type":"CDM"},{"code":"72205003960","type":"NDC"}],"standard_charges":[{"gross_charge":40.16,"discounted_cash":22.09,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Acetaminophen Liquid 160 MG/5ML","drug_information":{"unit":5.0,"type":"ML"},"code_information":[{"code":"26969","type":"CDM"},{"code":"54859080916","type":"NDC"}],"standard_charges":[{"gross_charge":3.07,"discounted_cash":1.69,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Methacholine Chloride Inhal For Soln 100 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"27032","type":"CDM"},{"code":"64281010000","type":"NDC"}],"standard_charges":[{"gross_charge":243.94,"discounted_cash":134.17,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Oxcarbazepine Tab 150 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"27049","type":"CDM"},{"code":"50268067911","type":"NDC"}],"standard_charges":[{"gross_charge":11.03,"discounted_cash":6.07,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Oxcarbazepine Tab 150 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"27049","type":"CDM"},{"code":"50268067915","type":"NDC"}],"standard_charges":[{"gross_charge":11.03,"discounted_cash":6.07,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Nitroglycerin TL Soln 0.4 MG/SPRAY (400 MCG/SPRAY)","drug_information":{"unit":4.9,"type":"GM"},"code_information":[{"code":"27096","type":"CDM"},{"code":"28595055049","type":"NDC"}],"standard_charges":[{"gross_charge":660.73,"discounted_cash":363.40,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Charcoal Activated Liq","drug_information":{"unit":120.0,"type":"ML"},"code_information":[{"code":"27099","type":"CDM"},{"code":"66689020108","type":"NDC"}],"standard_charges":[{"gross_charge":107.25,"discounted_cash":58.99,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Charcoal Activated Liq","drug_information":{"unit":120.0,"type":"ML"},"code_information":[{"code":"27099","type":"CDM"},{"code":"574052174","type":"NDC"}],"standard_charges":[{"gross_charge":91.23,"discounted_cash":50.18,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Charcoal Activated Liq","drug_information":{"unit":120.0,"type":"ML"},"code_information":[{"code":"27099","type":"CDM"},{"code":"574052176","type":"NDC"}],"standard_charges":[{"gross_charge":69.87,"discounted_cash":38.43,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Ceftazidime For IV Soln 2 GM","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"27291","type":"CDM"},{"code":"25021012867","type":"NDC"}],"standard_charges":[{"gross_charge":54.78,"discounted_cash":30.13,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Ceftazidime For IV Soln 2 GM","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"27291","type":"CDM"},{"code":"25021012850","type":"NDC"}],"standard_charges":[{"gross_charge":67.3,"discounted_cash":37.02,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Mineral Oil Light (Bulk)","drug_information":{"unit":10.0,"type":"ML"},"code_information":[{"code":"27386","type":"CDM"},{"code":"63323025410","type":"NDC"}],"standard_charges":[{"gross_charge":113.26,"discounted_cash":62.29,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Dinoprostone Vaginal Inserts 10 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"27467","type":"CDM"},{"code":"55566280001","type":"NDC"}],"standard_charges":[{"gross_charge":965.32,"discounted_cash":530.93,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Nitroglycerin TD Patch 24HR 0.1 MG/HR","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"27471","type":"CDM"},{"code":"378910293","type":"NDC"}],"standard_charges":[{"gross_charge":24.16,"discounted_cash":13.29,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Nitroglycerin TD Patch 24HR 0.2 MG/HR","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"27472","type":"CDM"},{"code":"378910493","type":"NDC"}],"standard_charges":[{"gross_charge":24.32,"discounted_cash":13.38,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Nitroglycerin TD Patch 24HR 0.6 MG/HR","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"27475","type":"CDM"},{"code":"378911616","type":"NDC"}],"standard_charges":[{"gross_charge":17.22,"discounted_cash":9.47,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Dextromethorphan-Guaifenesin Tab ER 12HR 30-600 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"27543","type":"CDM"},{"code":"63824005632","type":"NDC"}],"standard_charges":[{"gross_charge":11.44,"discounted_cash":6.29,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Fluorescein Sodium Ophth Strips 1 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"27663","type":"CDM"},{"code":"83851010030","type":"NDC"}],"standard_charges":[{"gross_charge":9.25,"discounted_cash":5.09,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Scopolamine TD Patch 72HR 1 MG/3DAYS","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"27696","type":"CDM"},{"code":"50742050524","type":"NDC"}],"standard_charges":[{"gross_charge":71.18,"discounted_cash":39.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Scopolamine TD Patch 72HR 1 MG/3DAYS","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"27696","type":"CDM"},{"code":"50742050510","type":"NDC"}],"standard_charges":[{"gross_charge":71.18,"discounted_cash":39.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Ondansetron Orally Disintegrating Tab 4 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"27697","type":"CDM"},{"code":"68462015740","type":"NDC"}],"standard_charges":[{"gross_charge":103.84,"discounted_cash":57.11,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Ondansetron Orally Disintegrating Tab 4 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"27697","type":"CDM"},{"code":"68462015713","type":"NDC"}],"standard_charges":[{"gross_charge":103.84,"discounted_cash":57.11,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Iopamidol IV Soln 61%","drug_information":{"unit":30.0,"type":"ML"},"code_information":[{"code":"27737","type":"CDM"},{"code":"270131525","type":"NDC"}],"standard_charges":[{"gross_charge":160.19,"discounted_cash":88.10,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Iopamidol IV Soln 61%","drug_information":{"unit":100.0,"type":"ML"},"code_information":[{"code":"27737","type":"CDM"},{"code":"270131535","type":"NDC"}],"standard_charges":[{"gross_charge":295.75,"discounted_cash":162.66,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Sodium Chloride IV Soln 0.9%","drug_information":{"unit":1000.0,"type":"ML"},"code_information":[{"code":"27838","type":"CDM"},{"code":"264780009","type":"NDC"}],"standard_charges":[{"gross_charge":63.59,"discounted_cash":34.97,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Sodium Chloride IV Soln 0.9%","drug_information":{"unit":150.0,"type":"ML"},"code_information":[{"code":"27838","type":"CDM"},{"code":"990798361","type":"NDC"}],"standard_charges":[{"gross_charge":68.64,"discounted_cash":37.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Sodium Chloride IV Soln 0.9%","drug_information":{"unit":500.0,"type":"ML"},"code_information":[{"code":"27838","type":"CDM"},{"code":"264780010","type":"NDC"}],"standard_charges":[{"gross_charge":65.12,"discounted_cash":35.82,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Sodium Chloride IV Soln 0.9%","drug_information":{"unit":100.0,"type":"ML"},"code_information":[{"code":"27838","type":"CDM"},{"code":"264180032","type":"NDC"}],"standard_charges":[{"gross_charge":62.69,"discounted_cash":34.48,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Sodium Chloride IV Soln 0.9%","drug_information":{"unit":50.0,"type":"ML"},"code_information":[{"code":"27838","type":"CDM"},{"code":"264180031","type":"NDC"}],"standard_charges":[{"gross_charge":62.46,"discounted_cash":34.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Sodium Chloride IV Soln 0.9%","drug_information":{"unit":250.0,"type":"ML"},"code_information":[{"code":"27838","type":"CDM"},{"code":"264780020","type":"NDC"}],"standard_charges":[{"gross_charge":64.36,"discounted_cash":35.40,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Venlafaxine HCl Cap ER 24HR 37.5 MG (Base Equivalent)","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"27857","type":"CDM"},{"code":"68084069811","type":"NDC"}],"standard_charges":[{"gross_charge":22.41,"discounted_cash":12.33,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Venlafaxine HCl Cap ER 24HR 37.5 MG (Base Equivalent)","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"27857","type":"CDM"},{"code":"68084069801","type":"NDC"}],"standard_charges":[{"gross_charge":22.41,"discounted_cash":12.33,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Venlafaxine HCl Cap ER 24HR 75 MG (Base Equivalent)","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"27858","type":"CDM"},{"code":"65862052890","type":"NDC"}],"standard_charges":[{"gross_charge":25.96,"discounted_cash":14.28,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Venlafaxine HCl Cap ER 24HR 150 MG (Base Equivalent)","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"27859","type":"CDM"},{"code":"68084071301","type":"NDC"}],"standard_charges":[{"gross_charge":25.6,"discounted_cash":14.08,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Venlafaxine HCl Cap ER 24HR 150 MG (Base Equivalent)","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"27859","type":"CDM"},{"code":"68084071311","type":"NDC"}],"standard_charges":[{"gross_charge":25.6,"discounted_cash":14.08,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Nicotine TD Patch 24HR 7 MG/24HR","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"27860","type":"CDM"},{"code":"536589488","type":"NDC"}],"standard_charges":[{"gross_charge":16.25,"discounted_cash":8.94,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Nicotine TD Patch 24HR 14 MG/24HR","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"27862","type":"CDM"},{"code":"536589588","type":"NDC"}],"standard_charges":[{"gross_charge":15.92,"discounted_cash":8.76,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Nicotine TD Patch 24HR 21 MG/24HR","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"27863","type":"CDM"},{"code":"536589688","type":"NDC"}],"standard_charges":[{"gross_charge":16.25,"discounted_cash":8.94,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Nicotine TD Patch 24HR 21 MG/24HR","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"27863","type":"CDM"},{"code":"536110888","type":"NDC"}],"standard_charges":[{"gross_charge":16.25,"discounted_cash":8.94,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Lidocaine HCl Viscous Soln 2%","drug_information":{"unit":5.0,"type":"ML"},"code_information":[{"code":"27898","type":"CDM"},{"code":"121495040","type":"NDC"}],"standard_charges":[{"gross_charge":46.68,"discounted_cash":25.67,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Lidocaine HCl Viscous Soln 2%","drug_information":{"unit":5.0,"type":"ML"},"code_information":[{"code":"27898","type":"CDM"},{"code":"121495015","type":"NDC"}],"standard_charges":[{"gross_charge":46.68,"discounted_cash":25.67,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Lidocaine HCl Viscous Soln 2%","drug_information":{"unit":100.0,"type":"ML"},"code_information":[{"code":"27898","type":"CDM"},{"code":"54350049","type":"NDC"}],"standard_charges":[{"gross_charge":97.2,"discounted_cash":53.46,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Lidocaine HCl Viscous Soln 2%","drug_information":{"unit":5.0,"type":"ML"},"code_information":[{"code":"27898","type":"CDM"},{"code":"121095003","type":"NDC"}],"standard_charges":[{"gross_charge":57.8,"discounted_cash":31.79,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Fentanyl TD Patch 72HR 25 MCG/HR","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"27905","type":"CDM"},{"code":"47781042447","type":"NDC"}],"standard_charges":[{"gross_charge":98.3,"discounted_cash":54.06,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Fentanyl TD Patch 72HR 50 MCG/HR","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"27906","type":"CDM"},{"code":"47781042647","type":"NDC"}],"standard_charges":[{"gross_charge":131.71,"discounted_cash":72.44,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Fentanyl TD Patch 72HR 75 MCG/HR","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"27907","type":"CDM"},{"code":"406907576","type":"NDC"}],"standard_charges":[{"gross_charge":135.03,"discounted_cash":74.27,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Fentanyl TD Patch 72HR 75 MCG/HR","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"27907","type":"CDM"},{"code":"47781042747","type":"NDC"}],"standard_charges":[{"gross_charge":153.11,"discounted_cash":84.21,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Fentanyl TD Patch 72HR 100 MCG/HR","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"27908","type":"CDM"},{"code":"406900076","type":"NDC"}],"standard_charges":[{"gross_charge":141.22,"discounted_cash":77.67,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Parenteral Therapy Supplies - Misc","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"2795","type":"CDM"},{"code":"63323000130","type":"NDC"}],"standard_charges":[{"gross_charge":38.85,"discounted_cash":21.37,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Sodium Polystyrene Sulfonate Susp 15 GM/60ML","drug_information":{"unit":60.0,"type":"ML"},"code_information":[{"code":"27999","type":"CDM"},{"code":"46287000660","type":"NDC"}],"standard_charges":[{"gross_charge":146.04,"discounted_cash":80.32,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Benzocaine-Menthol Aerosol 20-0.5%","drug_information":{"unit":78.0,"type":"GM"},"code_information":[{"code":"28048","type":"CDM"},{"code":"51409000722","type":"NDC"}],"standard_charges":[{"gross_charge":48.93,"discounted_cash":26.91,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Olanzapine Orally Disintegrating Tab 5 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"28159","type":"CDM"},{"code":"55111026281","type":"NDC"}],"standard_charges":[{"gross_charge":15.99,"discounted_cash":8.79,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Olanzapine Orally Disintegrating Tab 5 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"28159","type":"CDM"},{"code":"55111026279","type":"NDC"}],"standard_charges":[{"gross_charge":16.01,"discounted_cash":8.81,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Olanzapine Orally Disintegrating Tab 10 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"28160","type":"CDM"},{"code":"33342008407","type":"NDC"}],"standard_charges":[{"gross_charge":64.83,"discounted_cash":35.66,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Chlorhexidine Gluconate Soln 4%","drug_information":{"unit":15.0,"type":"ML"},"code_information":[{"code":"28188","type":"CDM"},{"code":"32319020027","type":"NDC"}],"standard_charges":[{"gross_charge":21.87,"discounted_cash":12.03,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Lidocaine Patch 5%","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"28203","type":"CDM"},{"code":"603188016","type":"NDC"}],"standard_charges":[{"gross_charge":36.26,"discounted_cash":19.94,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Lidocaine Patch 5%","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"28203","type":"CDM"},{"code":"591267930","type":"NDC"}],"standard_charges":[{"gross_charge":38.89,"discounted_cash":21.39,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Lidocaine Patch 5%","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"28203","type":"CDM"},{"code":"65162079108","type":"NDC"}],"standard_charges":[{"gross_charge":36.26,"discounted_cash":19.94,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Linezolid Tab 600 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"28224","type":"CDM"},{"code":"904655304","type":"NDC"}],"standard_charges":[{"gross_charge":271.7,"discounted_cash":149.44,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Pentamidine Isethionate For Nebulization Soln 300 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"28235","type":"CDM"},{"code":"13925052201","type":"NDC"}],"standard_charges":[{"gross_charge":337.85,"discounted_cash":185.82,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Carbidopa & Levodopa Tab ER 25-100 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"28264","type":"CDM"},{"code":"51079097820","type":"NDC"}],"standard_charges":[{"gross_charge":12.14,"discounted_cash":6.68,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Carbidopa & Levodopa Tab ER 25-100 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"28264","type":"CDM"},{"code":"51079097801","type":"NDC"}],"standard_charges":[{"gross_charge":12.14,"discounted_cash":6.68,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Doxercalciferol Inj 4 MCG/2ML (2 MCG/ML)","drug_information":{"unit":0.5,"type":"ML"},"code_information":[{"code":"28277","type":"CDM"},{"code":"71288080202","type":"NDC"}],"standard_charges":[{"gross_charge":16.76,"discounted_cash":9.22,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Doxercalciferol Inj 4 MCG/2ML (2 MCG/ML)","drug_information":{"unit":0.5,"type":"ML"},"code_information":[{"code":"28277","type":"CDM"},{"code":"71288080204","type":"NDC"}],"standard_charges":[{"gross_charge":16.76,"discounted_cash":9.22,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Azelastine HCl Ophth Soln 0.05%","drug_information":{"unit":6.0,"type":"ML"},"code_information":[{"code":"28351","type":"CDM"},{"code":"60505057804","type":"NDC"}],"standard_charges":[{"gross_charge":303.19,"discounted_cash":166.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Ferric Subsulfate Soln 259 MG/GM","drug_information":{"unit":8.0,"type":"GM"},"code_information":[{"code":"28357","type":"CDM"},{"code":"59365606500","type":"NDC"}],"standard_charges":[{"gross_charge":92.61,"discounted_cash":50.94,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Ferric Subsulfate Soln 259 MG/GM","drug_information":{"unit":8.0,"type":"GM"},"code_information":[{"code":"28357","type":"CDM"},{"code":"59365606501","type":"NDC"}],"standard_charges":[{"gross_charge":92.64,"discounted_cash":50.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Hydrocodone-Acetaminophen Tab 10-325 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"28384","type":"CDM"},{"code":"63629229801","type":"NDC"}],"standard_charges":[{"gross_charge":12.25,"discounted_cash":6.74,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Heparin Sodium (Porcine) Lock Flush IV Soln 100 Unit/ML,Heparin Sodium (Porcine) Lock Flush PF IV Soln 100 Unit/ML","drug_information":{"unit":1.0,"type":"ML"},"code_information":[{"code":"28393","type":"CDM"},{"code":"64253033335","type":"NDC"}],"standard_charges":[{"gross_charge":34.3,"discounted_cash":18.86,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Estradiol TD Patch Weekly 0.05 MG/24HR","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"28408","type":"CDM"},{"code":"378335016","type":"NDC"}],"standard_charges":[{"gross_charge":71.82,"discounted_cash":39.50,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Estradiol TD Patch Weekly 0.05 MG/24HR","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"28408","type":"CDM"},{"code":"378335099","type":"NDC"}],"standard_charges":[{"gross_charge":71.82,"discounted_cash":39.50,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Estradiol TD Patch Weekly 0.1 MG/24HR","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"28409","type":"CDM"},{"code":"378335216","type":"NDC"}],"standard_charges":[{"gross_charge":71.82,"discounted_cash":39.50,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"White Petrolatum Topical Gel","drug_information":{"unit":28.35,"type":"GM"},"code_information":[{"code":"28507","type":"CDM"},{"code":"8438911138","type":"NDC"}],"standard_charges":[{"gross_charge":20.78,"discounted_cash":11.43,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Tenecteplase For IV Soln Kit 50 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"28530","type":"CDM"},{"code":"50242017601","type":"NDC"}],"standard_charges":[{"gross_charge":14468.23,"discounted_cash":7957.53,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Tenecteplase For IV Soln Kit 50 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"28530","type":"CDM"},{"code":"50242003706","type":"NDC"}],"standard_charges":[{"gross_charge":14468.23,"discounted_cash":7957.53,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Electrolyte-R (PH 7.4) Solution","drug_information":{"unit":1000.0,"type":"ML"},"code_information":[{"code":"28605","type":"CDM"},{"code":"990767009","type":"NDC"}],"standard_charges":[{"gross_charge":68.18,"discounted_cash":37.50,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Nifedipine Tab ER 24HR Osmotic Release 30 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"28643","type":"CDM"},{"code":"68084059701","type":"NDC"}],"standard_charges":[{"gross_charge":14.88,"discounted_cash":8.18,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Nifedipine Tab ER 24HR Osmotic Release 30 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"28643","type":"CDM"},{"code":"68084059711","type":"NDC"}],"standard_charges":[{"gross_charge":14.89,"discounted_cash":8.19,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Methylphenidate HCl Tab ER Osmotic Release (OSM) 18 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"28750","type":"CDM"},{"code":"65162023109","type":"NDC"}],"standard_charges":[{"gross_charge":37.67,"discounted_cash":20.72,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Budesonide Inhalation Susp 0.25 MG/2ML","drug_information":{"unit":2.0,"type":"ML"},"code_information":[{"code":"28774","type":"CDM"},{"code":"487960101","type":"NDC"}],"standard_charges":[{"gross_charge":16.33,"discounted_cash":8.98,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Budesonide Inhalation Susp 0.5 MG/2ML","drug_information":{"unit":1.0,"type":"ML"},"code_information":[{"code":"28775","type":"CDM"},{"code":"487970101","type":"NDC"}],"standard_charges":[{"gross_charge":11.26,"discounted_cash":6.19,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Divalproex Sodium Tab ER 24 HR 500 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"28812","type":"CDM"},{"code":"50268026011","type":"NDC"}],"standard_charges":[{"gross_charge":14.34,"discounted_cash":7.89,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Divalproex Sodium Tab ER 24 HR 500 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"28812","type":"CDM"},{"code":"50268026013","type":"NDC"}],"standard_charges":[{"gross_charge":14.34,"discounted_cash":7.89,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Magnesium Hydroxide Susp 400 MG/5ML","drug_information":{"unit":15.0,"type":"ML"},"code_information":[{"code":"28836","type":"CDM"},{"code":"904078816","type":"NDC"}],"standard_charges":[{"gross_charge":18.0,"discounted_cash":9.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Magnesium Hydroxide Susp 400 MG/5ML","drug_information":{"unit":15.0,"type":"ML"},"code_information":[{"code":"28836","type":"CDM"},{"code":"69339015317","type":"NDC"}],"standard_charges":[{"gross_charge":23.01,"discounted_cash":12.66,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Cyclosporine Modified Cap 25 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"28842","type":"CDM"},{"code":"93901819","type":"NDC"}],"standard_charges":[{"gross_charge":13.29,"discounted_cash":7.31,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Erythromycin Ophth Oint 5 MG/GM","drug_information":{"unit":3.5,"type":"GM"},"code_information":[{"code":"2888","type":"CDM"},{"code":"24208091055","type":"NDC"}],"standard_charges":[{"gross_charge":70.7,"discounted_cash":38.88,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Erythromycin Ophth Oint 5 MG/GM","drug_information":{"unit":1.0,"type":"GM"},"code_information":[{"code":"2888","type":"CDM"},{"code":"72485067031","type":"NDC"}],"standard_charges":[{"gross_charge":63.1,"discounted_cash":34.70,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Erythromycin Tab 250 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"2889","type":"CDM"},{"code":"75834024230","type":"NDC"}],"standard_charges":[{"gross_charge":44.38,"discounted_cash":24.41,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Argatroban Inj 250 MG/2.5ML (Concentrate For IV Infusion)","drug_information":{"unit":2.5,"type":"ML"},"code_information":[{"code":"28947","type":"CDM"},{"code":"67457021202","type":"NDC"}],"standard_charges":[{"gross_charge":1071.4,"discounted_cash":589.27,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Levofloxacin Tab 750 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"28964","type":"CDM"},{"code":"904635361","type":"NDC"}],"standard_charges":[{"gross_charge":49.96,"discounted_cash":27.48,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Samarium Sm 153 Lexidronam Inj 1850 MBq/ML (50 mCi/ML)","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"28965","type":"CDM"},{"code":"11994001601","type":"NDC"}],"standard_charges":[{"gross_charge":21693.41,"discounted_cash":11931.38,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Metformin HCl Tab ER 24HR 500 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"28995","type":"CDM"},{"code":"67877015901","type":"NDC"}],"standard_charges":[{"gross_charge":11.44,"discounted_cash":6.29,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Erythromycin Ethylsuccinate For Susp 400 MG/5ML","drug_information":{"unit":2.5,"type":"ML"},"code_information":[{"code":"2900","type":"CDM"},{"code":"75834029401","type":"NDC"}],"standard_charges":[{"gross_charge":66.89,"discounted_cash":36.79,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Iron Sucrose Inj 20 MG/ML (Fe Equiv)","drug_information":{"unit":2.5,"type":"ML"},"code_information":[{"code":"29132","type":"CDM"},{"code":"517234025","type":"NDC"}],"standard_charges":[{"gross_charge":138.17,"discounted_cash":75.99,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Iron Sucrose Inj 20 MG/ML (Fe Equiv)","drug_information":{"unit":2.5,"type":"ML"},"code_information":[{"code":"29132","type":"CDM"},{"code":"517234010","type":"NDC"}],"standard_charges":[{"gross_charge":138.17,"discounted_cash":75.99,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Diltiazem HCl Coated Beads Cap ER 24HR 120 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"29270","type":"CDM"},{"code":"50742024890","type":"NDC"}],"standard_charges":[{"gross_charge":12.61,"discounted_cash":6.94,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Diltiazem HCl Coated Beads Cap ER 24HR 180 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"29272","type":"CDM"},{"code":"60687020601","type":"NDC"}],"standard_charges":[{"gross_charge":12.3,"discounted_cash":6.76,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Prednisolone Sod Phosphate Oral Soln 15 MG/5ML (Base Equiv)","drug_information":{"unit":5.0,"type":"ML"},"code_information":[{"code":"29302","type":"CDM"},{"code":"121075908","type":"NDC"}],"standard_charges":[{"gross_charge":23.94,"discounted_cash":13.17,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Hydrocortisone Perianal Cream 2.5%","drug_information":{"unit":28.0,"type":"GM"},"code_information":[{"code":"29371","type":"CDM"},{"code":"69315031228","type":"NDC"}],"standard_charges":[{"gross_charge":340.4,"discounted_cash":187.22,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Tolterodine Tartrate Cap ER 24HR 2 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"29434","type":"CDM"},{"code":"43975032203","type":"NDC"}],"standard_charges":[{"gross_charge":34.52,"discounted_cash":18.99,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Morphine Sulfate Inj PF 0.5 MG/ML","drug_information":{"unit":10.0,"type":"ML"},"code_information":[{"code":"29464","type":"CDM"},{"code":"409381412","type":"NDC"}],"standard_charges":[{"gross_charge":128.75,"discounted_cash":70.81,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Ethyl Chloride Aerosol Spray","drug_information":{"unit":1.0,"type":"ML"},"code_information":[{"code":"2951","type":"CDM"},{"code":"386000113","type":"NDC"}],"standard_charges":[{"gross_charge":18.36,"discounted_cash":10.10,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Ziprasidone HCl Cap 20 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"29778","type":"CDM"},{"code":"63739098832","type":"NDC"}],"standard_charges":[{"gross_charge":20.85,"discounted_cash":11.47,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Ziprasidone HCl Cap 40 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"29779","type":"CDM"},{"code":"904627008","type":"NDC"}],"standard_charges":[{"gross_charge":37.58,"discounted_cash":20.67,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Metoprolol Succinate Tab ER 24HR 25 MG (Tartrate Equiv)","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"29858","type":"CDM"},{"code":"904632206","type":"NDC"}],"standard_charges":[{"gross_charge":10.91,"discounted_cash":6.00,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Buspirone HCl Tab 7.5 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"29967","type":"CDM"},{"code":"60687080121","type":"NDC"}],"standard_charges":[{"gross_charge":16.91,"discounted_cash":9.30,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Influenza Virus Vaccine Split PF Susp Pref Syringe 0.5 ML","drug_information":{"unit":0.5,"type":"ML"},"code_information":[{"code":"300497","type":"CDM"},{"code":"19515090441","type":"NDC"}],"standard_charges":[{"gross_charge":26.0,"discounted_cash":14.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Influenza Virus Vaccine Split PF Susp Pref Syringe 0.5 ML","drug_information":{"unit":0.5,"type":"ML"},"code_information":[{"code":"300497","type":"CDM"},{"code":"19515090452","type":"NDC"}],"standard_charges":[{"gross_charge":26.0,"discounted_cash":14.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Metoprolol Succinate Tab ER 24HR 100 MG (Tartrate Equiv)","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"30071","type":"CDM"},{"code":"904632461","type":"NDC"}],"standard_charges":[{"gross_charge":15.18,"discounted_cash":8.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Citalopram Hydrobromide Tab 10 MG (Base Equiv)","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"30264","type":"CDM"},{"code":"904608461","type":"NDC"}],"standard_charges":[{"gross_charge":18.9,"discounted_cash":10.40,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Citalopram Hydrobromide Tab 10 MG (Base Equiv)","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"30264","type":"CDM"},{"code":"68084073711","type":"NDC"}],"standard_charges":[{"gross_charge":18.97,"discounted_cash":10.43,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Ipratropium-Albuterol Nebu Soln 0.5-2.5(3) MG/3ML","drug_information":{"unit":3.0,"type":"ML"},"code_information":[{"code":"30510","type":"CDM"},{"code":"76204060001","type":"NDC"}],"standard_charges":[{"gross_charge":18.71,"discounted_cash":10.29,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Hydromorphone HCl-Sodium Chloride 0.9% Inj 1 MG/ML","drug_information":{"unit":50.0,"type":"ML"},"code_information":[{"code":"30601","type":"CDM"},{"code":"8888802316","type":"NDC"}],"standard_charges":[{"gross_charge":153.96,"discounted_cash":84.68,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Allopurinol Tab 100 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"310","type":"CDM"},{"code":"60687067711","type":"NDC"}],"standard_charges":[{"gross_charge":10.22,"discounted_cash":5.62,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Allopurinol Tab 100 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"310","type":"CDM"},{"code":"60687067701","type":"NDC"}],"standard_charges":[{"gross_charge":10.22,"discounted_cash":5.62,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Amoxicillin & K Clavulanate For Susp 600-42.9 MG/5ML","drug_information":{"unit":125.0,"type":"ML"},"code_information":[{"code":"31177","type":"CDM"},{"code":"65862053513","type":"NDC"}],"standard_charges":[{"gross_charge":377.35,"discounted_cash":207.54,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Valsartan Tab 80 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"31209","type":"CDM"},{"code":"43547036809","type":"NDC"}],"standard_charges":[{"gross_charge":26.6,"discounted_cash":14.63,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Valsartan Tab 160 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"31210","type":"CDM"},{"code":"50268074815","type":"NDC"}],"standard_charges":[{"gross_charge":14.04,"discounted_cash":7.72,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Valsartan Tab 160 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"31210","type":"CDM"},{"code":"50268074811","type":"NDC"}],"standard_charges":[{"gross_charge":14.04,"discounted_cash":7.72,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Sodium Phosphates - Enema","drug_information":{"unit":133.0,"type":"ML"},"code_information":[{"code":"3123","type":"CDM"},{"code":"132020140","type":"NDC"}],"standard_charges":[{"gross_charge":25.88,"discounted_cash":14.23,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Sodium Phosphates - Enema (Pediatric)","drug_information":{"unit":33.3,"type":"ML"},"code_information":[{"code":"3128","type":"CDM"},{"code":"132020220","type":"NDC"}],"standard_charges":[{"gross_charge":22.33,"discounted_cash":12.28,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Alteplase For Inj 2 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"31310","type":"CDM"},{"code":"50242004164","type":"NDC"}],"standard_charges":[{"gross_charge":326.58,"discounted_cash":179.62,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Digoxin Immune Fab For Inj 40 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"31432","type":"CDM"},{"code":"50633012011","type":"NDC"}],"standard_charges":[{"gross_charge":8685.76,"discounted_cash":4777.17,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Tenofovir Disoproxil Fumarate Tab 300 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"31684","type":"CDM"},{"code":"904682104","type":"NDC"}],"standard_charges":[{"gross_charge":26.67,"discounted_cash":14.67,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Paricalcitol IV Soln 2 MCG/ML","drug_information":{"unit":0.5,"type":"ML"},"code_information":[{"code":"31688","type":"CDM"},{"code":"74463701","type":"NDC"}],"standard_charges":[{"gross_charge":20.59,"discounted_cash":11.32,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Oxycodone w/ Acetaminophen Tab 7.5-325 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"31863","type":"CDM"},{"code":"406052223","type":"NDC"}],"standard_charges":[{"gross_charge":22.51,"discounted_cash":12.38,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Oxycodone w/ Acetaminophen Tab 7.5-325 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"31863","type":"CDM"},{"code":"406052262","type":"NDC"}],"standard_charges":[{"gross_charge":22.53,"discounted_cash":12.39,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Oxycodone w/ Acetaminophen Tab 10-325 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"31864","type":"CDM"},{"code":"904709561","type":"NDC"}],"standard_charges":[{"gross_charge":13.53,"discounted_cash":7.44,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Fluphenazine Decanoate Inj 25 MG/ML","drug_information":{"unit":0.5,"type":"ML"},"code_information":[{"code":"3215","type":"CDM"},{"code":"55150026705","type":"NDC"}],"standard_charges":[{"gross_charge":70.6,"discounted_cash":38.83,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Fluphenazine HCl Tab 1 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"3218","type":"CDM"},{"code":"527178801","type":"NDC"}],"standard_charges":[{"gross_charge":24.91,"discounted_cash":13.70,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Fluphenazine HCl Tab 5 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"3221","type":"CDM"},{"code":"70954027510","type":"NDC"}],"standard_charges":[{"gross_charge":38.36,"discounted_cash":21.10,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Fondaparinux Sodium Subcutaneous Inj 2.5 MG/0.5ML","drug_information":{"unit":0.5,"type":"ML"},"code_information":[{"code":"32215","type":"CDM"},{"code":"67457058200","type":"NDC"}],"standard_charges":[{"gross_charge":137.57,"discounted_cash":75.66,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Folic Acid Inj 5 MG/ML","drug_information":{"unit":0.2,"type":"ML"},"code_information":[{"code":"3232","type":"CDM"},{"code":"63323018410","type":"NDC"}],"standard_charges":[{"gross_charge":36.06,"discounted_cash":19.83,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Folic Acid Tab 1 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"3233","type":"CDM"},{"code":"904722461","type":"NDC"}],"standard_charges":[{"gross_charge":8.9,"discounted_cash":4.90,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Alprazolam Tab 0.25 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"324","type":"CDM"},{"code":"781106101","type":"NDC"}],"standard_charges":[{"gross_charge":11.09,"discounted_cash":6.10,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Alprazolam Tab 0.5 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"325","type":"CDM"},{"code":"59762372001","type":"NDC"}],"standard_charges":[{"gross_charge":11.31,"discounted_cash":6.22,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Furosemide Inj 10 MG/ML","drug_information":{"unit":10.0,"type":"ML"},"code_information":[{"code":"3291","type":"CDM"},{"code":"25021031110","type":"NDC"}],"standard_charges":[{"gross_charge":6.5,"discounted_cash":3.58,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Furosemide Inj 10 MG/ML","drug_information":{"unit":2.0,"type":"ML"},"code_information":[{"code":"3291","type":"CDM"},{"code":"25021031102","type":"NDC"}],"standard_charges":[{"gross_charge":6.34,"discounted_cash":3.49,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Furosemide Inj 10 MG/ML","drug_information":{"unit":2.0,"type":"ML"},"code_information":[{"code":"3291","type":"CDM"},{"code":"409610225","type":"NDC"}],"standard_charges":[{"gross_charge":9.34,"discounted_cash":5.14,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Furosemide Inj 10 MG/ML","drug_information":{"unit":4.0,"type":"ML"},"code_information":[{"code":"3291","type":"CDM"},{"code":"71288020305","type":"NDC"}],"standard_charges":[{"gross_charge":6.11,"discounted_cash":3.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Furosemide Inj 10 MG/ML","drug_information":{"unit":4.0,"type":"ML"},"code_information":[{"code":"3291","type":"CDM"},{"code":"71288020304","type":"NDC"}],"standard_charges":[{"gross_charge":6.11,"discounted_cash":3.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Furosemide Inj 10 MG/ML","drug_information":{"unit":2.0,"type":"ML"},"code_information":[{"code":"3291","type":"CDM"},{"code":"409610235","type":"NDC"}],"standard_charges":[{"gross_charge":9.33,"discounted_cash":5.13,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Furosemide Tab 20 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"3294","type":"CDM"},{"code":"904717761","type":"NDC"}],"standard_charges":[{"gross_charge":8.4,"discounted_cash":4.62,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Imatinib Mesylate Tab 100 MG (Base Equivalent)","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"32979","type":"CDM"},{"code":"93762998","type":"NDC"}],"standard_charges":[{"gross_charge":205.2,"discounted_cash":112.86,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Voriconazole Tab 50 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"33008","type":"CDM"},{"code":"27241006203","type":"NDC"}],"standard_charges":[{"gross_charge":62.67,"discounted_cash":34.47,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Voriconazole Tab 200 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"33009","type":"CDM"},{"code":"27241006303","type":"NDC"}],"standard_charges":[{"gross_charge":163.06,"discounted_cash":89.68,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Voriconazole Tab 200 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"33009","type":"CDM"},{"code":"63739000833","type":"NDC"}],"standard_charges":[{"gross_charge":73.18,"discounted_cash":40.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Voriconazole For Inj 200 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"33010","type":"CDM"},{"code":"71288002730","type":"NDC"}],"standard_charges":[{"gross_charge":123.4,"discounted_cash":67.87,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Sodium Hyaluronate Intraocular Soln Pref Syr 13.8 MG/0.6ML","drug_information":{"unit":0.6,"type":"ML"},"code_information":[{"code":"33109","type":"CDM"},{"code":"85446036991","type":"NDC"}],"standard_charges":[{"gross_charge":219.55,"discounted_cash":120.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Ziprasidone Mesylate For Inj 20 MG (Base Equivalent)","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"33175","type":"CDM"},{"code":"72205020507","type":"NDC"}],"standard_charges":[{"gross_charge":117.33,"discounted_cash":64.53,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Ziprasidone Mesylate For Inj 20 MG (Base Equivalent)","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"33175","type":"CDM"},{"code":"72205020501","type":"NDC"}],"standard_charges":[{"gross_charge":117.33,"discounted_cash":64.53,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Amoxicillin & K Clavulanate Tab 500-125 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"33227","type":"CDM"},{"code":"65862050220","type":"NDC"}],"standard_charges":[{"gross_charge":22.57,"discounted_cash":12.41,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Amoxicillin & K Clavulanate Tab 500-125 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"33227","type":"CDM"},{"code":"93227434","type":"NDC"}],"standard_charges":[{"gross_charge":22.57,"discounted_cash":12.41,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Amoxicillin & K Clavulanate Tab 875-125 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"33228","type":"CDM"},{"code":"65862050301","type":"NDC"}],"standard_charges":[{"gross_charge":27.06,"discounted_cash":14.88,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Amoxicillin & K Clavulanate For Susp 400-57 MG/5ML","drug_information":{"unit":50.0,"type":"ML"},"code_information":[{"code":"33230","type":"CDM"},{"code":"65862053450","type":"NDC"}],"standard_charges":[{"gross_charge":173.42,"discounted_cash":95.38,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"B-Complex w/ C & Folic Acid Tab 1 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"33458","type":"CDM"},{"code":"10542001010","type":"NDC"}],"standard_charges":[{"gross_charge":8.89,"discounted_cash":4.89,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Escitalopram Oxalate Tab 10 MG (Base Equiv)","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"33512","type":"CDM"},{"code":"68084061711","type":"NDC"}],"standard_charges":[{"gross_charge":21.55,"discounted_cash":11.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Escitalopram Oxalate Tab 10 MG (Base Equiv)","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"33512","type":"CDM"},{"code":"68084061701","type":"NDC"}],"standard_charges":[{"gross_charge":21.55,"discounted_cash":11.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Valsartan Tab 40 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"33541","type":"CDM"},{"code":"60687061211","type":"NDC"}],"standard_charges":[{"gross_charge":11.85,"discounted_cash":6.52,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Rasburicase For IV Soln 1.5 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"33591","type":"CDM"},{"code":"24515010","type":"NDC"}],"standard_charges":[{"gross_charge":2042.59,"discounted_cash":1123.42,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Gentamicin Sulfate Cream 0.1%","drug_information":{"unit":15.0,"type":"GM"},"code_information":[{"code":"3423","type":"CDM"},{"code":"45802005635","type":"NDC"}],"standard_charges":[{"gross_charge":207.11,"discounted_cash":113.91,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Gentamicin Sulfate Cream 0.1%","drug_information":{"unit":15.0,"type":"GM"},"code_information":[{"code":"3423","type":"CDM"},{"code":"713068315","type":"NDC"}],"standard_charges":[{"gross_charge":207.11,"discounted_cash":113.91,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Gentamicin Sulfate Inj 10 MG/ML","drug_information":{"unit":2.0,"type":"ML"},"code_information":[{"code":"3425","type":"CDM"},{"code":"63323017302","type":"NDC"}],"standard_charges":[{"gross_charge":59.51,"discounted_cash":32.73,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Gentamicin Sulfate Inj 40 MG/ML","drug_information":{"unit":1.0,"type":"ML"},"code_information":[{"code":"3426","type":"CDM"},{"code":"63323001001","type":"NDC"}],"standard_charges":[{"gross_charge":41.72,"discounted_cash":22.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Gentamicin Sulfate Inj 40 MG/ML","drug_information":{"unit":1.0,"type":"ML"},"code_information":[{"code":"3426","type":"CDM"},{"code":"63323001020","type":"NDC"}],"standard_charges":[{"gross_charge":38.7,"discounted_cash":21.28,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Gentamicin Sulfate Inj 40 MG/ML","drug_information":{"unit":1.0,"type":"ML"},"code_information":[{"code":"3426","type":"CDM"},{"code":"63323001002","type":"NDC"}],"standard_charges":[{"gross_charge":41.72,"discounted_cash":22.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Fentanyl Citrate 2 MCG/ML-Ropivacaine 0.2%-NaCl 0.9% Inj,Fentanyl 0.5 mg/250ml-ropiv 0.2%-NaCl 0.9% epidural inj,Fentanyl Cit 0.2 MG/100ML-Ropiv 0.2%-NaCl 0.9% Epidural Inj","drug_information":{"unit":250.0,"type":"ML"},"code_information":[{"code":"34272","type":"CDM"},{"code":"70092922537","type":"NDC"}],"standard_charges":[{"gross_charge":561.66,"discounted_cash":308.91,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Gentian Violet Soln 1%","drug_information":{"unit":59.0,"type":"ML"},"code_information":[{"code":"3430","type":"CDM"},{"code":"395100392","type":"NDC"}],"standard_charges":[{"gross_charge":54.02,"discounted_cash":29.71,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Divalproex Sodium Tab ER 24 HR 250 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"34418","type":"CDM"},{"code":"68084031011","type":"NDC"}],"standard_charges":[{"gross_charge":17.42,"discounted_cash":9.58,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Divalproex Sodium Tab ER 24 HR 250 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"34418","type":"CDM"},{"code":"68084031001","type":"NDC"}],"standard_charges":[{"gross_charge":17.42,"discounted_cash":9.58,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Atomoxetine HCl Cap 40 MG (Base Equiv)","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"34447","type":"CDM"},{"code":"35573041830","type":"NDC"}],"standard_charges":[{"gross_charge":50.48,"discounted_cash":27.76,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Guaifenesin-Codeine Soln 100-10 MG/5ML","drug_information":{"unit":5.0,"type":"ML"},"code_information":[{"code":"34463","type":"CDM"},{"code":"58657050016","type":"NDC"}],"standard_charges":[{"gross_charge":10.25,"discounted_cash":5.64,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Guaifenesin-Codeine Soln 100-10 MG/5ML","drug_information":{"unit":5.0,"type":"ML"},"code_information":[{"code":"34463","type":"CDM"},{"code":"8883446305","type":"NDC"}],"standard_charges":[{"gross_charge":10.25,"discounted_cash":5.64,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Guaifenesin-Codeine Soln 100-10 MG/5ML","drug_information":{"unit":5.0,"type":"ML"},"code_information":[{"code":"34463","type":"CDM"},{"code":"121177540","type":"NDC"}],"standard_charges":[{"gross_charge":27.14,"discounted_cash":14.93,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Hydrocodone-Acetaminophen Tab 5-325 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"34505","type":"CDM"},{"code":"406012323","type":"NDC"}],"standard_charges":[{"gross_charge":12.27,"discounted_cash":6.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Hydrocodone-Acetaminophen Tab 5-325 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"34505","type":"CDM"},{"code":"406012362","type":"NDC"}],"standard_charges":[{"gross_charge":12.26,"discounted_cash":6.74,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Hydrocodone-Acetaminophen Tab 7.5-325 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"34544","type":"CDM"},{"code":"60687040711","type":"NDC"}],"standard_charges":[{"gross_charge":11.44,"discounted_cash":6.29,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Hydrocodone-Acetaminophen Tab 7.5-325 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"34544","type":"CDM"},{"code":"904682661","type":"NDC"}],"standard_charges":[{"gross_charge":10.0,"discounted_cash":5.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Diph-Tet Tox-Acell Pert-Hep B-Polio IPV Vac Susp Pref Syr","drug_information":{"unit":0.5,"type":"ML"},"code_information":[{"code":"34550","type":"CDM"},{"code":"58160081143","type":"NDC"}],"standard_charges":[{"gross_charge":241.11,"discounted_cash":132.61,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Lansoprazole Tab Delayed Release Orally Disintegrating 30 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"34595","type":"CDM"},{"code":"65862089678","type":"NDC"}],"standard_charges":[{"gross_charge":51.38,"discounted_cash":28.26,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Alum (Potassium) Powder","drug_information":{"unit":10.0,"type":"GM"},"code_information":[{"code":"346","type":"CDM"},{"code":"24357030001","type":"NDC"}],"standard_charges":[{"gross_charge":292.0,"discounted_cash":160.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Buprenorphine HCl SL Tab 2 MG (Base Equiv)","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"34711","type":"CDM"},{"code":"42858050103","type":"NDC"}],"standard_charges":[{"gross_charge":10.85,"discounted_cash":5.97,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Glycine Irrigation Soln 1.5%","drug_information":{"unit":3000.0,"type":"ML"},"code_information":[{"code":"3493","type":"CDM"},{"code":"264739060","type":"NDC"}],"standard_charges":[{"gross_charge":137.15,"discounted_cash":75.43,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Rosuvastatin Calcium Tab 20 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"35135","type":"CDM"},{"code":"50268071015","type":"NDC"}],"standard_charges":[{"gross_charge":13.7,"discounted_cash":7.54,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Rosuvastatin Calcium Tab 20 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"35135","type":"CDM"},{"code":"50268071011","type":"NDC"}],"standard_charges":[{"gross_charge":13.7,"discounted_cash":7.54,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Rosuvastatin Calcium Tab 20 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"35135","type":"CDM"},{"code":"68462026390","type":"NDC"}],"standard_charges":[{"gross_charge":37.52,"discounted_cash":20.64,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Cyclobenzaprine HCl Tab 5 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"35184","type":"CDM"},{"code":"72888001201","type":"NDC"}],"standard_charges":[{"gross_charge":14.32,"discounted_cash":7.88,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Zoledronic Acid Inj Conc For IV Infusion 4 MG/5ML","drug_information":{"unit":5.0,"type":"ML"},"code_information":[{"code":"35640","type":"CDM"},{"code":"16729024231","type":"NDC"}],"standard_charges":[{"gross_charge":1456.09,"discounted_cash":800.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Risperidone Orally Disintegrating Tab 1 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"35687","type":"CDM"},{"code":"59746002022","type":"NDC"}],"standard_charges":[{"gross_charge":26.16,"discounted_cash":14.39,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Moxifloxacin HCl Ophth Soln 0.5% (Base Equiv)","drug_information":{"unit":0.05,"type":"ML"},"code_information":[{"code":"35699","type":"CDM"},{"code":"82667070003","type":"NDC"}],"standard_charges":[{"gross_charge":18.27,"discounted_cash":10.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Haloperidol Tab 0.5 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"3578","type":"CDM"},{"code":"51079073301","type":"NDC"}],"standard_charges":[{"gross_charge":9.54,"discounted_cash":5.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Haloperidol Tab 0.5 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"3578","type":"CDM"},{"code":"51079073320","type":"NDC"}],"standard_charges":[{"gross_charge":9.54,"discounted_cash":5.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Haloperidol Tab 1 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"3579","type":"CDM"},{"code":"51079073401","type":"NDC"}],"standard_charges":[{"gross_charge":10.18,"discounted_cash":5.60,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Haloperidol Tab 5 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"3583","type":"CDM"},{"code":"904678261","type":"NDC"}],"standard_charges":[{"gross_charge":12.04,"discounted_cash":6.62,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Haloperidol Lactate Inj 5 MG/ML","drug_information":{"unit":0.4,"type":"ML"},"code_information":[{"code":"3584","type":"CDM"},{"code":"63323047400","type":"NDC"}],"standard_charges":[{"gross_charge":40.49,"discounted_cash":22.27,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Haloperidol Lactate Inj 5 MG/ML","drug_information":{"unit":0.4,"type":"ML"},"code_information":[{"code":"3584","type":"CDM"},{"code":"63323047401","type":"NDC"}],"standard_charges":[{"gross_charge":40.49,"discounted_cash":22.27,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Haloperidol Lactate Oral Conc 2 MG/ML","drug_information":{"unit":120.0,"type":"ML"},"code_information":[{"code":"3585","type":"CDM"},{"code":"54838050140","type":"NDC"}],"standard_charges":[{"gross_charge":249.9,"discounted_cash":137.44,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Potassium Chloride Microencapsulated Crys ER Tab 10 mEq","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"35942","type":"CDM"},{"code":"832532411","type":"NDC"}],"standard_charges":[{"gross_charge":10.65,"discounted_cash":5.86,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"KCl 20 MEQ/L (0.15%) in NaCl 0.45% Inj","drug_information":{"unit":1000.0,"type":"ML"},"code_information":[{"code":"36046","type":"CDM"},{"code":"990925739","type":"NDC"}],"standard_charges":[{"gross_charge":71.24,"discounted_cash":39.18,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Emtricitabine Caps 200 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"36252","type":"CDM"},{"code":"69097064202","type":"NDC"}],"standard_charges":[{"gross_charge":61.11,"discounted_cash":33.61,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Amantadine HCl Cap 100 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"364","type":"CDM"},{"code":"904704206","type":"NDC"}],"standard_charges":[{"gross_charge":14.48,"discounted_cash":7.96,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Amantadine HCl Cap 100 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"364","type":"CDM"},{"code":"50268006915","type":"NDC"}],"standard_charges":[{"gross_charge":21.41,"discounted_cash":11.78,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Amantadine HCl Cap 100 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"364","type":"CDM"},{"code":"50268006911","type":"NDC"}],"standard_charges":[{"gross_charge":21.41,"discounted_cash":11.78,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Aripiprazole Tab 5 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"36438","type":"CDM"},{"code":"904736706","type":"NDC"}],"standard_charges":[{"gross_charge":12.6,"discounted_cash":6.93,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Aripiprazole Tab 5 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"36438","type":"CDM"},{"code":"65162089709","type":"NDC"}],"standard_charges":[{"gross_charge":78.57,"discounted_cash":43.21,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Ciprofloxacin-Dexamethasone Otic Susp 0.3-0.1%","drug_information":{"unit":7.5,"type":"ML"},"code_information":[{"code":"36576","type":"CDM"},{"code":"43598032675","type":"NDC"}],"standard_charges":[{"gross_charge":841.55,"discounted_cash":462.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Levetiracetam Oral Soln 100 MG/ML","drug_information":{"unit":473.0,"type":"ML"},"code_information":[{"code":"36590","type":"CDM"},{"code":"51991065116","type":"NDC"}],"standard_charges":[{"gross_charge":1542.44,"discounted_cash":848.34,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Levetiracetam Oral Soln 100 MG/ML","drug_information":{"unit":5.0,"type":"ML"},"code_information":[{"code":"36590","type":"CDM"},{"code":"904726592","type":"NDC"}],"standard_charges":[{"gross_charge":25.51,"discounted_cash":14.03,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Palonosetron HCl IV Soln 0.25 MG/5ML (Base Equivalent)","drug_information":{"unit":5.0,"type":"ML"},"code_information":[{"code":"36591","type":"CDM"},{"code":"55111069407","type":"NDC"}],"standard_charges":[{"gross_charge":114.16,"discounted_cash":62.79,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Rosuvastatin Calcium Tab 5 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"36612","type":"CDM"},{"code":"68462026190","type":"NDC"}],"standard_charges":[{"gross_charge":37.52,"discounted_cash":20.64,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Bupropion HCl Tab ER 24HR 150 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"36775","type":"CDM"},{"code":"904750504","type":"NDC"}],"standard_charges":[{"gross_charge":14.08,"discounted_cash":7.74,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Amiodarone HCl Tab 100 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"36959","type":"CDM"},{"code":"245014489","type":"NDC"}],"standard_charges":[{"gross_charge":32.52,"discounted_cash":17.89,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Docusate Sodium Liquid 150 MG/15ML","drug_information":{"unit":10.0,"type":"ML"},"code_information":[{"code":"36962","type":"CDM"},{"code":"904727966","type":"NDC"}],"standard_charges":[{"gross_charge":4.37,"discounted_cash":2.40,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Hydralazine HCl Inj 20 MG/ML","drug_information":{"unit":0.5,"type":"ML"},"code_information":[{"code":"3697","type":"CDM"},{"code":"55150040025","type":"NDC"}],"standard_charges":[{"gross_charge":21.21,"discounted_cash":11.67,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Hydralazine HCl Inj 20 MG/ML","drug_information":{"unit":0.5,"type":"ML"},"code_information":[{"code":"3697","type":"CDM"},{"code":"63323061401","type":"NDC"}],"standard_charges":[{"gross_charge":29.81,"discounted_cash":16.40,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Hydralazine HCl Inj 20 MG/ML","drug_information":{"unit":0.5,"type":"ML"},"code_information":[{"code":"3697","type":"CDM"},{"code":"63323061400","type":"NDC"}],"standard_charges":[{"gross_charge":29.82,"discounted_cash":16.40,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Hydralazine HCl Inj 20 MG/ML","drug_information":{"unit":0.5,"type":"ML"},"code_information":[{"code":"3697","type":"CDM"},{"code":"55150040001","type":"NDC"}],"standard_charges":[{"gross_charge":21.21,"discounted_cash":11.67,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Theophylline Tab ER 24HR 400 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"36973","type":"CDM"},{"code":"68462038001","type":"NDC"}],"standard_charges":[{"gross_charge":14.44,"discounted_cash":7.94,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Hydralazine HCl Tab 10 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"3698","type":"CDM"},{"code":"50111039801","type":"NDC"}],"standard_charges":[{"gross_charge":9.83,"discounted_cash":5.41,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Eplerenone Tab 25 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"36983","type":"CDM"},{"code":"60687045111","type":"NDC"}],"standard_charges":[{"gross_charge":24.5,"discounted_cash":13.48,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Eplerenone Tab 25 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"36983","type":"CDM"},{"code":"60687045121","type":"NDC"}],"standard_charges":[{"gross_charge":24.5,"discounted_cash":13.48,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Zonisamide Cap 25 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"36987","type":"CDM"},{"code":"68001024200","type":"NDC"}],"standard_charges":[{"gross_charge":10.44,"discounted_cash":5.74,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Zonisamide Cap 50 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"36988","type":"CDM"},{"code":"68462012901","type":"NDC"}],"standard_charges":[{"gross_charge":12.22,"discounted_cash":6.72,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Zonisamide Cap 50 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"36988","type":"CDM"},{"code":"72578004101","type":"NDC"}],"standard_charges":[{"gross_charge":12.22,"discounted_cash":6.72,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Zonisamide Cap 50 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"36988","type":"CDM"},{"code":"68001024300","type":"NDC"}],"standard_charges":[{"gross_charge":12.22,"discounted_cash":6.72,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Daptomycin For IV Soln 500 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"36989","type":"CDM"},{"code":"43598041311","type":"NDC"}],"standard_charges":[{"gross_charge":183.5,"discounted_cash":100.92,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Daptomycin For IV Soln 500 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"36989","type":"CDM"},{"code":"72572010201","type":"NDC"}],"standard_charges":[{"gross_charge":58.19,"discounted_cash":32.00,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Daptomycin For IV Soln 500 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"36989","type":"CDM"},{"code":"71288001615","type":"NDC"}],"standard_charges":[{"gross_charge":65.9,"discounted_cash":36.24,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Hydralazine HCl Tab 25 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"3700","type":"CDM"},{"code":"904744861","type":"NDC"}],"standard_charges":[{"gross_charge":9.27,"discounted_cash":5.10,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Hydralazine HCl Tab 25 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"3700","type":"CDM"},{"code":"60687082211","type":"NDC"}],"standard_charges":[{"gross_charge":9.13,"discounted_cash":5.02,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Hydralazine HCl Tab 25 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"3700","type":"CDM"},{"code":"60687082201","type":"NDC"}],"standard_charges":[{"gross_charge":9.13,"discounted_cash":5.02,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Memantine HCl Tab 5 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"37170","type":"CDM"},{"code":"50268058713","type":"NDC"}],"standard_charges":[{"gross_charge":11.56,"discounted_cash":6.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Hydrochlorothiazide Tab 25 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"3720","type":"CDM"},{"code":"60687059311","type":"NDC"}],"standard_charges":[{"gross_charge":9.12,"discounted_cash":5.02,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Hydrochlorothiazide Tab 25 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"3720","type":"CDM"},{"code":"60687059301","type":"NDC"}],"standard_charges":[{"gross_charge":9.12,"discounted_cash":5.02,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Hydrocortisone Cream 1%","drug_information":{"unit":28.4,"type":"GM"},"code_information":[{"code":"3726","type":"CDM"},{"code":"51672533002","type":"NDC"}],"standard_charges":[{"gross_charge":34.57,"discounted_cash":19.01,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Hydrocortisone Cream 1%","drug_information":{"unit":28.0,"type":"GM"},"code_information":[{"code":"3726","type":"CDM"},{"code":"536140795","type":"NDC"}],"standard_charges":[{"gross_charge":24.73,"discounted_cash":13.60,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Hydrocortisone Cream 1%","drug_information":{"unit":28.0,"type":"GM"},"code_information":[{"code":"3726","type":"CDM"},{"code":"41167000210","type":"NDC"}],"standard_charges":[{"gross_charge":51.39,"discounted_cash":28.26,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Hydrocortisone Cream 2.5%","drug_information":{"unit":30.0,"type":"GM"},"code_information":[{"code":"3727","type":"CDM"},{"code":"168008031","type":"NDC"}],"standard_charges":[{"gross_charge":65.99,"discounted_cash":36.29,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Hydrocortisone Oint 1%","drug_information":{"unit":28.0,"type":"GM"},"code_information":[{"code":"3731","type":"CDM"},{"code":"45802027603","type":"NDC"}],"standard_charges":[{"gross_charge":34.82,"discounted_cash":19.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Hydrocortisone Tab 10 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"3733","type":"CDM"},{"code":"59762007401","type":"NDC"}],"standard_charges":[{"gross_charge":10.55,"discounted_cash":5.80,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Hydrocortisone Acetate Suppos 25 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"3738","type":"CDM"},{"code":"16571067621","type":"NDC"}],"standard_charges":[{"gross_charge":70.28,"discounted_cash":38.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Hydrocortisone Acetate Suppos 25 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"3738","type":"CDM"},{"code":"574709012","type":"NDC"}],"standard_charges":[{"gross_charge":47.67,"discounted_cash":26.22,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Cholestyramine Light Powder Packets 4 GM","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"37482","type":"CDM"},{"code":"68382052960","type":"NDC"}],"standard_charges":[{"gross_charge":20.9,"discounted_cash":11.50,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Tetanus-Diphtheria Toxoids (Td) Inj 2-2 LF/0.5ML","drug_information":{"unit":0.5,"type":"ML"},"code_information":[{"code":"37504","type":"CDM"},{"code":"13533013100","type":"NDC"}],"standard_charges":[{"gross_charge":101.68,"discounted_cash":55.92,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Tetanus-Diphtheria Toxoids (Td) Inj 2-2 LF/0.5ML","drug_information":{"unit":0.5,"type":"ML"},"code_information":[{"code":"37504","type":"CDM"},{"code":"13533013101","type":"NDC"}],"standard_charges":[{"gross_charge":101.66,"discounted_cash":55.91,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Carbamazepine Cap ER 12HR 100 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"37567","type":"CDM"},{"code":"60505280507","type":"NDC"}],"standard_charges":[{"gross_charge":15.56,"discounted_cash":8.56,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Hydromorphone HCl Inj 1 MG/ML","drug_information":{"unit":0.2,"type":"ML"},"code_information":[{"code":"3757","type":"CDM"},{"code":"76045000901","type":"NDC"}],"standard_charges":[{"gross_charge":34.83,"discounted_cash":19.16,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Hydromorphone HCl Inj 1 MG/ML","drug_information":{"unit":0.2,"type":"ML"},"code_information":[{"code":"3757","type":"CDM"},{"code":"409426411","type":"NDC"}],"standard_charges":[{"gross_charge":36.04,"discounted_cash":19.82,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Hydromorphone HCl Inj 1 MG/ML","drug_information":{"unit":0.2,"type":"ML"},"code_information":[{"code":"3757","type":"CDM"},{"code":"409426401","type":"NDC"}],"standard_charges":[{"gross_charge":36.04,"discounted_cash":19.82,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Hydromorphone HCl Inj 1 MG/ML","drug_information":{"unit":0.2,"type":"ML"},"code_information":[{"code":"3757","type":"CDM"},{"code":"76045000911","type":"NDC"}],"standard_charges":[{"gross_charge":34.83,"discounted_cash":19.16,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Ophthalmic Irrigation Solution - Intraocular","drug_information":{"unit":15.0,"type":"ML"},"code_information":[{"code":"37579","type":"CDM"},{"code":"65079515","type":"NDC"}],"standard_charges":[{"gross_charge":36.75,"discounted_cash":20.21,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Ophthalmic Irrigation Solution - Intraocular","drug_information":{"unit":500.0,"type":"ML"},"code_information":[{"code":"37579","type":"CDM"},{"code":"65079550","type":"NDC"}],"standard_charges":[{"gross_charge":80.6,"discounted_cash":44.33,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Hydromorphone HCl Inj 2 MG/ML","drug_information":{"unit":0.1,"type":"ML"},"code_information":[{"code":"3758","type":"CDM"},{"code":"409336510","type":"NDC"}],"standard_charges":[{"gross_charge":32.68,"discounted_cash":17.97,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Hydromorphone HCl Inj 2 MG/ML","drug_information":{"unit":0.1,"type":"ML"},"code_information":[{"code":"3758","type":"CDM"},{"code":"641234141","type":"NDC"}],"standard_charges":[{"gross_charge":31.5,"discounted_cash":17.32,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Hydromorphone HCl Tab 2 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"3760","type":"CDM"},{"code":"406324301","type":"NDC"}],"standard_charges":[{"gross_charge":10.76,"discounted_cash":5.92,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Escitalopram Oxalate Tab 5 MG (Base Equiv)","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"37635","type":"CDM"},{"code":"43547028010","type":"NDC"}],"standard_charges":[{"gross_charge":21.31,"discounted_cash":11.72,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Metoprolol Tartrate Tab 25 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"37637","type":"CDM"},{"code":"62332011231","type":"NDC"}],"standard_charges":[{"gross_charge":9.08,"discounted_cash":4.99,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Metoprolol Tartrate Tab 25 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"37637","type":"CDM"},{"code":"51079025520","type":"NDC"}],"standard_charges":[{"gross_charge":9.08,"discounted_cash":4.99,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Glipizide Tab ER 24HR 2.5 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"37648","type":"CDM"},{"code":"60687076811","type":"NDC"}],"standard_charges":[{"gross_charge":15.37,"discounted_cash":8.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Glipizide Tab ER 24HR 2.5 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"37648","type":"CDM"},{"code":"60687076821","type":"NDC"}],"standard_charges":[{"gross_charge":15.37,"discounted_cash":8.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Guaifenesin Tab ER 12HR 600 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"37651","type":"CDM"},{"code":"904671839","type":"NDC"}],"standard_charges":[{"gross_charge":12.11,"discounted_cash":6.66,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Hydroxyzine HCl IM Soln 25 MG/ML","drug_information":{"unit":0.5,"type":"ML"},"code_information":[{"code":"3769","type":"CDM"},{"code":"517420125","type":"NDC"}],"standard_charges":[{"gross_charge":71.35,"discounted_cash":39.24,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Hydroxyzine HCl IM Soln 50 MG/ML","drug_information":{"unit":0.25,"type":"ML"},"code_information":[{"code":"3770","type":"CDM"},{"code":"517560125","type":"NDC"}],"standard_charges":[{"gross_charge":53.25,"discounted_cash":29.29,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Hydroxyzine HCl Syrup 10 MG/5ML","drug_information":{"unit":473.0,"type":"ML"},"code_information":[{"code":"3771","type":"CDM"},{"code":"62135075047","type":"NDC"}],"standard_charges":[{"gross_charge":2318.91,"discounted_cash":1275.40,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Hydroxyzine HCl Tab 10 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"3772","type":"CDM"},{"code":"60687066401","type":"NDC"}],"standard_charges":[{"gross_charge":9.23,"discounted_cash":5.08,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Hydroxyzine HCl Tab 10 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"3772","type":"CDM"},{"code":"63739048310","type":"NDC"}],"standard_charges":[{"gross_charge":9.27,"discounted_cash":5.10,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Hydroxyzine HCl Tab 25 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"3774","type":"CDM"},{"code":"60687067511","type":"NDC"}],"standard_charges":[{"gross_charge":9.76,"discounted_cash":5.37,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Hydroxyzine HCl Tab 25 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"3774","type":"CDM"},{"code":"23155050101","type":"NDC"}],"standard_charges":[{"gross_charge":12.07,"discounted_cash":6.64,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Hydroxyzine HCl Tab 25 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"3774","type":"CDM"},{"code":"904661761","type":"NDC"}],"standard_charges":[{"gross_charge":9.35,"discounted_cash":5.14,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Hydroxyzine HCl Tab 25 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"3774","type":"CDM"},{"code":"60687067501","type":"NDC"}],"standard_charges":[{"gross_charge":9.76,"discounted_cash":5.37,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Hydrocodone-Acetaminophen Soln 7.5-325 MG/15ML","drug_information":{"unit":5.0,"type":"ML"},"code_information":[{"code":"37848","type":"CDM"},{"code":"66689002301","type":"NDC"}],"standard_charges":[{"gross_charge":15.9,"discounted_cash":8.74,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Pemetrexed Disodium For IV Soln 500 MG (Base Equiv)","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"37894","type":"CDM"},{"code":"25021026150","type":"NDC"}],"standard_charges":[{"gross_charge":345.8,"discounted_cash":190.19,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Mycophenolate Sodium Tab DR 360 MG (Mycophenolic Acid Equiv)","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"38063","type":"CDM"},{"code":"68084091825","type":"NDC"}],"standard_charges":[{"gross_charge":35.5,"discounted_cash":19.52,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Mycophenolate Sodium Tab DR 360 MG (Mycophenolic Acid Equiv)","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"38063","type":"CDM"},{"code":"68084091895","type":"NDC"}],"standard_charges":[{"gross_charge":35.5,"discounted_cash":19.52,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Cinacalcet HCl Tab 30 MG (Base Equiv)","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"38100","type":"CDM"},{"code":"69097041002","type":"NDC"}],"standard_charges":[{"gross_charge":75.44,"discounted_cash":41.49,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Lactulose Solution 10 GM/15ML","drug_information":{"unit":946.0,"type":"ML"},"code_information":[{"code":"38245","type":"CDM"},{"code":"116400532","type":"NDC"}],"standard_charges":[{"gross_charge":252.16,"discounted_cash":138.69,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Lactulose Solution 10 GM/15ML","drug_information":{"unit":15.0,"type":"ML"},"code_information":[{"code":"38245","type":"CDM"},{"code":"121115440","type":"NDC"}],"standard_charges":[{"gross_charge":13.47,"discounted_cash":7.41,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Lactulose Solution 10 GM/15ML","drug_information":{"unit":15.0,"type":"ML"},"code_information":[{"code":"38245","type":"CDM"},{"code":"121115430","type":"NDC"}],"standard_charges":[{"gross_charge":13.47,"discounted_cash":7.41,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Olanzapine For IM Inj 10 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"38263","type":"CDM"},{"code":"31722030801","type":"NDC"}],"standard_charges":[{"gross_charge":124.57,"discounted_cash":68.51,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Alum & Mag Hydroxide-Simethicone Susp 200-200-20 MG/5ML","drug_information":{"unit":15.0,"type":"ML"},"code_information":[{"code":"38285","type":"CDM"},{"code":"57896062912","type":"NDC"}],"standard_charges":[{"gross_charge":18.0,"discounted_cash":9.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Alum & Mag Hydroxide-Simethicone Susp 200-200-20 MG/5ML","drug_information":{"unit":15.0,"type":"ML"},"code_information":[{"code":"38285","type":"CDM"},{"code":"121176130","type":"NDC"}],"standard_charges":[{"gross_charge":25.41,"discounted_cash":13.98,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Acetylcysteine Inj 200 MG/ML","drug_information":{"unit":30.0,"type":"ML"},"code_information":[{"code":"38303","type":"CDM"},{"code":"70594011102","type":"NDC"}],"standard_charges":[{"gross_charge":308.2,"discounted_cash":169.51,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Ibuprofen Tab 200 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"3841","type":"CDM"},{"code":"904791259","type":"NDC"}],"standard_charges":[{"gross_charge":3.06,"discounted_cash":1.68,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Mirtazapine Tab 7.5 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"38421","type":"CDM"},{"code":"13107000130","type":"NDC"}],"standard_charges":[{"gross_charge":18.14,"discounted_cash":9.98,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Ibuprofen Tab 600 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"3844","type":"CDM"},{"code":"67877032001","type":"NDC"}],"standard_charges":[{"gross_charge":10.29,"discounted_cash":5.66,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Ibuprofen Tab 800 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"3845","type":"CDM"},{"code":"904585561","type":"NDC"}],"standard_charges":[{"gross_charge":9.78,"discounted_cash":5.38,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Azacitidine For Inj 100 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"38536","type":"CDM"},{"code":"43598046562","type":"NDC"}],"standard_charges":[{"gross_charge":407.0,"discounted_cash":223.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Multiple Vitamin IV Soln","drug_information":{"unit":10.0,"type":"ML"},"code_information":[{"code":"38595","type":"CDM"},{"code":"54643564901","type":"NDC"}],"standard_charges":[{"gross_charge":102.07,"discounted_cash":56.14,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Multiple Vitamin IV Soln","drug_information":{"unit":10.0,"type":"ML"},"code_information":[{"code":"38595","type":"CDM"},{"code":"54643565701","type":"NDC"}],"standard_charges":[{"gross_charge":102.07,"discounted_cash":56.14,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Multiple Vitamin IV Soln","drug_information":{"unit":10.0,"type":"ML"},"code_information":[{"code":"38595","type":"CDM"},{"code":"54643786208","type":"NDC"}],"standard_charges":[{"gross_charge":124.44,"discounted_cash":68.44,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Multiple Vitamin IV Soln","drug_information":{"unit":10.0,"type":"ML"},"code_information":[{"code":"38595","type":"CDM"},{"code":"54643786201","type":"NDC"}],"standard_charges":[{"gross_charge":102.07,"discounted_cash":56.14,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Multiple Vitamin IV Soln","drug_information":{"unit":10.0,"type":"ML"},"code_information":[{"code":"38595","type":"CDM"},{"code":"57513564901","type":"NDC"}],"standard_charges":[{"gross_charge":102.07,"discounted_cash":56.14,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Multiple Vitamin IV Soln","drug_information":{"unit":10.0,"type":"ML"},"code_information":[{"code":"38595","type":"CDM"},{"code":"54643565901","type":"NDC"}],"standard_charges":[{"gross_charge":102.07,"discounted_cash":56.14,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Imipramine HCl Tab 25 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"3861","type":"CDM"},{"code":"69315013401","type":"NDC"}],"standard_charges":[{"gross_charge":11.2,"discounted_cash":6.16,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Adenosine IV Soln 6 MG/2ML","drug_information":{"unit":2.0,"type":"ML"},"code_information":[{"code":"38703","type":"CDM"},{"code":"67457085502","type":"NDC"}],"standard_charges":[{"gross_charge":59.88,"discounted_cash":32.93,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Adenosine IV Soln 6 MG/2ML","drug_information":{"unit":2.0,"type":"ML"},"code_information":[{"code":"38703","type":"CDM"},{"code":"67457085500","type":"NDC"}],"standard_charges":[{"gross_charge":59.88,"discounted_cash":32.93,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Indomethacin Cap 25 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"3897","type":"CDM"},{"code":"68462040601","type":"NDC"}],"standard_charges":[{"gross_charge":9.79,"discounted_cash":5.38,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Indomethacin Suppos 50 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"3901","type":"CDM"},{"code":"70710185207","type":"NDC"}],"standard_charges":[{"gross_charge":626.86,"discounted_cash":344.77,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Rifaximin Tab 200 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"39063","type":"CDM"},{"code":"65649030103","type":"NDC"}],"standard_charges":[{"gross_charge":45.05,"discounted_cash":24.78,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Nystatin Topical Powder 100000 Unit/GM","drug_information":{"unit":15.0,"type":"GM"},"code_information":[{"code":"39136","type":"CDM"},{"code":"832046515","type":"NDC"}],"standard_charges":[{"gross_charge":161.2,"discounted_cash":88.66,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Emtricitabine-Tenofovir Disoproxil Fumarate Tab 200-300 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"39255","type":"CDM"},{"code":"42385095330","type":"NDC"}],"standard_charges":[{"gross_charge":144.51,"discounted_cash":79.48,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Duloxetine HCl Enteric Coated Pellets Cap 20 MG (Base Eq)","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"39275","type":"CDM"},{"code":"27241009706","type":"NDC"}],"standard_charges":[{"gross_charge":31.09,"discounted_cash":17.10,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Duloxetine HCl Enteric Coated Pellets Cap 20 MG (Base Eq)","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"39275","type":"CDM"},{"code":"60687072311","type":"NDC"}],"standard_charges":[{"gross_charge":34.94,"discounted_cash":19.22,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Duloxetine HCl Enteric Coated Pellets Cap 20 MG (Base Eq)","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"39275","type":"CDM"},{"code":"60687072321","type":"NDC"}],"standard_charges":[{"gross_charge":34.94,"discounted_cash":19.22,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Duloxetine HCl Enteric Coated Pellets Cap 30 MG (Base Eq)","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"39276","type":"CDM"},{"code":"68180029509","type":"NDC"}],"standard_charges":[{"gross_charge":33.91,"discounted_cash":18.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Cefdinir For Susp 250 MG/5ML","drug_information":{"unit":100.0,"type":"ML"},"code_information":[{"code":"39522","type":"CDM"},{"code":"65862021901","type":"NDC"}],"standard_charges":[{"gross_charge":613.99,"discounted_cash":337.69,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Cefdinir For Susp 250 MG/5ML","drug_information":{"unit":60.0,"type":"ML"},"code_information":[{"code":"39522","type":"CDM"},{"code":"68180072304","type":"NDC"}],"standard_charges":[{"gross_charge":391.0,"discounted_cash":215.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Iodine Solution Strong 5% (Lugol's)","drug_information":{"unit":0.1,"type":"ML"},"code_information":[{"code":"3961","type":"CDM"},{"code":"48433023015","type":"NDC"}],"standard_charges":[{"gross_charge":9.23,"discounted_cash":5.08,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Flumazenil IV Soln 0.5 MG/5ML (0.1 MG/ML)","drug_information":{"unit":5.0,"type":"ML"},"code_information":[{"code":"39744","type":"CDM"},{"code":"143978410","type":"NDC"}],"standard_charges":[{"gross_charge":62.28,"discounted_cash":34.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Flumazenil IV Soln 0.5 MG/5ML (0.1 MG/ML)","drug_information":{"unit":5.0,"type":"ML"},"code_information":[{"code":"39744","type":"CDM"},{"code":"143978401","type":"NDC"}],"standard_charges":[{"gross_charge":62.28,"discounted_cash":34.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Barium Sulfate Susp 40%","drug_information":{"unit":5.0,"type":"ML"},"code_information":[{"code":"39786","type":"CDM"},{"code":"32909012154","type":"NDC"}],"standard_charges":[{"gross_charge":15.14,"discounted_cash":8.33,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Pentafluoropropane-Tetrafluoroethane Aero Spray","drug_information":{"unit":116.0,"type":"ML"},"code_information":[{"code":"39802","type":"CDM"},{"code":"386000803","type":"NDC"}],"standard_charges":[{"gross_charge":171.86,"discounted_cash":94.52,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Iron Dextran Inj 50 MG/ML (Elemental Iron)","drug_information":{"unit":0.5,"type":"ML"},"code_information":[{"code":"3990","type":"CDM"},{"code":"23608210","type":"NDC"}],"standard_charges":[{"gross_charge":61.76,"discounted_cash":33.97,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Iron Dextran Inj 50 MG/ML (Elemental Iron)","drug_information":{"unit":0.5,"type":"ML"},"code_information":[{"code":"3990","type":"CDM"},{"code":"23608201","type":"NDC"}],"standard_charges":[{"gross_charge":58.9,"discounted_cash":32.40,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Fenofibrate Tab 48 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"40009","type":"CDM"},{"code":"31722059590","type":"NDC"}],"standard_charges":[{"gross_charge":15.35,"discounted_cash":8.44,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Fenofibrate Tab 145 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"40010","type":"CDM"},{"code":"378306677","type":"NDC"}],"standard_charges":[{"gross_charge":26.91,"discounted_cash":14.80,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Carboplatin IV Soln 600 MG/60ML","drug_information":{"unit":60.0,"type":"ML"},"code_information":[{"code":"40055","type":"CDM"},{"code":"16729029512","type":"NDC"}],"standard_charges":[{"gross_charge":381.25,"discounted_cash":209.69,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Isoflurane Inhal Soln","drug_information":{"unit":100.0,"type":"ML"},"code_information":[{"code":"4008","type":"CDM"},{"code":"66794001710","type":"NDC"}],"standard_charges":[{"gross_charge":123.8,"discounted_cash":68.09,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Natalizumab for IV Inj Conc 300 MG/15ML","drug_information":{"unit":15.0,"type":"ML"},"code_information":[{"code":"40120","type":"CDM"},{"code":"64406000801","type":"NDC"}],"standard_charges":[{"gross_charge":16017.08,"discounted_cash":8809.39,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Electrolyte-S (PH 7.4) Solution","drug_information":{"unit":1000.0,"type":"ML"},"code_information":[{"code":"4015","type":"CDM"},{"code":"264770700","type":"NDC"}],"standard_charges":[{"gross_charge":71.24,"discounted_cash":39.18,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Electrolyte-S (PH 7.4) Solution","drug_information":{"unit":500.0,"type":"ML"},"code_information":[{"code":"4015","type":"CDM"},{"code":"264770710","type":"NDC"}],"standard_charges":[{"gross_charge":68.18,"discounted_cash":37.50,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Aminocaproic Acid Inj 250 MG/ML","drug_information":{"unit":16.0,"type":"ML"},"code_information":[{"code":"403","type":"CDM"},{"code":"517912025","type":"NDC"}],"standard_charges":[{"gross_charge":74.86,"discounted_cash":41.17,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Aminocaproic Acid Inj 250 MG/ML","drug_information":{"unit":16.0,"type":"ML"},"code_information":[{"code":"403","type":"CDM"},{"code":"517912001","type":"NDC"}],"standard_charges":[{"gross_charge":74.86,"discounted_cash":41.17,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Isoproterenol HCl Inj 0.2 MG/ML","drug_information":{"unit":0.1,"type":"ML"},"code_information":[{"code":"4034","type":"CDM"},{"code":"14789001505","type":"NDC"}],"standard_charges":[{"gross_charge":59.08,"discounted_cash":32.49,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Isoproterenol HCl Inj 0.2 MG/ML","drug_information":{"unit":0.1,"type":"ML"},"code_information":[{"code":"4034","type":"CDM"},{"code":"69918073101","type":"NDC"}],"standard_charges":[{"gross_charge":56.5,"discounted_cash":31.08,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Isoproterenol HCl Inj 0.2 MG/ML","drug_information":{"unit":0.1,"type":"ML"},"code_information":[{"code":"4034","type":"CDM"},{"code":"69918073110","type":"NDC"}],"standard_charges":[{"gross_charge":56.5,"discounted_cash":31.08,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Isoproterenol HCl Inj 0.2 MG/ML","drug_information":{"unit":0.1,"type":"ML"},"code_information":[{"code":"4034","type":"CDM"},{"code":"83634030301","type":"NDC"}],"standard_charges":[{"gross_charge":56.5,"discounted_cash":31.08,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Paclitaxel Protein-Bound Particles For IV Susp 100 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"40475","type":"CDM"},{"code":"68817013450","type":"NDC"}],"standard_charges":[{"gross_charge":2894.11,"discounted_cash":1591.76,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Isosorbide Dinitrate Tab 20 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"4065","type":"CDM"},{"code":"50268044911","type":"NDC"}],"standard_charges":[{"gross_charge":12.63,"discounted_cash":6.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Isosorbide Dinitrate Tab 20 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"4065","type":"CDM"},{"code":"50268044915","type":"NDC"}],"standard_charges":[{"gross_charge":12.63,"discounted_cash":6.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Isosorbide Dinitrate Tab 5 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"4068","type":"CDM"},{"code":"72888008101","type":"NDC"}],"standard_charges":[{"gross_charge":12.38,"discounted_cash":6.81,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Aminophylline Inj 25 MG/ML","drug_information":{"unit":20.0,"type":"ML"},"code_information":[{"code":"407","type":"CDM"},{"code":"409592216","type":"NDC"}],"standard_charges":[{"gross_charge":99.71,"discounted_cash":54.84,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Aminophylline Inj 25 MG/ML","drug_information":{"unit":20.0,"type":"ML"},"code_information":[{"code":"407","type":"CDM"},{"code":"409592201","type":"NDC"}],"standard_charges":[{"gross_charge":99.71,"discounted_cash":54.84,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Aminophylline Inj 25 MG/ML","drug_information":{"unit":10.0,"type":"ML"},"code_information":[{"code":"407","type":"CDM"},{"code":"409592116","type":"NDC"}],"standard_charges":[{"gross_charge":123.36,"discounted_cash":67.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Midazolam HCl Inj 2 MG/2ML (Base Equivalent)","drug_information":{"unit":2.0,"type":"ML"},"code_information":[{"code":"40872","type":"CDM"},{"code":"72572043001","type":"NDC"}],"standard_charges":[{"gross_charge":38.38,"discounted_cash":21.11,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Midazolam HCl Inj 2 MG/2ML (Base Equivalent)","drug_information":{"unit":2.0,"type":"ML"},"code_information":[{"code":"40872","type":"CDM"},{"code":"23155060041","type":"NDC"}],"standard_charges":[{"gross_charge":39.51,"discounted_cash":21.73,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Midazolam HCl Inj 2 MG/2ML (Base Equivalent)","drug_information":{"unit":2.0,"type":"ML"},"code_information":[{"code":"40872","type":"CDM"},{"code":"23155060031","type":"NDC"}],"standard_charges":[{"gross_charge":39.51,"discounted_cash":21.73,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Midazolam HCl Inj 2 MG/2ML (Base Equivalent)","drug_information":{"unit":2.0,"type":"ML"},"code_information":[{"code":"40872","type":"CDM"},{"code":"72572043025","type":"NDC"}],"standard_charges":[{"gross_charge":38.38,"discounted_cash":21.11,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Gadobenate Dimeglumine IV Soln 529 MG/ML","drug_information":{"unit":15.0,"type":"ML"},"code_information":[{"code":"41137","type":"CDM"},{"code":"270516415","type":"NDC"}],"standard_charges":[{"gross_charge":365.57,"discounted_cash":201.06,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Micafungin Sodium For IV Soln 50 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"41144","type":"CDM"},{"code":"25021019010","type":"NDC"}],"standard_charges":[{"gross_charge":172.58,"discounted_cash":94.92,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Micafungin Sodium For IV Soln 50 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"41144","type":"CDM"},{"code":"25021019011","type":"NDC"}],"standard_charges":[{"gross_charge":172.58,"discounted_cash":94.92,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Fentanyl TD Patch 72HR 12 MCG/HR","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"41382","type":"CDM"},{"code":"60505708000","type":"NDC"}],"standard_charges":[{"gross_charge":95.4,"discounted_cash":52.47,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Sodium Tetradecyl Sulfate Inj 3%","drug_information":{"unit":0.5,"type":"ML"},"code_information":[{"code":"41793","type":"CDM"},{"code":"24201020101","type":"NDC"}],"standard_charges":[{"gross_charge":81.82,"discounted_cash":45.00,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Lidocaine Oint 5%","drug_information":{"unit":35.44,"type":"GM"},"code_information":[{"code":"41831","type":"CDM"},{"code":"70752011303","type":"NDC"}],"standard_charges":[{"gross_charge":1142.92,"discounted_cash":628.61,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Sildenafil Citrate Tab 20 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"41832","type":"CDM"},{"code":"50268071711","type":"NDC"}],"standard_charges":[{"gross_charge":53.32,"discounted_cash":29.33,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Sildenafil Citrate Tab 20 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"41832","type":"CDM"},{"code":"50268071715","type":"NDC"}],"standard_charges":[{"gross_charge":53.32,"discounted_cash":29.33,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Amino Acid Infusion 15%","drug_information":{"unit":1000.0,"type":"ML"},"code_information":[{"code":"419","type":"CDM"},{"code":"264450005","type":"NDC"}],"standard_charges":[{"gross_charge":204.55,"discounted_cash":112.50,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Amino Acid Infusion 15%","drug_information":{"unit":1000.0,"type":"ML"},"code_information":[{"code":"419","type":"CDM"},{"code":"264450000","type":"NDC"}],"standard_charges":[{"gross_charge":244.6,"discounted_cash":134.53,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Ramelteon Tab 8 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"42064","type":"CDM"},{"code":"832125030","type":"NDC"}],"standard_charges":[{"gross_charge":46.47,"discounted_cash":25.56,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Pregabalin Cap 25 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"42162","type":"CDM"},{"code":"60687047311","type":"NDC"}],"standard_charges":[{"gross_charge":17.76,"discounted_cash":9.77,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Pregabalin Cap 25 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"42162","type":"CDM"},{"code":"60687047301","type":"NDC"}],"standard_charges":[{"gross_charge":17.76,"discounted_cash":9.77,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Pregabalin Cap 50 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"42163","type":"CDM"},{"code":"69238131109","type":"NDC"}],"standard_charges":[{"gross_charge":27.3,"discounted_cash":15.02,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Pregabalin Cap 100 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"42165","type":"CDM"},{"code":"60687050611","type":"NDC"}],"standard_charges":[{"gross_charge":14.23,"discounted_cash":7.83,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Pregabalin Cap 150 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"42166","type":"CDM"},{"code":"69238131409","type":"NDC"}],"standard_charges":[{"gross_charge":27.3,"discounted_cash":15.02,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Ketamine HCl Inj 50 MG/ML","drug_information":{"unit":10.0,"type":"ML"},"code_information":[{"code":"4238","type":"CDM"},{"code":"65219018801","type":"NDC"}],"standard_charges":[{"gross_charge":76.7,"discounted_cash":42.18,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Ketamine HCl Inj 50 MG/ML","drug_information":{"unit":10.0,"type":"ML"},"code_information":[{"code":"4238","type":"CDM"},{"code":"65219018810","type":"NDC"}],"standard_charges":[{"gross_charge":76.7,"discounted_cash":42.18,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Zidovudine Syrup 10 MG/ML","drug_information":{"unit":240.0,"type":"ML"},"code_information":[{"code":"42918","type":"CDM"},{"code":"65862004824","type":"NDC"}],"standard_charges":[{"gross_charge":258.98,"discounted_cash":142.44,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Lactated Ringer's Solution","drug_information":{"unit":1000.0,"type":"ML"},"code_information":[{"code":"4318","type":"CDM"},{"code":"338011704","type":"NDC"}],"standard_charges":[{"gross_charge":68.18,"discounted_cash":37.50,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Lactated Ringer's for Irrigation","drug_information":{"unit":1000.0,"type":"ML"},"code_information":[{"code":"4319","type":"CDM"},{"code":"264220300","type":"NDC"}],"standard_charges":[{"gross_charge":48.15,"discounted_cash":26.48,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Amitriptyline HCl Tab 10 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"432","type":"CDM"},{"code":"29300041901","type":"NDC"}],"standard_charges":[{"gross_charge":9.42,"discounted_cash":5.18,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Amitriptyline HCl Tab 25 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"435","type":"CDM"},{"code":"60687043301","type":"NDC"}],"standard_charges":[{"gross_charge":10.3,"discounted_cash":5.66,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Amitriptyline HCl Tab 25 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"435","type":"CDM"},{"code":"60687043311","type":"NDC"}],"standard_charges":[{"gross_charge":10.3,"discounted_cash":5.66,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Lidocaine HCl Laryngotracheal Soln 4%","drug_information":{"unit":4.0,"type":"ML"},"code_information":[{"code":"43717","type":"CDM"},{"code":"76329630005","type":"NDC"}],"standard_charges":[{"gross_charge":161.34,"discounted_cash":88.74,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Leucovorin Calcium For Inj 350 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"4393","type":"CDM"},{"code":"25021081630","type":"NDC"}],"standard_charges":[{"gross_charge":213.8,"discounted_cash":117.59,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Levothyroxine Sodium Tab 25 MCG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"4420","type":"CDM"},{"code":"60687045311","type":"NDC"}],"standard_charges":[{"gross_charge":10.49,"discounted_cash":5.77,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Levothyroxine Sodium Tab 25 MCG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"4420","type":"CDM"},{"code":"60687045301","type":"NDC"}],"standard_charges":[{"gross_charge":10.49,"discounted_cash":5.77,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Levothyroxine Sodium Tab 50 MCG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"4421","type":"CDM"},{"code":"904695061","type":"NDC"}],"standard_charges":[{"gross_charge":10.51,"discounted_cash":5.78,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Levothyroxine Sodium Tab 75 MCG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"4422","type":"CDM"},{"code":"60687047511","type":"NDC"}],"standard_charges":[{"gross_charge":11.14,"discounted_cash":6.13,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Levothyroxine Sodium Tab 75 MCG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"4422","type":"CDM"},{"code":"60687047501","type":"NDC"}],"standard_charges":[{"gross_charge":11.14,"discounted_cash":6.13,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Levothyroxine Sodium Tab 100 MCG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"4423","type":"CDM"},{"code":"904695361","type":"NDC"}],"standard_charges":[{"gross_charge":11.13,"discounted_cash":6.12,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Levothyroxine Sodium Tab 100 MCG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"4423","type":"CDM"},{"code":"60687049711","type":"NDC"}],"standard_charges":[{"gross_charge":11.22,"discounted_cash":6.17,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Levothyroxine Sodium Tab 100 MCG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"4423","type":"CDM"},{"code":"60687049701","type":"NDC"}],"standard_charges":[{"gross_charge":11.22,"discounted_cash":6.17,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Lidocaine HCl Soln 4%","drug_information":{"unit":50.0,"type":"ML"},"code_information":[{"code":"4450","type":"CDM"},{"code":"527600480","type":"NDC"}],"standard_charges":[{"gross_charge":293.1,"discounted_cash":161.20,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Lidocaine HCl Local Inj 1%","drug_information":{"unit":10.0,"type":"ML"},"code_information":[{"code":"4452","type":"CDM"},{"code":"70756064586","type":"NDC"}],"standard_charges":[{"gross_charge":55.59,"discounted_cash":30.57,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Lidocaine HCl Local Inj 1%","drug_information":{"unit":10.0,"type":"ML"},"code_information":[{"code":"4452","type":"CDM"},{"code":"63323020110","type":"NDC"}],"standard_charges":[{"gross_charge":49.65,"discounted_cash":27.31,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Lidocaine HCl Local Inj 1%","drug_information":{"unit":20.0,"type":"ML"},"code_information":[{"code":"4452","type":"CDM"},{"code":"409427601","type":"NDC"}],"standard_charges":[{"gross_charge":52.55,"discounted_cash":28.90,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Lidocaine HCl Local Inj 1%","drug_information":{"unit":50.0,"type":"ML"},"code_information":[{"code":"4452","type":"CDM"},{"code":"63323048557","type":"NDC"}],"standard_charges":[{"gross_charge":67.04,"discounted_cash":36.87,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Lidocaine HCl Local Inj 1%","drug_information":{"unit":50.0,"type":"ML"},"code_information":[{"code":"4452","type":"CDM"},{"code":"63323048503","type":"NDC"}],"standard_charges":[{"gross_charge":67.04,"discounted_cash":36.87,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Lidocaine HCl Local Inj 1%","drug_information":{"unit":10.0,"type":"ML"},"code_information":[{"code":"4452","type":"CDM"},{"code":"70756064525","type":"NDC"}],"standard_charges":[{"gross_charge":55.59,"discounted_cash":30.57,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Lidocaine HCl Local Inj 1%","drug_information":{"unit":10.0,"type":"ML"},"code_information":[{"code":"4452","type":"CDM"},{"code":"63323020103","type":"NDC"}],"standard_charges":[{"gross_charge":49.65,"discounted_cash":27.31,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Lidocaine HCl Local Inj 1%","drug_information":{"unit":20.0,"type":"ML"},"code_information":[{"code":"4452","type":"CDM"},{"code":"409427616","type":"NDC"}],"standard_charges":[{"gross_charge":52.55,"discounted_cash":28.90,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Lidocaine HCl Local Inj 2%","drug_information":{"unit":20.0,"type":"ML"},"code_information":[{"code":"4454","type":"CDM"},{"code":"55150025520","type":"NDC"}],"standard_charges":[{"gross_charge":58.44,"discounted_cash":32.14,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Lidocaine HCl Local Inj 2%","drug_information":{"unit":50.0,"type":"ML"},"code_information":[{"code":"4454","type":"CDM"},{"code":"143957510","type":"NDC"}],"standard_charges":[{"gross_charge":55.4,"discounted_cash":30.47,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Lidocaine HCl Local Inj 2%","drug_information":{"unit":50.0,"type":"ML"},"code_information":[{"code":"4454","type":"CDM"},{"code":"143957501","type":"NDC"}],"standard_charges":[{"gross_charge":55.4,"discounted_cash":30.47,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Amoxicillin (Trihydrate) Cap 250 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"450","type":"CDM"},{"code":"781202001","type":"NDC"}],"standard_charges":[{"gross_charge":9.11,"discounted_cash":5.01,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Lithium Carbonate Cap 150 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"4528","type":"CDM"},{"code":"54852625","type":"NDC"}],"standard_charges":[{"gross_charge":8.84,"discounted_cash":4.86,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Lithium Carbonate Cap 300 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"4529","type":"CDM"},{"code":"54852725","type":"NDC"}],"standard_charges":[{"gross_charge":9.63,"discounted_cash":5.30,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Loperamide HCl Cap 2 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"4560","type":"CDM"},{"code":"60687022901","type":"NDC"}],"standard_charges":[{"gross_charge":4.02,"discounted_cash":2.21,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Loperamide HCl Cap 2 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"4560","type":"CDM"},{"code":"60687022911","type":"NDC"}],"standard_charges":[{"gross_charge":4.02,"discounted_cash":2.21,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Lorazepam Conc 2 MG/ML","drug_information":{"unit":30.0,"type":"ML"},"code_information":[{"code":"4571","type":"CDM"},{"code":"54353244","type":"NDC"}],"standard_charges":[{"gross_charge":192.92,"discounted_cash":106.11,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Lorazepam Tab 0.5 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"4572","type":"CDM"},{"code":"69315090401","type":"NDC"}],"standard_charges":[{"gross_charge":10.86,"discounted_cash":5.97,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Lorazepam Tab 1 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"4573","type":"CDM"},{"code":"69315090501","type":"NDC"}],"standard_charges":[{"gross_charge":11.73,"discounted_cash":6.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Loxapine Succinate Cap 10 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"4599","type":"CDM"},{"code":"527139501","type":"NDC"}],"standard_charges":[{"gross_charge":12.9,"discounted_cash":7.10,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Ampicillin Sodium For Inj 1 GM","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"469","type":"CDM"},{"code":"781340485","type":"NDC"}],"standard_charges":[{"gross_charge":27.6,"discounted_cash":15.18,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Ampicillin Sodium For Inj 1 GM","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"469","type":"CDM"},{"code":"781340495","type":"NDC"}],"standard_charges":[{"gross_charge":27.59,"discounted_cash":15.17,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Magnesium Citrate Soln","drug_information":{"unit":300.0,"type":"ML"},"code_information":[{"code":"4712","type":"CDM"},{"code":"71399005101","type":"NDC"}],"standard_charges":[{"gross_charge":33.02,"discounted_cash":18.16,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Ampicillin Sodium For Inj 2 GM","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"472","type":"CDM"},{"code":"72572001710","type":"NDC"}],"standard_charges":[{"gross_charge":19.41,"discounted_cash":10.68,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Ampicillin Sodium For Inj 2 GM","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"472","type":"CDM"},{"code":"72572001701","type":"NDC"}],"standard_charges":[{"gross_charge":19.41,"discounted_cash":10.68,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Magnesium Sulfate Inj 50%","drug_information":{"unit":2.0,"type":"ML"},"code_information":[{"code":"4720","type":"CDM"},{"code":"63323006423","type":"NDC"}],"standard_charges":[{"gross_charge":17.52,"discounted_cash":9.64,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Magnesium Sulfate Inj 50%","drug_information":{"unit":2.0,"type":"ML"},"code_information":[{"code":"4720","type":"CDM"},{"code":"63323006404","type":"NDC"}],"standard_charges":[{"gross_charge":16.45,"discounted_cash":9.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Magnesium Sulfate Inj 50%","drug_information":{"unit":2.0,"type":"ML"},"code_information":[{"code":"4720","type":"CDM"},{"code":"63323006401","type":"NDC"}],"standard_charges":[{"gross_charge":19.31,"discounted_cash":10.62,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Magnesium Sulfate Inj 50%","drug_information":{"unit":2.0,"type":"ML"},"code_information":[{"code":"4720","type":"CDM"},{"code":"63323006411","type":"NDC"}],"standard_charges":[{"gross_charge":16.45,"discounted_cash":9.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Magnesium Sulfate Inj 50%","drug_information":{"unit":2.0,"type":"ML"},"code_information":[{"code":"4720","type":"CDM"},{"code":"63323064220","type":"NDC"}],"standard_charges":[{"gross_charge":17.02,"discounted_cash":9.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Magnesium Sulfate Inj 50%","drug_information":{"unit":2.0,"type":"ML"},"code_information":[{"code":"4720","type":"CDM"},{"code":"63323064250","type":"NDC"}],"standard_charges":[{"gross_charge":17.07,"discounted_cash":9.39,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Magnesium Sulfate Inj 50%","drug_information":{"unit":2.0,"type":"ML"},"code_information":[{"code":"4720","type":"CDM"},{"code":"63323006403","type":"NDC"}],"standard_charges":[{"gross_charge":19.31,"discounted_cash":10.62,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Ampicillin Sodium For Inj 500 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"474","type":"CDM"},{"code":"781940778","type":"NDC"}],"standard_charges":[{"gross_charge":21.67,"discounted_cash":11.92,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Mannitol IV Soln 20%","drug_information":{"unit":500.0,"type":"ML"},"code_information":[{"code":"4749","type":"CDM"},{"code":"338035703","type":"NDC"}],"standard_charges":[{"gross_charge":366.98,"discounted_cash":201.84,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Mannitol IV Soln 25%","drug_information":{"unit":25.0,"type":"ML"},"code_information":[{"code":"4750","type":"CDM"},{"code":"409403116","type":"NDC"}],"standard_charges":[{"gross_charge":47.24,"discounted_cash":25.98,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Mannitol IV Soln 25%","drug_information":{"unit":25.0,"type":"ML"},"code_information":[{"code":"4750","type":"CDM"},{"code":"409403101","type":"NDC"}],"standard_charges":[{"gross_charge":47.24,"discounted_cash":25.98,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Medroxyprogesterone Acetate Tab 2.5 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"4855","type":"CDM"},{"code":"555087202","type":"NDC"}],"standard_charges":[{"gross_charge":9.39,"discounted_cash":5.16,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Meperidine HCl Inj 50 MG/ML","drug_information":{"unit":0.5,"type":"ML"},"code_information":[{"code":"4904","type":"CDM"},{"code":"409117803","type":"NDC"}],"standard_charges":[{"gross_charge":45.95,"discounted_cash":25.27,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Meperidine HCl Inj 50 MG/ML","drug_information":{"unit":0.5,"type":"ML"},"code_information":[{"code":"4904","type":"CDM"},{"code":"641605301","type":"NDC"}],"standard_charges":[{"gross_charge":37.1,"discounted_cash":20.40,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Meperidine HCl Inj 50 MG/ML","drug_information":{"unit":0.5,"type":"ML"},"code_information":[{"code":"4904","type":"CDM"},{"code":"409125311","type":"NDC"}],"standard_charges":[{"gross_charge":40.24,"discounted_cash":22.13,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Methadone HCl Tab 10 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"4953","type":"CDM"},{"code":"406577123","type":"NDC"}],"standard_charges":[{"gross_charge":11.03,"discounted_cash":6.07,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Methadone HCl Tab 10 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"4953","type":"CDM"},{"code":"406577162","type":"NDC"}],"standard_charges":[{"gross_charge":11.01,"discounted_cash":6.06,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Methadone HCl Tab 5 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"4954","type":"CDM"},{"code":"406575523","type":"NDC"}],"standard_charges":[{"gross_charge":10.63,"discounted_cash":5.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Methocarbamol Tab 500 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"4971","type":"CDM"},{"code":"904705761","type":"NDC"}],"standard_charges":[{"gross_charge":9.41,"discounted_cash":5.18,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Methotrexate Sodium Tab 2.5 MG (Base Equiv)","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"4973","type":"CDM"},{"code":"51079067005","type":"NDC"}],"standard_charges":[{"gross_charge":28.58,"discounted_cash":15.72,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Methotrexate Sodium Tab 2.5 MG (Base Equiv)","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"4973","type":"CDM"},{"code":"51079067001","type":"NDC"}],"standard_charges":[{"gross_charge":28.59,"discounted_cash":15.72,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Methylphenidate HCl Tab 5 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"4988","type":"CDM"},{"code":"16729047801","type":"NDC"}],"standard_charges":[{"gross_charge":11.17,"discounted_cash":6.14,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Methylprednisolone Tab 4 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"4993","type":"CDM"},{"code":"68382091601","type":"NDC"}],"standard_charges":[{"gross_charge":14.35,"discounted_cash":7.89,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Methylprednisolone Acetate Inj Susp 40 MG/ML","drug_information":{"unit":1.0,"type":"ML"},"code_information":[{"code":"4995","type":"CDM"},{"code":"9307301","type":"NDC"}],"standard_charges":[{"gross_charge":68.48,"discounted_cash":37.66,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Methylprednisolone Acetate Inj Susp 40 MG/ML","drug_information":{"unit":1.0,"type":"ML"},"code_information":[{"code":"4995","type":"CDM"},{"code":"9307303","type":"NDC"}],"standard_charges":[{"gross_charge":68.52,"discounted_cash":37.69,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Methylprednisolone Acetate Inj Susp 80 MG/ML","drug_information":{"unit":1.0,"type":"ML"},"code_information":[{"code":"4996","type":"CDM"},{"code":"9347501","type":"NDC"}],"standard_charges":[{"gross_charge":96.07,"discounted_cash":52.84,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Methylprednisolone Acetate Inj Susp 80 MG/ML","drug_information":{"unit":1.0,"type":"ML"},"code_information":[{"code":"4996","type":"CDM"},{"code":"70121157401","type":"NDC"}],"standard_charges":[{"gross_charge":84.85,"discounted_cash":46.67,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Metoclopramide HCl Inj 5 MG/ML (Base Equivalent)","drug_information":{"unit":2.0,"type":"ML"},"code_information":[{"code":"5002","type":"CDM"},{"code":"409341411","type":"NDC"}],"standard_charges":[{"gross_charge":41.58,"discounted_cash":22.87,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Metoclopramide HCl Inj 5 MG/ML (Base Equivalent)","drug_information":{"unit":2.0,"type":"ML"},"code_information":[{"code":"5002","type":"CDM"},{"code":"83634077902","type":"NDC"}],"standard_charges":[{"gross_charge":42.48,"discounted_cash":23.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Metoclopramide HCl Inj 5 MG/ML (Base Equivalent)","drug_information":{"unit":2.0,"type":"ML"},"code_information":[{"code":"5002","type":"CDM"},{"code":"23155024031","type":"NDC"}],"standard_charges":[{"gross_charge":45.06,"discounted_cash":24.78,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Metoclopramide HCl Inj 5 MG/ML (Base Equivalent)","drug_information":{"unit":2.0,"type":"ML"},"code_information":[{"code":"5002","type":"CDM"},{"code":"23155024041","type":"NDC"}],"standard_charges":[{"gross_charge":45.06,"discounted_cash":24.78,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Metoclopramide HCl Inj 5 MG/ML (Base Equivalent)","drug_information":{"unit":2.0,"type":"ML"},"code_information":[{"code":"5002","type":"CDM"},{"code":"409341418","type":"NDC"}],"standard_charges":[{"gross_charge":41.58,"discounted_cash":22.87,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Metoclopramide HCl Inj 5 MG/ML (Base Equivalent)","drug_information":{"unit":2.0,"type":"ML"},"code_information":[{"code":"5002","type":"CDM"},{"code":"83634077941","type":"NDC"}],"standard_charges":[{"gross_charge":42.48,"discounted_cash":23.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Metoclopramide HCl Inj 5 MG/ML (Base Equivalent)","drug_information":{"unit":2.0,"type":"ML"},"code_information":[{"code":"5002","type":"CDM"},{"code":"703450204","type":"NDC"}],"standard_charges":[{"gross_charge":50.59,"discounted_cash":27.82,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Metoclopramide HCl Tab 10 MG (Base Equivalent)","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"5005","type":"CDM"},{"code":"60687063111","type":"NDC"}],"standard_charges":[{"gross_charge":37.92,"discounted_cash":20.86,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Metoclopramide HCl Tab 10 MG (Base Equivalent)","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"5005","type":"CDM"},{"code":"60687063101","type":"NDC"}],"standard_charges":[{"gross_charge":37.92,"discounted_cash":20.86,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Metoclopramide HCl Tab 5 MG (Base Equivalent)","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"5006","type":"CDM"},{"code":"93220401","type":"NDC"}],"standard_charges":[{"gross_charge":36.08,"discounted_cash":19.84,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Metoprolol Tartrate Tab 50 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"5009","type":"CDM"},{"code":"62584026601","type":"NDC"}],"standard_charges":[{"gross_charge":8.59,"discounted_cash":4.72,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Metoprolol Tartrate Tab 50 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"5009","type":"CDM"},{"code":"62584026611","type":"NDC"}],"standard_charges":[{"gross_charge":8.58,"discounted_cash":4.72,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Metronidazole Tab 250 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"5015","type":"CDM"},{"code":"60687052601","type":"NDC"}],"standard_charges":[{"gross_charge":10.19,"discounted_cash":5.60,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Metronidazole Tab 250 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"5015","type":"CDM"},{"code":"60687052611","type":"NDC"}],"standard_charges":[{"gross_charge":10.19,"discounted_cash":5.60,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Metronidazole Tab 500 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"5016","type":"CDM"},{"code":"60687055011","type":"NDC"}],"standard_charges":[{"gross_charge":12.09,"discounted_cash":6.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Metronidazole Tab 500 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"5016","type":"CDM"},{"code":"60687055001","type":"NDC"}],"standard_charges":[{"gross_charge":12.09,"discounted_cash":6.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Mineral Oil","drug_information":{"unit":15.0,"type":"ML"},"code_information":[{"code":"5086","type":"CDM"},{"code":"48433020230","type":"NDC"}],"standard_charges":[{"gross_charge":22.34,"discounted_cash":12.29,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Mineral Oil","drug_information":{"unit":15.0,"type":"ML"},"code_information":[{"code":"5086","type":"CDM"},{"code":"869083143","type":"NDC"}],"standard_charges":[{"gross_charge":18.0,"discounted_cash":9.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Mineral Oil Enema","drug_information":{"unit":133.0,"type":"ML"},"code_information":[{"code":"5087","type":"CDM"},{"code":"132030140","type":"NDC"}],"standard_charges":[{"gross_charge":23.39,"discounted_cash":12.86,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Minocycline HCl Cap 50 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"5111","type":"CDM"},{"code":"68382031601","type":"NDC"}],"standard_charges":[{"gross_charge":14.54,"discounted_cash":8.00,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Minoxidil Tab 10 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"5114","type":"CDM"},{"code":"68084020511","type":"NDC"}],"standard_charges":[{"gross_charge":16.16,"discounted_cash":8.89,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Minoxidil Tab 10 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"5114","type":"CDM"},{"code":"49884025701","type":"NDC"}],"standard_charges":[{"gross_charge":14.5,"discounted_cash":7.98,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Minoxidil Tab 2.5 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"5115","type":"CDM"},{"code":"72789027801","type":"NDC"}],"standard_charges":[{"gross_charge":9.14,"discounted_cash":5.03,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Morphine Sulfate Inj 2 MG/ML","drug_information":{"unit":0.5,"type":"ML"},"code_information":[{"code":"5170","type":"CDM"},{"code":"76045000401","type":"NDC"}],"standard_charges":[{"gross_charge":37.63,"discounted_cash":20.70,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Morphine Sulfate Inj 2 MG/ML","drug_information":{"unit":0.5,"type":"ML"},"code_information":[{"code":"5170","type":"CDM"},{"code":"76045000411","type":"NDC"}],"standard_charges":[{"gross_charge":37.63,"discounted_cash":20.70,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Morphine Sulfate Inj 4 MG/ML","drug_information":{"unit":0.5,"type":"ML"},"code_information":[{"code":"5172","type":"CDM"},{"code":"76045000501","type":"NDC"}],"standard_charges":[{"gross_charge":37.63,"discounted_cash":20.70,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Morphine Sulfate Inj 4 MG/ML","drug_information":{"unit":0.5,"type":"ML"},"code_information":[{"code":"5172","type":"CDM"},{"code":"76045000511","type":"NDC"}],"standard_charges":[{"gross_charge":37.63,"discounted_cash":20.70,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Morphine Sulfate Tab 15 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"5178","type":"CDM"},{"code":"54023524","type":"NDC"}],"standard_charges":[{"gross_charge":12.05,"discounted_cash":6.63,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Morphine Sulfate Tab 15 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"5178","type":"CDM"},{"code":"54023525","type":"NDC"}],"standard_charges":[{"gross_charge":10.31,"discounted_cash":5.67,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Morphine Sulfate Tab 30 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"5179","type":"CDM"},{"code":"54023624","type":"NDC"}],"standard_charges":[{"gross_charge":13.94,"discounted_cash":7.67,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Nafcillin Sodium For Inj 2 GM","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"5335","type":"CDM"},{"code":"72485040601","type":"NDC"}],"standard_charges":[{"gross_charge":20.04,"discounted_cash":11.02,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Nafcillin Sodium For Inj 2 GM","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"5335","type":"CDM"},{"code":"72485040610","type":"NDC"}],"standard_charges":[{"gross_charge":20.04,"discounted_cash":11.02,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Nalbuphine HCl Inj 10 MG/ML","drug_information":{"unit":1.0,"type":"ML"},"code_information":[{"code":"5339","type":"CDM"},{"code":"409146301","type":"NDC"}],"standard_charges":[{"gross_charge":48.66,"discounted_cash":26.76,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Naproxen Tab 250 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"5391","type":"CDM"},{"code":"50268059411","type":"NDC"}],"standard_charges":[{"gross_charge":11.46,"discounted_cash":6.30,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Naproxen Tab 500 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"5393","type":"CDM"},{"code":"60687049101","type":"NDC"}],"standard_charges":[{"gross_charge":13.16,"discounted_cash":7.24,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Naproxen Tab 500 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"5393","type":"CDM"},{"code":"60687049111","type":"NDC"}],"standard_charges":[{"gross_charge":13.16,"discounted_cash":7.24,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Neomycin Sulfate Tab 500 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"5472","type":"CDM"},{"code":"93117701","type":"NDC"}],"standard_charges":[{"gross_charge":13.72,"discounted_cash":7.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Nifedipine Cap 10 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"5558","type":"CDM"},{"code":"23155019401","type":"NDC"}],"standard_charges":[{"gross_charge":10.05,"discounted_cash":5.53,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Nitroglycerin IV Soln 5 MG/ML","drug_information":{"unit":10.0,"type":"ML"},"code_information":[{"code":"5599","type":"CDM"},{"code":"517481025","type":"NDC"}],"standard_charges":[{"gross_charge":102.84,"discounted_cash":56.56,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Nitroglycerin SL Tab 0.4 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"5604","type":"CDM"},{"code":"43598043611","type":"NDC"}],"standard_charges":[{"gross_charge":11.91,"discounted_cash":6.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Nitroglycerin SL Tab 0.4 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"5604","type":"CDM"},{"code":"70756001402","type":"NDC"}],"standard_charges":[{"gross_charge":11.95,"discounted_cash":6.57,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Nitroglycerin Oint 2%","drug_information":{"unit":1.0,"type":"GM"},"code_information":[{"code":"5606","type":"CDM"},{"code":"281032608","type":"NDC"}],"standard_charges":[{"gross_charge":28.66,"discounted_cash":15.76,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Nortriptyline HCl Cap 10 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"5674","type":"CDM"},{"code":"93081001","type":"NDC"}],"standard_charges":[{"gross_charge":11.27,"discounted_cash":6.20,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Nortriptyline HCl Cap 25 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"5675","type":"CDM"},{"code":"93081101","type":"NDC"}],"standard_charges":[{"gross_charge":13.65,"discounted_cash":7.51,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Nystatin Cream 100000 Unit/GM","drug_information":{"unit":30.0,"type":"GM"},"code_information":[{"code":"5749","type":"CDM"},{"code":"45802005911","type":"NDC"}],"standard_charges":[{"gross_charge":133.81,"discounted_cash":73.60,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Nystatin Susp 100000 Unit/ML","drug_information":{"unit":5.0,"type":"ML"},"code_information":[{"code":"5751","type":"CDM"},{"code":"121104516","type":"NDC"}],"standard_charges":[{"gross_charge":22.45,"discounted_cash":12.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Nystatin Susp 100000 Unit/ML","drug_information":{"unit":5.0,"type":"ML"},"code_information":[{"code":"5751","type":"CDM"},{"code":"63739016070","type":"NDC"}],"standard_charges":[{"gross_charge":24.36,"discounted_cash":13.40,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Nystatin Susp 100000 Unit/ML","drug_information":{"unit":60.0,"type":"ML"},"code_information":[{"code":"5751","type":"CDM"},{"code":"60432053760","type":"NDC"}],"standard_charges":[{"gross_charge":92.29,"discounted_cash":50.76,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Nystatin Susp 100000 Unit/ML","drug_information":{"unit":5.0,"type":"ML"},"code_information":[{"code":"5751","type":"CDM"},{"code":"8890575105","type":"NDC"}],"standard_charges":[{"gross_charge":18.09,"discounted_cash":9.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Emollient - Ointment","drug_information":{"unit":396.0,"type":"GM"},"code_information":[{"code":"5796","type":"CDM"},{"code":"72140003147","type":"NDC"}],"standard_charges":[{"gross_charge":117.45,"discounted_cash":64.60,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Emollient - Ointment","drug_information":{"unit":396.0,"type":"GM"},"code_information":[{"code":"5796","type":"CDM"},{"code":"72140063386","type":"NDC"}],"standard_charges":[{"gross_charge":131.54,"discounted_cash":72.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Emollient - Ointment","drug_information":{"unit":396.0,"type":"GM"},"code_information":[{"code":"5796","type":"CDM"},{"code":"72140063608","type":"NDC"}],"standard_charges":[{"gross_charge":131.54,"discounted_cash":72.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Oral Vehicles","drug_information":{"unit":5.0,"type":"ML"},"code_information":[{"code":"5851","type":"CDM"},{"code":"574030316","type":"NDC"}],"standard_charges":[{"gross_charge":9.05,"discounted_cash":4.98,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Oxacillin Sodium For Inj 1 GM (Base Equivalent)","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"5924","type":"CDM"},{"code":"63323081301","type":"NDC"}],"standard_charges":[{"gross_charge":69.54,"discounted_cash":38.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Oxacillin Sodium For Inj 2 GM (Base Equivalent)","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"5926","type":"CDM"},{"code":"63323081201","type":"NDC"}],"standard_charges":[{"gross_charge":92.67,"discounted_cash":50.97,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Oxacillin Sodium For Inj 2 GM (Base Equivalent)","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"5926","type":"CDM"},{"code":"63323081220","type":"NDC"}],"standard_charges":[{"gross_charge":92.67,"discounted_cash":50.97,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Oxycodone w/ Acetaminophen Tab 5-325 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"5940","type":"CDM"},{"code":"406051262","type":"NDC"}],"standard_charges":[{"gross_charge":15.33,"discounted_cash":8.43,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Oxymetazoline HCl Nasal Soln 0.05%","drug_information":{"unit":15.0,"type":"ML"},"code_information":[{"code":"5943","type":"CDM"},{"code":"904743535","type":"NDC"}],"standard_charges":[{"gross_charge":27.61,"discounted_cash":15.19,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Oxymetazoline HCl Nasal Soln 0.05%","drug_information":{"unit":30.0,"type":"ML"},"code_information":[{"code":"5943","type":"CDM"},{"code":"41100081125","type":"NDC"}],"standard_charges":[{"gross_charge":66.4,"discounted_cash":36.52,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Oxytocin Inj 10 Unit/ML","drug_information":{"unit":0.3,"type":"ML"},"code_information":[{"code":"5944","type":"CDM"},{"code":"63323001211","type":"NDC"}],"standard_charges":[{"gross_charge":35.78,"discounted_cash":19.68,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Oxytocin Inj 10 Unit/ML","drug_information":{"unit":0.3,"type":"ML"},"code_information":[{"code":"5944","type":"CDM"},{"code":"42023011625","type":"NDC"}],"standard_charges":[{"gross_charge":35.99,"discounted_cash":19.79,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Oxytocin Inj 10 Unit/ML","drug_information":{"unit":0.3,"type":"ML"},"code_information":[{"code":"5944","type":"CDM"},{"code":"63323001210","type":"NDC"}],"standard_charges":[{"gross_charge":32.42,"discounted_cash":17.83,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Noncdm Charge Record","code_information":[{"code":"60000130","type":"CDM"},{"code":"310","type":"RC"},{"code":"G0416","type":"HCPCS"}],"standard_charges":[{"gross_charge":1249.0,"discounted_cash":686.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Lchg Glucon (1,3) Beta-D-Glucon (Fungitell)","code_information":[{"code":"60000210","type":"CDM"},{"code":"306","type":"RC"},{"code":"87449","type":"HCPCS"}],"standard_charges":[{"gross_charge":246.0,"discounted_cash":135.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Mopath Procedure Level 5 Hbb","code_information":[{"code":"60000330","type":"CDM"},{"code":"310","type":"RC"},{"code":"81404","type":"HCPCS"}],"standard_charges":[{"gross_charge":1742.0,"discounted_cash":958.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Flt3 Gene Analysis","code_information":[{"code":"60000370","type":"CDM"},{"code":"310","type":"RC"},{"code":"81245","type":"HCPCS"}],"standard_charges":[{"gross_charge":802.0,"discounted_cash":441.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Bcr-Abl1 Gene Major Qual","code_information":[{"code":"60000520","type":"CDM"},{"code":"310","type":"RC"},{"code":"81206","type":"HCPCS"}],"standard_charges":[{"gross_charge":984.0,"discounted_cash":541.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Bcr-Abl1 Gene Minor Qual","code_information":[{"code":"60000530","type":"CDM"},{"code":"310","type":"RC"},{"code":"81207","type":"HCPCS"}],"standard_charges":[{"gross_charge":8.0,"discounted_cash":4.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Jak2 Gene V6172F Qual","code_information":[{"code":"60000540","type":"CDM"},{"code":"310","type":"RC"},{"code":"81270","type":"HCPCS"}],"standard_charges":[{"gross_charge":924.0,"discounted_cash":508.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg C Burnetii (Q Fever) Antibody","code_information":[{"code":"60000580","type":"CDM"},{"code":"302","type":"RC"},{"code":"86638","type":"HCPCS"}],"standard_charges":[{"gross_charge":37.0,"discounted_cash":20.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Cebpa Mutation Detection I","code_information":[{"code":"60000711","type":"CDM"},{"code":"310","type":"RC"},{"code":"81479","type":"HCPCS"}],"standard_charges":[{"gross_charge":2081.0,"discounted_cash":1144.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Hepatitis B Surface Ag Confirmation","code_information":[{"code":"60000770","type":"CDM"},{"code":"306","type":"RC"},{"code":"87341","type":"HCPCS"}],"standard_charges":[{"gross_charge":32.0,"discounted_cash":17.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Cmv Antibody Igg Avidity","code_information":[{"code":"60000790","type":"CDM"},{"code":"302","type":"RC"},{"code":"86644","type":"HCPCS"}],"standard_charges":[{"gross_charge":138.0,"discounted_cash":75.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Pm/Scl Antibody I","code_information":[{"code":"60000951","type":"CDM"},{"code":"302","type":"RC"},{"code":"86235","type":"HCPCS"}],"standard_charges":[{"gross_charge":269.0,"discounted_cash":147.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Call In Bb Fee Ref","code_information":[{"code":"60001300","type":"CDM"},{"code":"300","type":"RC"}],"standard_charges":[{"gross_charge":308.0,"discounted_cash":169.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Platelet Assoc Assay Ref","code_information":[{"code":"60001310","type":"CDM"},{"code":"300","type":"RC"},{"code":"86023","type":"HCPCS"}],"standard_charges":[{"gross_charge":284.0,"discounted_cash":156.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Platelet Ab Ref","code_information":[{"code":"60001320","type":"CDM"},{"code":"300","type":"RC"},{"code":"86022","type":"HCPCS"}],"standard_charges":[{"gross_charge":151.0,"discounted_cash":83.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Dna Or Rna Multi Org Ampl Probe","code_information":[{"code":"60001480","type":"CDM"},{"code":"306","type":"RC"},{"code":"87801","type":"HCPCS"}],"standard_charges":[{"gross_charge":285.0,"discounted_cash":156.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Mycobacterium Species Ampl Probe","code_information":[{"code":"60001490","type":"CDM"},{"code":"306","type":"RC"},{"code":"87551","type":"HCPCS"}],"standard_charges":[{"gross_charge":196.0,"discounted_cash":107.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Heterophile Antibody Screen W/ Reflx","code_information":[{"code":"60001500","type":"CDM"},{"code":"302","type":"RC"},{"code":"86308","type":"HCPCS"}],"standard_charges":[{"gross_charge":16.0,"discounted_cash":8.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Treponema Pallidum Ab Igg By Elisa","code_information":[{"code":"60001690","type":"CDM"},{"code":"302","type":"RC"},{"code":"86780","type":"HCPCS"}],"standard_charges":[{"gross_charge":385.0,"discounted_cash":211.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Meperidine + Metabolite Urine I","code_information":[{"code":"60001741","type":"CDM"},{"code":"301","type":"RC"},{"code":"80362","type":"HCPCS"}],"standard_charges":[{"gross_charge":353.0,"discounted_cash":194.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Tramadol + Metabolite Urine I","code_information":[{"code":"60001751","type":"CDM"},{"code":"301","type":"RC"},{"code":"80373","type":"HCPCS"}],"standard_charges":[{"gross_charge":343.0,"discounted_cash":188.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Genotype Analysis By Nuc Acid","code_information":[{"code":"60001820","type":"CDM"},{"code":"306","type":"RC"},{"code":"87900","type":"HCPCS"}],"standard_charges":[{"gross_charge":978.0,"discounted_cash":537.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Mopath Procedure Unlisted Ibd","code_information":[{"code":"60002990","type":"CDM"},{"code":"310","type":"RC"},{"code":"81479","type":"HCPCS"}],"standard_charges":[{"gross_charge":8870.0,"discounted_cash":4878.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Calprotectin Fecal","code_information":[{"code":"60003030","type":"CDM"},{"code":"301","type":"RC"},{"code":"83993","type":"HCPCS"}],"standard_charges":[{"gross_charge":67.0,"discounted_cash":36.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Aripiprazole Blood Ii","code_information":[{"code":"60003192","type":"CDM"},{"code":"301","type":"RC"},{"code":"80342","type":"HCPCS"}],"standard_charges":[{"gross_charge":272.0,"discounted_cash":149.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Microdissection Manual Braf V600","code_information":[{"code":"60003230","type":"CDM"},{"code":"310","type":"RC"},{"code":"88381","type":"HCPCS"}],"standard_charges":[{"gross_charge":217.0,"discounted_cash":119.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Microsatellite Instability Analysis","code_information":[{"code":"60003550","type":"CDM"},{"code":"310","type":"RC"},{"code":"81301","type":"HCPCS"}],"standard_charges":[{"gross_charge":792.0,"discounted_cash":435.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Immunofixation","code_information":[{"code":"60003560","type":"CDM"},{"code":"302","type":"RC"},{"code":"86334","type":"HCPCS"}],"standard_charges":[{"gross_charge":244.0,"discounted_cash":134.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Sgpg Antibody Igm","code_information":[{"code":"60003570","type":"CDM"},{"code":"301","type":"RC"},{"code":"83516","type":"HCPCS"}],"standard_charges":[{"gross_charge":179.0,"discounted_cash":98.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Culture Nocardia","code_information":[{"code":"60003580","type":"CDM"},{"code":"306","type":"RC"},{"code":"87070","type":"HCPCS"}],"standard_charges":[{"gross_charge":165.0,"discounted_cash":90.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Pneumocystis Jirovecii By Pcr","code_information":[{"code":"60003630","type":"CDM"},{"code":"306","type":"RC"},{"code":"87798","type":"HCPCS"}],"standard_charges":[{"gross_charge":508.0,"discounted_cash":279.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Pro Brain Natriuretic Peptide","code_information":[{"code":"60003640","type":"CDM"},{"code":"301","type":"RC"},{"code":"83880","type":"HCPCS"}],"standard_charges":[{"gross_charge":355.0,"discounted_cash":195.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Trapentadol+Metabolite Urine Conf I","code_information":[{"code":"60003681","type":"CDM"},{"code":"301","type":"RC"},{"code":"80372","type":"HCPCS"}],"standard_charges":[{"gross_charge":343.0,"discounted_cash":188.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Urovysion Fish","code_information":[{"code":"60003720","type":"CDM"},{"code":"310","type":"RC"},{"code":"88121","type":"HCPCS"}],"standard_charges":[{"gross_charge":1339.0,"discounted_cash":736.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Viral Culture Mumps","code_information":[{"code":"60003740","type":"CDM"},{"code":"306","type":"RC"},{"code":"87252","type":"HCPCS"}],"standard_charges":[{"gross_charge":442.0,"discounted_cash":243.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Thrombin Time Mix","code_information":[{"code":"60004080","type":"CDM"},{"code":"305","type":"RC"},{"code":"85670","type":"HCPCS"}],"standard_charges":[{"gross_charge":90.0,"discounted_cash":49.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Dexamethasone Level","code_information":[{"code":"60004090","type":"CDM"},{"code":"301","type":"RC"},{"code":"80299","type":"HCPCS"}],"standard_charges":[{"gross_charge":303.0,"discounted_cash":166.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Respiratory Virus 6-11 Targets","code_information":[{"code":"60004160","type":"CDM"},{"code":"306","type":"RC"},{"code":"87632","type":"HCPCS"}],"standard_charges":[{"gross_charge":1874.0,"discounted_cash":1030.7,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Respiratory Virus 3-5 Targets","code_information":[{"code":"60004170","type":"CDM"},{"code":"306","type":"RC"},{"code":"87631","type":"HCPCS"}],"standard_charges":[{"gross_charge":1063.0,"discounted_cash":584.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Coenzyme Q10 I","code_information":[{"code":"60004201","type":"CDM"},{"code":"301","type":"RC"},{"code":"82542","type":"HCPCS"}],"standard_charges":[{"gross_charge":288.0,"discounted_cash":158.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Hiv-1 Antibody","code_information":[{"code":"60004660","type":"CDM"},{"code":"302","type":"RC"},{"code":"86701","type":"HCPCS"}],"standard_charges":[{"gross_charge":28.0,"discounted_cash":15.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Susceptibility Each Refer","code_information":[{"code":"60004670","type":"CDM"},{"code":"306","type":"RC"},{"code":"87186","type":"HCPCS"}],"standard_charges":[{"gross_charge":174.0,"discounted_cash":95.7,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Blood Collection/Central Line Cath","code_information":[{"code":"60004690","type":"CDM"},{"code":"300","type":"RC"},{"code":"36592","type":"HCPCS"}],"standard_charges":[{"gross_charge":200.0,"discounted_cash":110.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Nmo Igg","code_information":[{"code":"60005030","type":"CDM"},{"code":"302","type":"RC"},{"code":"86255","type":"HCPCS"}],"standard_charges":[{"gross_charge":105.0,"discounted_cash":57.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Rheumatoid Factor Fluid Quant","code_information":[{"code":"60005280","type":"CDM"},{"code":"302","type":"RC"},{"code":"86431","type":"HCPCS"}],"standard_charges":[{"gross_charge":91.0,"discounted_cash":50.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Chlamydia Dna Probe Tprep","code_information":[{"code":"60005460","type":"CDM"},{"code":"306","type":"RC"},{"code":"87491","type":"HCPCS"}],"standard_charges":[{"gross_charge":482.0,"discounted_cash":265.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Gc Dna Probe Tprep","code_information":[{"code":"60005470","type":"CDM"},{"code":"306","type":"RC"},{"code":"87591","type":"HCPCS"}],"standard_charges":[{"gross_charge":482.0,"discounted_cash":265.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Fibrinogen Antigen","code_information":[{"code":"60005640","type":"CDM"},{"code":"305","type":"RC"},{"code":"85385","type":"HCPCS"}],"standard_charges":[{"gross_charge":47.0,"discounted_cash":25.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Hla I Typing Antigen Lr","code_information":[{"code":"60006030","type":"CDM"},{"code":"300","type":"RC"},{"code":"81374","type":"HCPCS"}],"standard_charges":[{"gross_charge":1482.0,"discounted_cash":815.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Oligoclonal Bands Blood","code_information":[{"code":"60006250","type":"CDM"},{"code":"301","type":"RC"},{"code":"83916","type":"HCPCS"}],"standard_charges":[{"gross_charge":227.0,"discounted_cash":124.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Braf V600 Mutation","code_information":[{"code":"60006260","type":"CDM"},{"code":"310","type":"RC"},{"code":"81210","type":"HCPCS"}],"standard_charges":[{"gross_charge":848.0,"discounted_cash":466.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Braf V600 Mutation I","code_information":[{"code":"60006261","type":"CDM"},{"code":"310","type":"RC"},{"code":"81210","type":"HCPCS"}],"standard_charges":[{"gross_charge":848.0,"discounted_cash":466.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Adenovirus Pcr Qual","code_information":[{"code":"60006430","type":"CDM"},{"code":"306","type":"RC"},{"code":"87798","type":"HCPCS"}],"standard_charges":[{"gross_charge":508.0,"discounted_cash":279.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Metapneumovirus Rt-Pcr","code_information":[{"code":"60006440","type":"CDM"},{"code":"306","type":"RC"},{"code":"87798","type":"HCPCS"}],"standard_charges":[{"gross_charge":508.0,"discounted_cash":279.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Organism Id Staph","code_information":[{"code":"60006460","type":"CDM"},{"code":"306","type":"RC"},{"code":"87147","type":"HCPCS"}],"standard_charges":[{"gross_charge":66.0,"discounted_cash":36.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Arbovirus Antibody Each Blood","code_information":[{"code":"60006890","type":"CDM"},{"code":"302","type":"RC"},{"code":"86790","type":"HCPCS"}],"standard_charges":[{"gross_charge":98.0,"discounted_cash":53.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Adalimumab Level","code_information":[{"code":"60007240","type":"CDM"},{"code":"301","type":"RC"},{"code":"80299","type":"HCPCS"}],"standard_charges":[{"gross_charge":303.0,"discounted_cash":166.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Adalimumab Level I","code_information":[{"code":"60007241","type":"CDM"},{"code":"301","type":"RC"},{"code":"82397","type":"HCPCS"}],"standard_charges":[{"gross_charge":226.0,"discounted_cash":124.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg C-Telopeptide Crossl Blood","code_information":[{"code":"60007270","type":"CDM"},{"code":"301","type":"RC"},{"code":"82523","type":"HCPCS"}],"standard_charges":[{"gross_charge":165.0,"discounted_cash":90.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Compatibility Test Electronic","code_information":[{"code":"60007290","type":"CDM"},{"code":"302","type":"RC"},{"code":"86923","type":"HCPCS"}],"standard_charges":[{"gross_charge":161.0,"discounted_cash":88.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Dna Or Rna Multi Org Ampl Probe Fungi","code_information":[{"code":"60007340","type":"CDM"},{"code":"306","type":"RC"},{"code":"87801","type":"HCPCS"}],"standard_charges":[{"gross_charge":289.0,"discounted_cash":158.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Urovysion Fish (Manual Reflex)","code_information":[{"code":"60007440","type":"CDM"},{"code":"310","type":"RC"},{"code":"88120","type":"HCPCS"}],"standard_charges":[{"gross_charge":687.0,"discounted_cash":377.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Noncdm Charge Record","code_information":[{"code":"60007680","type":"CDM"},{"code":"302","type":"RC"},{"code":"86005","type":"HCPCS"}],"standard_charges":[{"gross_charge":117.0,"discounted_cash":64.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Lchg Fetal Congenital Abnorm Four Analytes","code_information":[{"code":"60007700","type":"CDM"},{"code":"310","type":"RC"},{"code":"81511","type":"HCPCS"}],"standard_charges":[{"gross_charge":280.0,"discounted_cash":154.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Mgmt Methylation Analysis","code_information":[{"code":"60007750","type":"CDM"},{"code":"310","type":"RC"},{"code":"81287","type":"HCPCS"}],"standard_charges":[{"gross_charge":604.0,"discounted_cash":332.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Trichomonas Vaginalis Amplified Probe","code_information":[{"code":"60007780","type":"CDM"},{"code":"306","type":"RC"},{"code":"87661","type":"HCPCS"}],"standard_charges":[{"gross_charge":147.0,"discounted_cash":80.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Ihc Adtl Stn Same Sld Tc I","code_information":[{"code":"60007792","type":"CDM"},{"code":"310","type":"RC"},{"code":"88344","type":"HCPCS"}],"standard_charges":[{"gross_charge":747.0,"discounted_cash":410.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Ihc Adtl Stn Same Sld Pc I","code_information":[{"code":"60007801","type":"CDM"},{"code":"971","type":"RC"},{"code":"88344","type":"HCPCS"}],"standard_charges":[{"gross_charge":747.0,"discounted_cash":410.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg P0 Antibodies","code_information":[{"code":"60007870","type":"CDM"},{"code":"301","type":"RC"},{"code":"84182","type":"HCPCS"}],"standard_charges":[{"gross_charge":96.0,"discounted_cash":52.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Trichomonas Vaginalis Amplified Probe I","code_information":[{"code":"60007881","type":"CDM"},{"code":"306","type":"RC"},{"code":"87661","type":"HCPCS"}],"standard_charges":[{"gross_charge":147.0,"discounted_cash":80.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Hemoglobin Electrophoresis Capillary I","code_information":[{"code":"60007961","type":"CDM"},{"code":"301","type":"RC"},{"code":"83020","type":"HCPCS"}],"standard_charges":[{"gross_charge":50.0,"discounted_cash":27.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Immunoperoxidase 1St Tc","code_information":[{"code":"60008030","type":"CDM"},{"code":"310","type":"RC"},{"code":"88342","type":"HCPCS"}],"standard_charges":[{"gross_charge":494.0,"discounted_cash":271.7,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Bcr/Abl1 Gene Other Bp","code_information":[{"code":"60008060","type":"CDM"},{"code":"310","type":"RC"},{"code":"81208","type":"HCPCS"}],"standard_charges":[{"gross_charge":984.0,"discounted_cash":541.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Microdissection Manual Mgmt","code_information":[{"code":"60008190","type":"CDM"},{"code":"310","type":"RC"},{"code":"88381","type":"HCPCS"}],"standard_charges":[{"gross_charge":112.0,"discounted_cash":61.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Htlv 2","code_information":[{"code":"60008250","type":"CDM"},{"code":"306","type":"RC"},{"code":"87798","type":"HCPCS"}],"standard_charges":[{"gross_charge":508.0,"discounted_cash":279.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Culture Hardware","code_information":[{"code":"60008330","type":"CDM"},{"code":"306","type":"RC"},{"code":"87070","type":"HCPCS"}],"standard_charges":[{"gross_charge":175.0,"discounted_cash":96.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Celiac Hla Dq","code_information":[{"code":"60008340","type":"CDM"},{"code":"300","type":"RC"},{"code":"81376","type":"HCPCS"}],"standard_charges":[{"gross_charge":592.0,"discounted_cash":325.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Inflixmab Drug Level","code_information":[{"code":"60008660","type":"CDM"},{"code":"301","type":"RC"},{"code":"80299","type":"HCPCS"}],"standard_charges":[{"gross_charge":303.0,"discounted_cash":166.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Inflixmab Antibody","code_information":[{"code":"60008670","type":"CDM"},{"code":"301","type":"RC"},{"code":"82397","type":"HCPCS"}],"standard_charges":[{"gross_charge":226.0,"discounted_cash":124.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Antigen Type Patient Ref Tier I","code_information":[{"code":"60008710","type":"CDM"},{"code":"300","type":"RC"},{"code":"86905","type":"HCPCS"}],"standard_charges":[{"gross_charge":832.0,"discounted_cash":457.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Antigen Type Patient Ref Tier Ii","code_information":[{"code":"60008720","type":"CDM"},{"code":"300","type":"RC"},{"code":"86905","type":"HCPCS"}],"standard_charges":[{"gross_charge":832.0,"discounted_cash":457.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Antigen Type Patient Ref Tier Iii","code_information":[{"code":"60008730","type":"CDM"},{"code":"300","type":"RC"},{"code":"86905","type":"HCPCS"}],"standard_charges":[{"gross_charge":832.0,"discounted_cash":457.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Antigen Type Patient Ref Tier Iv","code_information":[{"code":"60008740","type":"CDM"},{"code":"300","type":"RC"},{"code":"86905","type":"HCPCS"}],"standard_charges":[{"gross_charge":832.0,"discounted_cash":457.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Antigen Type Patient Rare Antisera","code_information":[{"code":"60008750","type":"CDM"},{"code":"300","type":"RC"},{"code":"86905","type":"HCPCS"}],"standard_charges":[{"gross_charge":832.0,"discounted_cash":457.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Enzyme Activity","code_information":[{"code":"60008890","type":"CDM"},{"code":"301","type":"RC"},{"code":"82657","type":"HCPCS"}],"standard_charges":[{"gross_charge":288.0,"discounted_cash":158.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Blastomyces Antigen Fluid","code_information":[{"code":"60008900","type":"CDM"},{"code":"306","type":"RC"},{"code":"87449","type":"HCPCS"}],"standard_charges":[{"gross_charge":48.0,"discounted_cash":26.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Bacterium Antibody","code_information":[{"code":"60008970","type":"CDM"},{"code":"302","type":"RC"},{"code":"86609","type":"HCPCS"}],"standard_charges":[{"gross_charge":39.0,"discounted_cash":21.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Mopath Procedure Level 3 Mpl","code_information":[{"code":"60009040","type":"CDM"},{"code":"310","type":"RC"},{"code":"81402","type":"HCPCS"}],"standard_charges":[{"gross_charge":750.0,"discounted_cash":412.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Microdissection Manual Stp","code_information":[{"code":"60009160","type":"CDM"},{"code":"310","type":"RC"},{"code":"88381","type":"HCPCS"}],"standard_charges":[{"gross_charge":217.0,"discounted_cash":119.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Cannabinoids Urine Confirm Iii","code_information":[{"code":"60009182","type":"CDM"},{"code":"301","type":"RC"},{"code":"80349","type":"HCPCS"}],"standard_charges":[{"gross_charge":136.0,"discounted_cash":74.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Ihc Adtl Stn Pc","code_information":[{"code":"60009300","type":"CDM"},{"code":"971","type":"RC"},{"code":"88342","type":"HCPCS"}],"standard_charges":[{"gross_charge":323.0,"discounted_cash":177.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Ihc 1St Stn Ref Tc","code_information":[{"code":"60009310","type":"CDM"},{"code":"310","type":"RC"},{"code":"88342","type":"HCPCS"}],"standard_charges":[{"gross_charge":494.0,"discounted_cash":271.7,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Ihc Adtl Stn Ref Tc","code_information":[{"code":"60009340","type":"CDM"},{"code":"310","type":"RC"},{"code":"88342","type":"HCPCS"}],"standard_charges":[{"gross_charge":494.0,"discounted_cash":271.7,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Ihc Adtl Stn Ref Tc Nl","code_information":[{"code":"60009350","type":"CDM"},{"code":"310","type":"RC"},{"code":"88342","type":"HCPCS"}],"standard_charges":[{"gross_charge":494.0,"discounted_cash":271.7,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Ihc Adtl Stn Ref Pc","code_information":[{"code":"60009360","type":"CDM"},{"code":"971","type":"RC"},{"code":"88342","type":"HCPCS"}],"standard_charges":[{"gross_charge":362.0,"discounted_cash":199.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Methylphenidate Level Urine I","code_information":[{"code":"60009491","type":"CDM"},{"code":"301","type":"RC"},{"code":"80360","type":"HCPCS"}],"standard_charges":[{"gross_charge":343.0,"discounted_cash":188.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Mycobacterium Tb Pcr","code_information":[{"code":"60009590","type":"CDM"},{"code":"306","type":"RC"},{"code":"87556","type":"HCPCS"}],"standard_charges":[{"gross_charge":169.0,"discounted_cash":92.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Mtb Rifampin By Pcr","code_information":[{"code":"60009600","type":"CDM"},{"code":"306","type":"RC"},{"code":"87798","type":"HCPCS"}],"standard_charges":[{"gross_charge":508.0,"discounted_cash":279.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Monacetylmorphine-6 Urine I","code_information":[{"code":"60009851","type":"CDM"},{"code":"301","type":"RC"},{"code":"80356","type":"HCPCS"}],"standard_charges":[{"gross_charge":192.0,"discounted_cash":105.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Ihc Adtl Stn Ref Tc I","code_information":[{"code":"60009910","type":"CDM"},{"code":"310","type":"RC"},{"code":"88342","type":"HCPCS"}],"standard_charges":[{"gross_charge":624.0,"discounted_cash":343.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Acetaminophen Level Ii","code_information":[{"code":"60010002","type":"CDM"},{"code":"301","type":"RC"},{"code":"80329","type":"HCPCS"}],"standard_charges":[{"gross_charge":63.0,"discounted_cash":34.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Acetaminophen Level Iv","code_information":[{"code":"60010004","type":"CDM"},{"code":"301","type":"RC"},{"code":"80307","type":"HCPCS"}],"standard_charges":[{"gross_charge":340.0,"discounted_cash":187.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Amitriptyline Level I","code_information":[{"code":"60010011","type":"CDM"},{"code":"301","type":"RC"},{"code":"80335","type":"HCPCS"}],"standard_charges":[{"gross_charge":261.0,"discounted_cash":143.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Clonazepam Level I","code_information":[{"code":"60010031","type":"CDM"},{"code":"301","type":"RC"},{"code":"80346","type":"HCPCS"}],"standard_charges":[{"gross_charge":289.0,"discounted_cash":158.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Carbamazepine Level Total","code_information":[{"code":"60010090","type":"CDM"},{"code":"301","type":"RC"},{"code":"80156","type":"HCPCS"}],"standard_charges":[{"gross_charge":247.0,"discounted_cash":135.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Amikacin Level Trough","code_information":[{"code":"60010100","type":"CDM"},{"code":"301","type":"RC"},{"code":"80150","type":"HCPCS"}],"standard_charges":[{"gross_charge":251.0,"discounted_cash":138.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Cyclosporine Level","code_information":[{"code":"60010140","type":"CDM"},{"code":"301","type":"RC"},{"code":"80158","type":"HCPCS"}],"standard_charges":[{"gross_charge":247.0,"discounted_cash":135.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Desipramine Level I","code_information":[{"code":"60010161","type":"CDM"},{"code":"301","type":"RC"},{"code":"80335","type":"HCPCS"}],"standard_charges":[{"gross_charge":354.0,"discounted_cash":194.7,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Valproic Acid Level","code_information":[{"code":"60010170","type":"CDM"},{"code":"301","type":"RC"},{"code":"80164","type":"HCPCS"}],"standard_charges":[{"gross_charge":218.0,"discounted_cash":119.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Ethosuximide Level","code_information":[{"code":"60010190","type":"CDM"},{"code":"301","type":"RC"},{"code":"80168","type":"HCPCS"}],"standard_charges":[{"gross_charge":246.0,"discounted_cash":135.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Hcg Beta Blood Tumor Marker","code_information":[{"code":"60010200","type":"CDM"},{"code":"301","type":"RC"},{"code":"84702","type":"HCPCS"}],"standard_charges":[{"gross_charge":238.0,"discounted_cash":130.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Imipramine Level I","code_information":[{"code":"60010221","type":"CDM"},{"code":"301","type":"RC"},{"code":"80335","type":"HCPCS"}],"standard_charges":[{"gross_charge":52.0,"discounted_cash":28.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Lidocaine Level","code_information":[{"code":"60010230","type":"CDM"},{"code":"301","type":"RC"},{"code":"80176","type":"HCPCS"}],"standard_charges":[{"gross_charge":44.0,"discounted_cash":24.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Nortriptyline Level Blood I","code_information":[{"code":"60010241","type":"CDM"},{"code":"301","type":"RC"},{"code":"80335","type":"HCPCS"}],"standard_charges":[{"gross_charge":190.0,"discounted_cash":104.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Phenytoin Free Level","code_information":[{"code":"60010280","type":"CDM"},{"code":"301","type":"RC"},{"code":"80186","type":"HCPCS"}],"standard_charges":[{"gross_charge":172.0,"discounted_cash":94.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Complement C3","code_information":[{"code":"60010300","type":"CDM"},{"code":"302","type":"RC"},{"code":"86160","type":"HCPCS"}],"standard_charges":[{"gross_charge":180.0,"discounted_cash":99.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Haloperidol Level","code_information":[{"code":"60010360","type":"CDM"},{"code":"301","type":"RC"},{"code":"80173","type":"HCPCS"}],"standard_charges":[{"gross_charge":141.0,"discounted_cash":77.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Cea Blood","code_information":[{"code":"60010400","type":"CDM"},{"code":"301","type":"RC"},{"code":"82378","type":"HCPCS"}],"standard_charges":[{"gross_charge":288.0,"discounted_cash":158.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Lipid Profile","code_information":[{"code":"60010420","type":"CDM"},{"code":"301","type":"RC"},{"code":"80061","type":"HCPCS"}],"standard_charges":[{"gross_charge":216.0,"discounted_cash":118.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Cortisol Blood","code_information":[{"code":"60010450","type":"CDM"},{"code":"301","type":"RC"},{"code":"82533","type":"HCPCS"}],"standard_charges":[{"gross_charge":240.0,"discounted_cash":132.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Cortisol Blood Am","code_information":[{"code":"60010460","type":"CDM"},{"code":"301","type":"RC"},{"code":"82533","type":"HCPCS"}],"standard_charges":[{"gross_charge":240.0,"discounted_cash":132.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Cortisol Blood Pm","code_information":[{"code":"60010470","type":"CDM"},{"code":"301","type":"RC"},{"code":"82533","type":"HCPCS"}],"standard_charges":[{"gross_charge":258.0,"discounted_cash":141.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Digoxin Level","code_information":[{"code":"60010500","type":"CDM"},{"code":"301","type":"RC"},{"code":"80162","type":"HCPCS"}],"standard_charges":[{"gross_charge":179.0,"discounted_cash":98.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Ferritin","code_information":[{"code":"60010550","type":"CDM"},{"code":"301","type":"RC"},{"code":"82728","type":"HCPCS"}],"standard_charges":[{"gross_charge":216.0,"discounted_cash":118.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Hepatitis B Core Antibody Igm","code_information":[{"code":"60010590","type":"CDM"},{"code":"302","type":"RC"},{"code":"86705","type":"HCPCS"}],"standard_charges":[{"gross_charge":181.0,"discounted_cash":99.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Gentamicin Level Peak","code_information":[{"code":"60010600","type":"CDM"},{"code":"301","type":"RC"},{"code":"80170","type":"HCPCS"}],"standard_charges":[{"gross_charge":281.0,"discounted_cash":154.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Hepatitis A Antibody","code_information":[{"code":"60010610","type":"CDM"},{"code":"302","type":"RC"},{"code":"86708","type":"HCPCS"}],"standard_charges":[{"gross_charge":38.0,"discounted_cash":20.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Gentamicin Level Random","code_information":[{"code":"60010620","type":"CDM"},{"code":"301","type":"RC"},{"code":"80170","type":"HCPCS"}],"standard_charges":[{"gross_charge":263.0,"discounted_cash":144.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Hepatitis A Antibody Igm","code_information":[{"code":"60010640","type":"CDM"},{"code":"302","type":"RC"},{"code":"86709","type":"HCPCS"}],"standard_charges":[{"gross_charge":179.0,"discounted_cash":98.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Gentamicin Level Trough","code_information":[{"code":"60010650","type":"CDM"},{"code":"301","type":"RC"},{"code":"80170","type":"HCPCS"}],"standard_charges":[{"gross_charge":278.0,"discounted_cash":152.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Hepatitis C Antibody","code_information":[{"code":"60010660","type":"CDM"},{"code":"302","type":"RC"},{"code":"86803","type":"HCPCS"}],"standard_charges":[{"gross_charge":227.0,"discounted_cash":124.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Hcg Blood Qualitative","code_information":[{"code":"60010670","type":"CDM"},{"code":"301","type":"RC"},{"code":"84703","type":"HCPCS"}],"standard_charges":[{"gross_charge":138.0,"discounted_cash":75.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Warfarin I","code_information":[{"code":"60010691","type":"CDM"},{"code":"301","type":"RC"},{"code":"80375","type":"HCPCS"}],"standard_charges":[{"gross_charge":343.0,"discounted_cash":188.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Haptoglobin","code_information":[{"code":"60010700","type":"CDM"},{"code":"301","type":"RC"},{"code":"83010","type":"HCPCS"}],"standard_charges":[{"gross_charge":179.0,"discounted_cash":98.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Ph Gastric","code_information":[{"code":"60010720","type":"CDM"},{"code":"301","type":"RC"},{"code":"83986","type":"HCPCS"}],"standard_charges":[{"gross_charge":12.0,"discounted_cash":6.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Iga Blood","code_information":[{"code":"60010750","type":"CDM"},{"code":"301","type":"RC"},{"code":"82784","type":"HCPCS"}],"standard_charges":[{"gross_charge":152.0,"discounted_cash":83.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Igg Blood","code_information":[{"code":"60010800","type":"CDM"},{"code":"301","type":"RC"},{"code":"82784","type":"HCPCS"}],"standard_charges":[{"gross_charge":178.0,"discounted_cash":97.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Igg Blood I","code_information":[{"code":"60010801","type":"CDM"},{"code":"301","type":"RC"},{"code":"82784","type":"HCPCS"}],"standard_charges":[{"gross_charge":238.0,"discounted_cash":130.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Igg Csf","code_information":[{"code":"60010810","type":"CDM"},{"code":"301","type":"RC"},{"code":"82784","type":"HCPCS"}],"standard_charges":[{"gross_charge":106.0,"discounted_cash":58.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Igm Blood","code_information":[{"code":"60010850","type":"CDM"},{"code":"301","type":"RC"},{"code":"82784","type":"HCPCS"}],"standard_charges":[{"gross_charge":178.0,"discounted_cash":97.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Hepatitis Screen Acute","code_information":[{"code":"60010860","type":"CDM"},{"code":"301","type":"RC"},{"code":"80074","type":"HCPCS"}],"standard_charges":[{"gross_charge":571.0,"discounted_cash":314.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Ige","code_information":[{"code":"60010870","type":"CDM"},{"code":"301","type":"RC"},{"code":"82785","type":"HCPCS"}],"standard_charges":[{"gross_charge":257.0,"discounted_cash":141.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Ige Refer","code_information":[{"code":"60010871","type":"CDM"},{"code":"301","type":"RC"},{"code":"82785","type":"HCPCS"}],"standard_charges":[{"gross_charge":1283.0,"discounted_cash":705.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Ck Isoenzymes","code_information":[{"code":"60010900","type":"CDM"},{"code":"301","type":"RC"},{"code":"82552","type":"HCPCS"}],"standard_charges":[{"gross_charge":182.0,"discounted_cash":100.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Ldh Isoenzymes","code_information":[{"code":"60010950","type":"CDM"},{"code":"301","type":"RC"},{"code":"83625","type":"HCPCS"}],"standard_charges":[{"gross_charge":93.0,"discounted_cash":51.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Phenobarbital Level","code_information":[{"code":"60011000","type":"CDM"},{"code":"301","type":"RC"},{"code":"80184","type":"HCPCS"}],"standard_charges":[{"gross_charge":190.0,"discounted_cash":104.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg T3 Total","code_information":[{"code":"60011040","type":"CDM"},{"code":"301","type":"RC"},{"code":"84480","type":"HCPCS"}],"standard_charges":[{"gross_charge":222.0,"discounted_cash":122.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Protein Electrophoresis Csf","code_information":[{"code":"60011150","type":"CDM"},{"code":"301","type":"RC"},{"code":"84166","type":"HCPCS"}],"standard_charges":[{"gross_charge":204.0,"discounted_cash":112.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Protein Electrophoresis Blood","code_information":[{"code":"60011200","type":"CDM"},{"code":"301","type":"RC"},{"code":"84165","type":"HCPCS"}],"standard_charges":[{"gross_charge":197.0,"discounted_cash":108.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Protein Electrophoresis Blood I","code_information":[{"code":"60011202","type":"CDM"},{"code":"301","type":"RC"},{"code":"84165","type":"HCPCS"}],"standard_charges":[{"gross_charge":197.0,"discounted_cash":108.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Protein Electrophoresis Urine Timed","code_information":[{"code":"60011250","type":"CDM"},{"code":"301","type":"RC"},{"code":"84166","type":"HCPCS"}],"standard_charges":[{"gross_charge":204.0,"discounted_cash":112.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Salicylate Level Blood Iv","code_information":[{"code":"60011354","type":"CDM"},{"code":"301","type":"RC"},{"code":"80307","type":"HCPCS"}],"standard_charges":[{"gross_charge":186.0,"discounted_cash":102.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg T4 Total","code_information":[{"code":"60011450","type":"CDM"},{"code":"301","type":"RC"},{"code":"84436","type":"HCPCS"}],"standard_charges":[{"gross_charge":111.0,"discounted_cash":61.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg T4 Total I","code_information":[{"code":"60011451","type":"CDM"},{"code":"301","type":"RC"},{"code":"84436","type":"HCPCS"}],"standard_charges":[{"gross_charge":122.0,"discounted_cash":67.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg T4 Free","code_information":[{"code":"60011470","type":"CDM"},{"code":"301","type":"RC"},{"code":"84439","type":"HCPCS"}],"standard_charges":[{"gross_charge":148.0,"discounted_cash":81.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg T4 Free I","code_information":[{"code":"60011471","type":"CDM"},{"code":"301","type":"RC"},{"code":"84439","type":"HCPCS"}],"standard_charges":[{"gross_charge":148.0,"discounted_cash":81.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Theophylline Level","code_information":[{"code":"60011500","type":"CDM"},{"code":"301","type":"RC"},{"code":"80198","type":"HCPCS"}],"standard_charges":[{"gross_charge":220.0,"discounted_cash":121.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Tsh","code_information":[{"code":"60011600","type":"CDM"},{"code":"301","type":"RC"},{"code":"84443","type":"HCPCS"}],"standard_charges":[{"gross_charge":252.0,"discounted_cash":138.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Tobramicin Level Peak","code_information":[{"code":"60011650","type":"CDM"},{"code":"301","type":"RC"},{"code":"80200","type":"HCPCS"}],"standard_charges":[{"gross_charge":253.0,"discounted_cash":139.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Tobramicin Level Random","code_information":[{"code":"60011670","type":"CDM"},{"code":"301","type":"RC"},{"code":"80200","type":"HCPCS"}],"standard_charges":[{"gross_charge":239.0,"discounted_cash":131.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Tobramicin Level Trough","code_information":[{"code":"60011700","type":"CDM"},{"code":"301","type":"RC"},{"code":"80200","type":"HCPCS"}],"standard_charges":[{"gross_charge":240.0,"discounted_cash":132.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Vancomycin Level Random","code_information":[{"code":"60011770","type":"CDM"},{"code":"301","type":"RC"},{"code":"80202","type":"HCPCS"}],"standard_charges":[{"gross_charge":224.0,"discounted_cash":123.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Vancomycin Level Trough","code_information":[{"code":"60011800","type":"CDM"},{"code":"301","type":"RC"},{"code":"80202","type":"HCPCS"}],"standard_charges":[{"gross_charge":218.0,"discounted_cash":119.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Gtt 3 Spec + Dose","code_information":[{"code":"60011880","type":"CDM"},{"code":"301","type":"RC"},{"code":"82951","type":"HCPCS"}],"standard_charges":[{"gross_charge":68.0,"discounted_cash":37.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Gtt Each Add Spec","code_information":[{"code":"60011890","type":"CDM"},{"code":"301","type":"RC"},{"code":"82952","type":"HCPCS"}],"standard_charges":[{"gross_charge":68.0,"discounted_cash":37.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Chloride Urine Random","code_information":[{"code":"60012010","type":"CDM"},{"code":"301","type":"RC"},{"code":"82436","type":"HCPCS"}],"standard_charges":[{"gross_charge":75.0,"discounted_cash":41.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Methemoglobin","code_information":[{"code":"60012020","type":"CDM"},{"code":"301","type":"RC"},{"code":"83050","type":"HCPCS"}],"standard_charges":[{"gross_charge":47.0,"discounted_cash":25.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Albumin Blood","code_information":[{"code":"60012100","type":"CDM"},{"code":"301","type":"RC"},{"code":"82040","type":"HCPCS"}],"standard_charges":[{"gross_charge":87.0,"discounted_cash":47.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Alcohol Ethyl Blood Ii","code_information":[{"code":"60012152","type":"CDM"},{"code":"301","type":"RC"},{"code":"80320","type":"HCPCS"}],"standard_charges":[{"gross_charge":354.0,"discounted_cash":194.7,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Alcohol Ethyl Blood V","code_information":[{"code":"60012155","type":"CDM"},{"code":"301","type":"RC"},{"code":"80307","type":"HCPCS"}],"standard_charges":[{"gross_charge":354.0,"discounted_cash":194.7,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Phosphorus Urine Random","code_information":[{"code":"60012160","type":"CDM"},{"code":"301","type":"RC"},{"code":"84105","type":"HCPCS"}],"standard_charges":[{"gross_charge":88.0,"discounted_cash":48.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Alkaline Phosphatase Blood","code_information":[{"code":"60012200","type":"CDM"},{"code":"301","type":"RC"},{"code":"84075","type":"HCPCS"}],"standard_charges":[{"gross_charge":80.0,"discounted_cash":44.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Alcohol Legal Collection","code_information":[{"code":"60012210","type":"CDM"},{"code":"300","type":"RC"},{"code":"36415","type":"HCPCS"}],"standard_charges":[{"gross_charge":38.0,"discounted_cash":20.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Cea Fluid","code_information":[{"code":"60012240","type":"CDM"},{"code":"301","type":"RC"},{"code":"82378","type":"HCPCS"}],"standard_charges":[{"gross_charge":288.0,"discounted_cash":158.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Ammonia","code_information":[{"code":"60012250","type":"CDM"},{"code":"301","type":"RC"},{"code":"82140","type":"HCPCS"}],"standard_charges":[{"gross_charge":230.0,"discounted_cash":126.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Blood Gases Capillary","code_information":[{"code":"60012290","type":"CDM"},{"code":"301","type":"RC"},{"code":"82805","type":"HCPCS"}],"standard_charges":[{"gross_charge":52.0,"discounted_cash":28.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Amylase Blood","code_information":[{"code":"60012300","type":"CDM"},{"code":"301","type":"RC"},{"code":"82150","type":"HCPCS"}],"standard_charges":[{"gross_charge":114.0,"discounted_cash":62.7,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Blood Gases Cord Arterial","code_information":[{"code":"60012310","type":"CDM"},{"code":"301","type":"RC"},{"code":"82805","type":"HCPCS"}],"standard_charges":[{"gross_charge":79.0,"discounted_cash":43.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Amylase Fluid","code_information":[{"code":"60012350","type":"CDM"},{"code":"301","type":"RC"},{"code":"82150","type":"HCPCS"}],"standard_charges":[{"gross_charge":114.0,"discounted_cash":62.7,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Amylase Urine Random","code_information":[{"code":"60012400","type":"CDM"},{"code":"301","type":"RC"},{"code":"82150","type":"HCPCS"}],"standard_charges":[{"gross_charge":114.0,"discounted_cash":62.7,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Glucose Whole Blood","code_information":[{"code":"60012470","type":"CDM"},{"code":"301","type":"RC"},{"code":"82962","type":"HCPCS"}],"standard_charges":[{"gross_charge":46.0,"discounted_cash":25.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Vitamin B12","code_information":[{"code":"60012500","type":"CDM"},{"code":"301","type":"RC"},{"code":"82607","type":"HCPCS"}],"standard_charges":[{"gross_charge":166.0,"discounted_cash":91.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Bicarbonate Blood","code_information":[{"code":"60012600","type":"CDM"},{"code":"301","type":"RC"},{"code":"82374","type":"HCPCS"}],"standard_charges":[{"gross_charge":83.0,"discounted_cash":45.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Bilirubin Cord Blood","code_information":[{"code":"60012610","type":"CDM"},{"code":"301","type":"RC"},{"code":"82247","type":"HCPCS"}],"standard_charges":[{"gross_charge":33.0,"discounted_cash":18.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Bilirubin Direct","code_information":[{"code":"60012620","type":"CDM"},{"code":"301","type":"RC"},{"code":"82248","type":"HCPCS"}],"standard_charges":[{"gross_charge":33.0,"discounted_cash":18.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Bilirubin Total Blood","code_information":[{"code":"60012650","type":"CDM"},{"code":"301","type":"RC"},{"code":"82247","type":"HCPCS"}],"standard_charges":[{"gross_charge":33.0,"discounted_cash":18.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Blood Gases Arterial","code_information":[{"code":"60012690","type":"CDM"},{"code":"301","type":"RC"},{"code":"82805","type":"HCPCS"}],"standard_charges":[{"gross_charge":285.0,"discounted_cash":156.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Sodium Whole Blood","code_information":[{"code":"60012710","type":"CDM"},{"code":"301","type":"RC"},{"code":"84295","type":"HCPCS"}],"standard_charges":[{"gross_charge":71.0,"discounted_cash":39.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Blood Gases","code_information":[{"code":"60012720","type":"CDM"},{"code":"301","type":"RC"},{"code":"82805","type":"HCPCS"}],"standard_charges":[{"gross_charge":114.0,"discounted_cash":62.7,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Bun","code_information":[{"code":"60012800","type":"CDM"},{"code":"301","type":"RC"},{"code":"84520","type":"HCPCS"}],"standard_charges":[{"gross_charge":87.0,"discounted_cash":47.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Calcium Blood","code_information":[{"code":"60012850","type":"CDM"},{"code":"301","type":"RC"},{"code":"82310","type":"HCPCS"}],"standard_charges":[{"gross_charge":79.0,"discounted_cash":43.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Calcium Ionized Blood","code_information":[{"code":"60012860","type":"CDM"},{"code":"301","type":"RC"},{"code":"82330","type":"HCPCS"}],"standard_charges":[{"gross_charge":173.0,"discounted_cash":95.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Carbon Monoxide","code_information":[{"code":"60012870","type":"CDM"},{"code":"301","type":"RC"},{"code":"82375","type":"HCPCS"}],"standard_charges":[{"gross_charge":211.0,"discounted_cash":116.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Calcium Urine Timed","code_information":[{"code":"60012900","type":"CDM"},{"code":"301","type":"RC"},{"code":"82340","type":"HCPCS"}],"standard_charges":[{"gross_charge":105.0,"discounted_cash":57.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Amylase Urine Timed","code_information":[{"code":"60012950","type":"CDM"},{"code":"301","type":"RC"},{"code":"82150","type":"HCPCS"}],"standard_charges":[{"gross_charge":114.0,"discounted_cash":62.7,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Carbon Dioxide","code_information":[{"code":"60013000","type":"CDM"},{"code":"301","type":"RC"},{"code":"82374","type":"HCPCS"}],"standard_charges":[{"gross_charge":45.0,"discounted_cash":24.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Chloride Blood","code_information":[{"code":"60013200","type":"CDM"},{"code":"301","type":"RC"},{"code":"82435","type":"HCPCS"}],"standard_charges":[{"gross_charge":70.0,"discounted_cash":38.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Cholesterol Blood","code_information":[{"code":"60013300","type":"CDM"},{"code":"301","type":"RC"},{"code":"82465","type":"HCPCS"}],"standard_charges":[{"gross_charge":81.0,"discounted_cash":44.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Hdl Cholesterol","code_information":[{"code":"60013350","type":"CDM"},{"code":"301","type":"RC"},{"code":"83718","type":"HCPCS"}],"standard_charges":[{"gross_charge":122.0,"discounted_cash":67.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Ck Blood","code_information":[{"code":"60013400","type":"CDM"},{"code":"301","type":"RC"},{"code":"82550","type":"HCPCS"}],"standard_charges":[{"gross_charge":106.0,"discounted_cash":58.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Ck Blood Refer","code_information":[{"code":"60013401","type":"CDM"},{"code":"301","type":"RC"},{"code":"82550","type":"HCPCS"}],"standard_charges":[{"gross_charge":103.0,"discounted_cash":56.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Creatinine Clearance Urine Timed","code_information":[{"code":"60013550","type":"CDM"},{"code":"301","type":"RC"},{"code":"82575","type":"HCPCS"}],"standard_charges":[{"gross_charge":156.0,"discounted_cash":85.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Creatinine Fluid","code_information":[{"code":"60013600","type":"CDM"},{"code":"301","type":"RC"},{"code":"82570","type":"HCPCS"}],"standard_charges":[{"gross_charge":83.0,"discounted_cash":45.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Creatinine Blood","code_information":[{"code":"60013650","type":"CDM"},{"code":"301","type":"RC"},{"code":"82565","type":"HCPCS"}],"standard_charges":[{"gross_charge":82.0,"discounted_cash":45.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Creatinine Urine Random","code_information":[{"code":"60013750","type":"CDM"},{"code":"301","type":"RC"},{"code":"82570","type":"HCPCS"}],"standard_charges":[{"gross_charge":75.0,"discounted_cash":41.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Creatinine Urine Timed","code_information":[{"code":"60013800","type":"CDM"},{"code":"301","type":"RC"},{"code":"82570","type":"HCPCS"}],"standard_charges":[{"gross_charge":78.0,"discounted_cash":42.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Phenytoin Level","code_information":[{"code":"60013850","type":"CDM"},{"code":"301","type":"RC"},{"code":"80185","type":"HCPCS"}],"standard_charges":[{"gross_charge":212.0,"discounted_cash":116.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Phenytoin Level Refer","code_information":[{"code":"60013851","type":"CDM"},{"code":"301","type":"RC"},{"code":"80185","type":"HCPCS"}],"standard_charges":[{"gross_charge":218.0,"discounted_cash":119.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Magnesium Urine Quant","code_information":[{"code":"60013870","type":"CDM"},{"code":"301","type":"RC"},{"code":"83735","type":"HCPCS"}],"standard_charges":[{"gross_charge":115.0,"discounted_cash":63.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Chloride Urine Timed","code_information":[{"code":"60013920","type":"CDM"},{"code":"301","type":"RC"},{"code":"82436","type":"HCPCS"}],"standard_charges":[{"gross_charge":85.0,"discounted_cash":46.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Folate","code_information":[{"code":"60014300","type":"CDM"},{"code":"301","type":"RC"},{"code":"82746","type":"HCPCS"}],"standard_charges":[{"gross_charge":234.0,"discounted_cash":128.7,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Ggt","code_information":[{"code":"60014350","type":"CDM"},{"code":"301","type":"RC"},{"code":"82977","type":"HCPCS"}],"standard_charges":[{"gross_charge":117.0,"discounted_cash":64.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Glucose Fluid","code_information":[{"code":"60014650","type":"CDM"},{"code":"301","type":"RC"},{"code":"82945","type":"HCPCS"}],"standard_charges":[{"gross_charge":80.0,"discounted_cash":44.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Glucose Csf","code_information":[{"code":"60014700","type":"CDM"},{"code":"301","type":"RC"},{"code":"82945","type":"HCPCS"}],"standard_charges":[{"gross_charge":80.0,"discounted_cash":44.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Dexamethasone Suppression Test 1 Spec","code_information":[{"code":"60014780","type":"CDM"},{"code":"301","type":"RC"},{"code":"82533","type":"HCPCS"}],"standard_charges":[{"gross_charge":240.0,"discounted_cash":132.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Hepatitis B Surface Antigen","code_information":[{"code":"60014850","type":"CDM"},{"code":"306","type":"RC"},{"code":"87340","type":"HCPCS"}],"standard_charges":[{"gross_charge":216.0,"discounted_cash":118.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Hepatitis B Surface Antigen Ii","code_information":[{"code":"60014853","type":"CDM"},{"code":"302","type":"RC"},{"code":"87340","type":"HCPCS"}],"standard_charges":[{"gross_charge":43.0,"discounted_cash":23.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Hepatitis B Core Antibody I","code_information":[{"code":"60014861","type":"CDM"},{"code":"302","type":"RC"},{"code":"86704","type":"HCPCS"}],"standard_charges":[{"gross_charge":123.0,"discounted_cash":67.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Hepatitis B Surface Antibody","code_information":[{"code":"60014870","type":"CDM"},{"code":"302","type":"RC"},{"code":"86706","type":"HCPCS"}],"standard_charges":[{"gross_charge":176.0,"discounted_cash":96.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Hepatitis Be Antibody","code_information":[{"code":"60014880","type":"CDM"},{"code":"302","type":"RC"},{"code":"86707","type":"HCPCS"}],"standard_charges":[{"gross_charge":171.0,"discounted_cash":94.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Ldl Cholesterol","code_information":[{"code":"60015030","type":"CDM"},{"code":"301","type":"RC"},{"code":"83721","type":"HCPCS"}],"standard_charges":[{"gross_charge":141.0,"discounted_cash":77.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Iron Blood","code_information":[{"code":"60015050","type":"CDM"},{"code":"301","type":"RC"},{"code":"83540","type":"HCPCS"}],"standard_charges":[{"gross_charge":98.0,"discounted_cash":53.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Tibc","code_information":[{"code":"60015110","type":"CDM"},{"code":"301","type":"RC"},{"code":"83550","type":"HCPCS"}],"standard_charges":[{"gross_charge":28.0,"discounted_cash":15.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Lactic Acid Blood","code_information":[{"code":"60015150","type":"CDM"},{"code":"301","type":"RC"},{"code":"83605","type":"HCPCS"}],"standard_charges":[{"gross_charge":95.0,"discounted_cash":52.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Lactic Acid Csf","code_information":[{"code":"60015160","type":"CDM"},{"code":"301","type":"RC"},{"code":"83605","type":"HCPCS"}],"standard_charges":[{"gross_charge":175.0,"discounted_cash":96.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Ldh Blood","code_information":[{"code":"60015250","type":"CDM"},{"code":"301","type":"RC"},{"code":"83615","type":"HCPCS"}],"standard_charges":[{"gross_charge":97.0,"discounted_cash":53.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Ldh Blood Refer","code_information":[{"code":"60015251","type":"CDM"},{"code":"301","type":"RC"},{"code":"83615","type":"HCPCS"}],"standard_charges":[{"gross_charge":93.0,"discounted_cash":51.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Ldh Csf","code_information":[{"code":"60015260","type":"CDM"},{"code":"301","type":"RC"},{"code":"83615","type":"HCPCS"}],"standard_charges":[{"gross_charge":96.0,"discounted_cash":52.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Ldh Fluid","code_information":[{"code":"60015300","type":"CDM"},{"code":"301","type":"RC"},{"code":"83615","type":"HCPCS"}],"standard_charges":[{"gross_charge":97.0,"discounted_cash":53.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Lipase Blood","code_information":[{"code":"60015350","type":"CDM"},{"code":"301","type":"RC"},{"code":"83690","type":"HCPCS"}],"standard_charges":[{"gross_charge":120.0,"discounted_cash":66.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Lipase Fluid","code_information":[{"code":"60015370","type":"CDM"},{"code":"301","type":"RC"},{"code":"83690","type":"HCPCS"}],"standard_charges":[{"gross_charge":120.0,"discounted_cash":66.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Lithium Level","code_information":[{"code":"60015450","type":"CDM"},{"code":"301","type":"RC"},{"code":"80178","type":"HCPCS"}],"standard_charges":[{"gross_charge":129.0,"discounted_cash":70.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Calcium Urine Random","code_information":[{"code":"60015490","type":"CDM"},{"code":"301","type":"RC"},{"code":"82340","type":"HCPCS"}],"standard_charges":[{"gross_charge":97.0,"discounted_cash":53.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Uric Acid Urine Random","code_information":[{"code":"60015520","type":"CDM"},{"code":"301","type":"RC"},{"code":"84560","type":"HCPCS"}],"standard_charges":[{"gross_charge":83.0,"discounted_cash":45.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Magnesium Blood","code_information":[{"code":"60015550","type":"CDM"},{"code":"301","type":"RC"},{"code":"83735","type":"HCPCS"}],"standard_charges":[{"gross_charge":103.0,"discounted_cash":56.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Magnesium Urine Random","code_information":[{"code":"60015560","type":"CDM"},{"code":"301","type":"RC"},{"code":"83735","type":"HCPCS"}],"standard_charges":[{"gross_charge":136.0,"discounted_cash":74.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Primidone Level","code_information":[{"code":"60015600","type":"CDM"},{"code":"301","type":"RC"},{"code":"80188","type":"HCPCS"}],"standard_charges":[{"gross_charge":193.0,"discounted_cash":106.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Osmolality Blood","code_information":[{"code":"60015700","type":"CDM"},{"code":"301","type":"RC"},{"code":"83930","type":"HCPCS"}],"standard_charges":[{"gross_charge":106.0,"discounted_cash":58.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Osmolality Urine","code_information":[{"code":"60015750","type":"CDM"},{"code":"301","type":"RC"},{"code":"83935","type":"HCPCS"}],"standard_charges":[{"gross_charge":100.0,"discounted_cash":55.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Hepatic Function Panel","code_information":[{"code":"60015770","type":"CDM"},{"code":"301","type":"RC"},{"code":"80076","type":"HCPCS"}],"standard_charges":[{"gross_charge":170.0,"discounted_cash":93.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg O2 Saturation","code_information":[{"code":"60015780","type":"CDM"},{"code":"301","type":"RC"},{"code":"82810","type":"HCPCS"}],"standard_charges":[{"gross_charge":61.0,"discounted_cash":33.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Ph Venous","code_information":[{"code":"60015820","type":"CDM"},{"code":"301","type":"RC"},{"code":"82800","type":"HCPCS"}],"standard_charges":[{"gross_charge":114.0,"discounted_cash":62.7,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Ph Fluid","code_information":[{"code":"60015900","type":"CDM"},{"code":"301","type":"RC"},{"code":"83986","type":"HCPCS"}],"standard_charges":[{"gross_charge":91.0,"discounted_cash":50.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Phosphorus Blood","code_information":[{"code":"60015950","type":"CDM"},{"code":"301","type":"RC"},{"code":"84100","type":"HCPCS"}],"standard_charges":[{"gross_charge":70.0,"discounted_cash":38.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Phosphorus Urine Timed","code_information":[{"code":"60016000","type":"CDM"},{"code":"301","type":"RC"},{"code":"84105","type":"HCPCS"}],"standard_charges":[{"gross_charge":85.0,"discounted_cash":46.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Sodium I","code_information":[{"code":"60016060","type":"CDM"},{"code":"301","type":"RC"},{"code":"84295","type":"HCPCS"}],"standard_charges":[{"gross_charge":41.0,"discounted_cash":22.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Potassium I","code_information":[{"code":"60016070","type":"CDM"},{"code":"301","type":"RC"},{"code":"84132","type":"HCPCS"}],"standard_charges":[{"gross_charge":40.0,"discounted_cash":22.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Potassium Whole Blood","code_information":[{"code":"60016110","type":"CDM"},{"code":"301","type":"RC"},{"code":"84132","type":"HCPCS"}],"standard_charges":[{"gross_charge":87.0,"discounted_cash":47.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Potassium Blood","code_information":[{"code":"60016150","type":"CDM"},{"code":"301","type":"RC"},{"code":"84132","type":"HCPCS"}],"standard_charges":[{"gross_charge":87.0,"discounted_cash":47.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Bilirubin Total Fluid","code_information":[{"code":"60016190","type":"CDM"},{"code":"301","type":"RC"},{"code":"82247","type":"HCPCS"}],"standard_charges":[{"gross_charge":17.0,"discounted_cash":9.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Potassium Urine Timed","code_information":[{"code":"60016200","type":"CDM"},{"code":"301","type":"RC"},{"code":"84133","type":"HCPCS"}],"standard_charges":[{"gross_charge":74.0,"discounted_cash":40.7,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Prealbumin","code_information":[{"code":"60016210","type":"CDM"},{"code":"301","type":"RC"},{"code":"84134","type":"HCPCS"}],"standard_charges":[{"gross_charge":126.0,"discounted_cash":69.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Albumin Fluid","code_information":[{"code":"60016240","type":"CDM"},{"code":"301","type":"RC"},{"code":"82042","type":"HCPCS"}],"standard_charges":[{"gross_charge":60.0,"discounted_cash":33.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Potassium Urine Random","code_information":[{"code":"60016250","type":"CDM"},{"code":"301","type":"RC"},{"code":"84133","type":"HCPCS"}],"standard_charges":[{"gross_charge":69.0,"discounted_cash":37.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Hcg Beta Blood Quantitative","code_information":[{"code":"60016300","type":"CDM"},{"code":"301","type":"RC"},{"code":"84702","type":"HCPCS"}],"standard_charges":[{"gross_charge":166.0,"discounted_cash":91.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Istat Troponin","code_information":[{"code":"60016350","type":"CDM"},{"code":"301","type":"RC"},{"code":"84484","type":"HCPCS"}],"standard_charges":[{"gross_charge":159.0,"discounted_cash":87.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Protein Fluid","code_information":[{"code":"60016400","type":"CDM"},{"code":"301","type":"RC"},{"code":"84157","type":"HCPCS"}],"standard_charges":[{"gross_charge":82.0,"discounted_cash":45.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Protein Csf","code_information":[{"code":"60016450","type":"CDM"},{"code":"301","type":"RC"},{"code":"84157","type":"HCPCS"}],"standard_charges":[{"gross_charge":96.0,"discounted_cash":52.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Magnesium Rbc","code_information":[{"code":"60016470","type":"CDM"},{"code":"301","type":"RC"},{"code":"83735","type":"HCPCS"}],"standard_charges":[{"gross_charge":211.0,"discounted_cash":116.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Protein Total Blood","code_information":[{"code":"60016500","type":"CDM"},{"code":"301","type":"RC"},{"code":"84155","type":"HCPCS"}],"standard_charges":[{"gross_charge":96.0,"discounted_cash":52.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Protein Urine Timed Quantitative","code_information":[{"code":"60016550","type":"CDM"},{"code":"301","type":"RC"},{"code":"84156","type":"HCPCS"}],"standard_charges":[{"gross_charge":87.0,"discounted_cash":47.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Protein Urine Timed Quantitative I","code_information":[{"code":"60016551","type":"CDM"},{"code":"301","type":"RC"},{"code":"84156","type":"HCPCS"}],"standard_charges":[{"gross_charge":85.0,"discounted_cash":46.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Gq1B Antibody I","code_information":[{"code":"60016581","type":"CDM"},{"code":"301","type":"RC"},{"code":"83516","type":"HCPCS"}],"standard_charges":[{"gross_charge":159.0,"discounted_cash":87.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Ast Blood","code_information":[{"code":"60016600","type":"CDM"},{"code":"301","type":"RC"},{"code":"84450","type":"HCPCS"}],"standard_charges":[{"gross_charge":39.0,"discounted_cash":21.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Alt","code_information":[{"code":"60016650","type":"CDM"},{"code":"301","type":"RC"},{"code":"84460","type":"HCPCS"}],"standard_charges":[{"gross_charge":91.0,"discounted_cash":50.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Prostate Specific Antigen Screen","code_information":[{"code":"60016660","type":"CDM"},{"code":"301","type":"RC"},{"code":"G0103","type":"HCPCS"}],"standard_charges":[{"gross_charge":249.0,"discounted_cash":136.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Renal Function Panel","code_information":[{"code":"60016670","type":"CDM"},{"code":"301","type":"RC"},{"code":"80069","type":"HCPCS"}],"standard_charges":[{"gross_charge":105.0,"discounted_cash":57.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Comprehensive Metabolic Panel","code_information":[{"code":"60016690","type":"CDM"},{"code":"301","type":"RC"},{"code":"80053","type":"HCPCS"}],"standard_charges":[{"gross_charge":241.0,"discounted_cash":132.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Fetal Fibronectin","code_information":[{"code":"60016720","type":"CDM"},{"code":"301","type":"RC"},{"code":"82731","type":"HCPCS"}],"standard_charges":[{"gross_charge":920.0,"discounted_cash":506.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Sodium Blood","code_information":[{"code":"60016750","type":"CDM"},{"code":"301","type":"RC"},{"code":"84295","type":"HCPCS"}],"standard_charges":[{"gross_charge":71.0,"discounted_cash":39.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Urea Nitrogen Urine Random","code_information":[{"code":"60016790","type":"CDM"},{"code":"301","type":"RC"},{"code":"84540","type":"HCPCS"}],"standard_charges":[{"gross_charge":68.0,"discounted_cash":37.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Sodium Urine Timed","code_information":[{"code":"60016800","type":"CDM"},{"code":"301","type":"RC"},{"code":"84300","type":"HCPCS"}],"standard_charges":[{"gross_charge":81.0,"discounted_cash":44.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Blood Gases Poc","code_information":[{"code":"60016820","type":"CDM"},{"code":"301","type":"RC"},{"code":"82803","type":"HCPCS"}],"standard_charges":[{"gross_charge":234.0,"discounted_cash":128.7,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Sodium Urine Random","code_information":[{"code":"60016850","type":"CDM"},{"code":"301","type":"RC"},{"code":"84300","type":"HCPCS"}],"standard_charges":[{"gross_charge":79.0,"discounted_cash":43.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Triglycerides Blood","code_information":[{"code":"60016900","type":"CDM"},{"code":"301","type":"RC"},{"code":"84478","type":"HCPCS"}],"standard_charges":[{"gross_charge":35.0,"discounted_cash":19.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Triglycerides Fluid","code_information":[{"code":"60016910","type":"CDM"},{"code":"301","type":"RC"},{"code":"84478","type":"HCPCS"}],"standard_charges":[{"gross_charge":91.0,"discounted_cash":50.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Urea Nitrogen Urine Timed","code_information":[{"code":"60016940","type":"CDM"},{"code":"301","type":"RC"},{"code":"84540","type":"HCPCS"}],"standard_charges":[{"gross_charge":85.0,"discounted_cash":46.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Noncdm Charge Record","code_information":[{"code":"60016980","type":"CDM"},{"code":"301","type":"RC"},{"code":"82803","type":"HCPCS"}],"standard_charges":[{"gross_charge":358.0,"discounted_cash":196.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Lchg B-Type Natriuretic Peptide","code_information":[{"code":"60016990","type":"CDM"},{"code":"301","type":"RC"},{"code":"83880","type":"HCPCS"}],"standard_charges":[{"gross_charge":355.0,"discounted_cash":195.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Uric Acid Blood","code_information":[{"code":"60017000","type":"CDM"},{"code":"301","type":"RC"},{"code":"84550","type":"HCPCS"}],"standard_charges":[{"gross_charge":73.0,"discounted_cash":40.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Uric Acid Fluid","code_information":[{"code":"60017010","type":"CDM"},{"code":"301","type":"RC"},{"code":"84560","type":"HCPCS"}],"standard_charges":[{"gross_charge":85.0,"discounted_cash":46.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Uric Acid Urine Timed","code_information":[{"code":"60017050","type":"CDM"},{"code":"301","type":"RC"},{"code":"84560","type":"HCPCS"}],"standard_charges":[{"gross_charge":85.0,"discounted_cash":46.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Lytes (Na K Cl Co2) Blood","code_information":[{"code":"60017200","type":"CDM"},{"code":"301","type":"RC"},{"code":"80051","type":"HCPCS"}],"standard_charges":[{"gross_charge":92.0,"discounted_cash":50.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Basic Metabolic Panel (Ca Total)","code_information":[{"code":"60017350","type":"CDM"},{"code":"301","type":"RC"},{"code":"80048","type":"HCPCS"}],"standard_charges":[{"gross_charge":182.0,"discounted_cash":100.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Protein Urine Random Quantitative","code_information":[{"code":"60018090","type":"CDM"},{"code":"301","type":"RC"},{"code":"84156","type":"HCPCS"}],"standard_charges":[{"gross_charge":87.0,"discounted_cash":47.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Glucose","code_information":[{"code":"60018100","type":"CDM"},{"code":"301","type":"RC"},{"code":"82947","type":"HCPCS"}],"standard_charges":[{"gross_charge":53.0,"discounted_cash":29.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Alkaline Phosphatase Fluid","code_information":[{"code":"60018320","type":"CDM"},{"code":"301","type":"RC"},{"code":"84075","type":"HCPCS"}],"standard_charges":[{"gross_charge":83.0,"discounted_cash":45.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Complement C4","code_information":[{"code":"60018740","type":"CDM"},{"code":"302","type":"RC"},{"code":"86160","type":"HCPCS"}],"standard_charges":[{"gross_charge":180.0,"discounted_cash":99.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Complement C4 I","code_information":[{"code":"60018741","type":"CDM"},{"code":"302","type":"RC"},{"code":"86160","type":"HCPCS"}],"standard_charges":[{"gross_charge":181.0,"discounted_cash":99.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Blood Gases Cord Venous","code_information":[{"code":"60018750","type":"CDM"},{"code":"301","type":"RC"},{"code":"82805","type":"HCPCS"}],"standard_charges":[{"gross_charge":79.0,"discounted_cash":43.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Urea Nitrogen Fluid","code_information":[{"code":"60018870","type":"CDM"},{"code":"301","type":"RC"},{"code":"84520","type":"HCPCS"}],"standard_charges":[{"gross_charge":43.0,"discounted_cash":23.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Blood Gases Venous","code_information":[{"code":"60018890","type":"CDM"},{"code":"301","type":"RC"},{"code":"82805","type":"HCPCS"}],"standard_charges":[{"gross_charge":275.0,"discounted_cash":151.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Albumin Fluid I","code_information":[{"code":"60019450","type":"CDM"},{"code":"301","type":"RC"},{"code":"82042","type":"HCPCS"}],"standard_charges":[{"gross_charge":60.0,"discounted_cash":33.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Blood Draw Capillary","code_information":[{"code":"60019580","type":"CDM"},{"code":"300","type":"RC"},{"code":"36416","type":"HCPCS"}],"standard_charges":[{"gross_charge":27.0,"discounted_cash":14.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Psa Total Refer","code_information":[{"code":"60019721","type":"CDM"},{"code":"301","type":"RC"},{"code":"84153","type":"HCPCS"}],"standard_charges":[{"gross_charge":225.0,"discounted_cash":123.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Noncdm Charge Record","code_information":[{"code":"60019851","type":"CDM"},{"code":"301","type":"RC"},{"code":"83605","type":"HCPCS"}],"standard_charges":[{"gross_charge":196.0,"discounted_cash":107.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Lchg Arterial Puncture W Withdraw","code_information":[{"code":"60019940","type":"CDM"},{"code":"300","type":"RC"},{"code":"36600","type":"HCPCS"}],"standard_charges":[{"gross_charge":150.0,"discounted_cash":82.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Blood Draw","code_information":[{"code":"60019950","type":"CDM"},{"code":"300","type":"RC"},{"code":"36415","type":"HCPCS"}],"standard_charges":[{"gross_charge":38.0,"discounted_cash":20.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Hemoglobin","code_information":[{"code":"60020150","type":"CDM"},{"code":"305","type":"RC"},{"code":"85018","type":"HCPCS"}],"standard_charges":[{"gross_charge":32.0,"discounted_cash":17.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Hematocrit","code_information":[{"code":"60020160","type":"CDM"},{"code":"305","type":"RC"},{"code":"85014","type":"HCPCS"}],"standard_charges":[{"gross_charge":37.0,"discounted_cash":20.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Antithrombin Iii Activity I","code_information":[{"code":"60020210","type":"CDM"},{"code":"305","type":"RC"},{"code":"85300","type":"HCPCS"}],"standard_charges":[{"gross_charge":187.0,"discounted_cash":102.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Cbc W/O Auto Differential","code_information":[{"code":"60020260","type":"CDM"},{"code":"305","type":"RC"},{"code":"85027","type":"HCPCS"}],"standard_charges":[{"gross_charge":108.0,"discounted_cash":59.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Cbc W Auto Differential","code_information":[{"code":"60020290","type":"CDM"},{"code":"305","type":"RC"},{"code":"85025","type":"HCPCS"}],"standard_charges":[{"gross_charge":137.0,"discounted_cash":75.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Wbc Count Auto","code_information":[{"code":"60020330","type":"CDM"},{"code":"305","type":"RC"},{"code":"85048","type":"HCPCS"}],"standard_charges":[{"gross_charge":61.0,"discounted_cash":33.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Malaria Smear","code_information":[{"code":"60020360","type":"CDM"},{"code":"306","type":"RC"},{"code":"87207","type":"HCPCS"}],"standard_charges":[{"gross_charge":133.0,"discounted_cash":73.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg G6Pd Qualitative","code_information":[{"code":"60020370","type":"CDM"},{"code":"301","type":"RC"},{"code":"82955","type":"HCPCS"}],"standard_charges":[{"gross_charge":153.0,"discounted_cash":84.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Rbc Morphology","code_information":[{"code":"60020400","type":"CDM"},{"code":"305","type":"RC"},{"code":"85008","type":"HCPCS"}],"standard_charges":[{"gross_charge":20.0,"discounted_cash":11.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Allergen Spec Ige Quant Each","code_information":[{"code":"60020450","type":"CDM"},{"code":"302","type":"RC"},{"code":"86003","type":"HCPCS"}],"standard_charges":[{"gross_charge":48.0,"discounted_cash":26.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Ria Nonantibody Paval","code_information":[{"code":"60020730","type":"CDM"},{"code":"301","type":"RC"},{"code":"83519","type":"HCPCS"}],"standard_charges":[{"gross_charge":141.0,"discounted_cash":77.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Immunoassay Analyte Quan Nos Nonab Paval","code_information":[{"code":"60020740","type":"CDM"},{"code":"301","type":"RC"},{"code":"83520","type":"HCPCS"}],"standard_charges":[{"gross_charge":203.0,"discounted_cash":111.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Cell Count W Differential Fluid","code_information":[{"code":"60021030","type":"CDM"},{"code":"309","type":"RC"},{"code":"89051","type":"HCPCS"}],"standard_charges":[{"gross_charge":129.0,"discounted_cash":70.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Cell Count W Differential Csf","code_information":[{"code":"60021040","type":"CDM"},{"code":"309","type":"RC"},{"code":"89051","type":"HCPCS"}],"standard_charges":[{"gross_charge":129.0,"discounted_cash":70.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Antithrombin Iii Activity Ii","code_information":[{"code":"60021420","type":"CDM"},{"code":"305","type":"RC"},{"code":"85300","type":"HCPCS"}],"standard_charges":[{"gross_charge":187.0,"discounted_cash":102.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Microdissection Manual Kit","code_information":[{"code":"60021460","type":"CDM"},{"code":"310","type":"RC"},{"code":"88381","type":"HCPCS"}],"standard_charges":[{"gross_charge":217.0,"discounted_cash":119.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Penicillin Binding Protein Screen","code_information":[{"code":"60021500","type":"CDM"},{"code":"306","type":"RC"},{"code":"87147","type":"HCPCS"}],"standard_charges":[{"gross_charge":21.0,"discounted_cash":11.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Ptt Inhibitor I","code_information":[{"code":"60021510","type":"CDM"},{"code":"305","type":"RC"},{"code":"85730","type":"HCPCS"}],"standard_charges":[{"gross_charge":36.0,"discounted_cash":19.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Typhus Fever Antibody Igg","code_information":[{"code":"60021570","type":"CDM"},{"code":"302","type":"RC"},{"code":"86757","type":"HCPCS"}],"standard_charges":[{"gross_charge":174.0,"discounted_cash":95.7,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Typhus Fever Antibody Igm","code_information":[{"code":"60021580","type":"CDM"},{"code":"302","type":"RC"},{"code":"86757","type":"HCPCS"}],"standard_charges":[{"gross_charge":174.0,"discounted_cash":95.7,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Eosinophil Count Auto","code_information":[{"code":"60021700","type":"CDM"},{"code":"305","type":"RC"},{"code":"85048","type":"HCPCS"}],"standard_charges":[{"gross_charge":88.0,"discounted_cash":48.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Culture Dna Probe","code_information":[{"code":"60021720","type":"CDM"},{"code":"306","type":"RC"},{"code":"87149","type":"HCPCS"}],"standard_charges":[{"gross_charge":176.0,"discounted_cash":96.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Retic Count","code_information":[{"code":"60021910","type":"CDM"},{"code":"305","type":"RC"},{"code":"85045","type":"HCPCS"}],"standard_charges":[{"gross_charge":63.0,"discounted_cash":34.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Rbc Count","code_information":[{"code":"60022120","type":"CDM"},{"code":"305","type":"RC"},{"code":"85041","type":"HCPCS"}],"standard_charges":[{"gross_charge":46.0,"discounted_cash":25.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Protein S Activity","code_information":[{"code":"60022280","type":"CDM"},{"code":"305","type":"RC"},{"code":"85306","type":"HCPCS"}],"standard_charges":[{"gross_charge":226.0,"discounted_cash":124.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Protein S Activity I","code_information":[{"code":"60022281","type":"CDM"},{"code":"305","type":"RC"},{"code":"85306","type":"HCPCS"}],"standard_charges":[{"gross_charge":226.0,"discounted_cash":124.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Platelet Count Auto","code_information":[{"code":"60022290","type":"CDM"},{"code":"305","type":"RC"},{"code":"85049","type":"HCPCS"}],"standard_charges":[{"gross_charge":66.0,"discounted_cash":36.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Cryofibrinogen","code_information":[{"code":"60022370","type":"CDM"},{"code":"301","type":"RC"},{"code":"82585","type":"HCPCS"}],"standard_charges":[{"gross_charge":46.0,"discounted_cash":25.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Pt Poct","code_information":[{"code":"60022931","type":"CDM"},{"code":"305","type":"RC"},{"code":"85610","type":"HCPCS"}],"standard_charges":[{"gross_charge":57.0,"discounted_cash":31.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Istat Hemoglobin","code_information":[{"code":"60022940","type":"CDM"},{"code":"305","type":"RC"},{"code":"85018","type":"HCPCS"}],"standard_charges":[{"gross_charge":38.0,"discounted_cash":20.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Differential Manual","code_information":[{"code":"60023120","type":"CDM"},{"code":"305","type":"RC"},{"code":"85007","type":"HCPCS"}],"standard_charges":[{"gross_charge":22.0,"discounted_cash":12.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Flow 1 Mrkr Tc","code_information":[{"code":"60023330","type":"CDM"},{"code":"311","type":"RC"},{"code":"88184","type":"HCPCS"}],"standard_charges":[{"gross_charge":185.0,"discounted_cash":101.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Flow Add Each Marker Tc","code_information":[{"code":"60023340","type":"CDM"},{"code":"311","type":"RC"},{"code":"88185","type":"HCPCS"}],"standard_charges":[{"gross_charge":175.0,"discounted_cash":96.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Vitamin D 25-Hydroxy D2+D3","code_information":[{"code":"60023560","type":"CDM"},{"code":"301","type":"RC"},{"code":"82306","type":"HCPCS"}],"standard_charges":[{"gross_charge":459.0,"discounted_cash":252.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Microdissection Manual Kras","code_information":[{"code":"60023580","type":"CDM"},{"code":"310","type":"RC"},{"code":"88381","type":"HCPCS"}],"standard_charges":[{"gross_charge":217.0,"discounted_cash":119.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Microdissection Manual Egfr","code_information":[{"code":"60023630","type":"CDM"},{"code":"310","type":"RC"},{"code":"88381","type":"HCPCS"}],"standard_charges":[{"gross_charge":212.0,"discounted_cash":116.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Dna Probe Fish Alk 2P23","code_information":[{"code":"60023660","type":"CDM"},{"code":"310","type":"RC"},{"code":"88271","type":"HCPCS"}],"standard_charges":[{"gross_charge":142.0,"discounted_cash":78.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Pt-Inr","code_information":[{"code":"60024010","type":"CDM"},{"code":"305","type":"RC"},{"code":"85610","type":"HCPCS"}],"standard_charges":[{"gross_charge":57.0,"discounted_cash":31.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Ptt","code_information":[{"code":"60024020","type":"CDM"},{"code":"305","type":"RC"},{"code":"85730","type":"HCPCS"}],"standard_charges":[{"gross_charge":36.0,"discounted_cash":19.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg D-Dimer Quantitative","code_information":[{"code":"60024040","type":"CDM"},{"code":"305","type":"RC"},{"code":"85379","type":"HCPCS"}],"standard_charges":[{"gross_charge":126.0,"discounted_cash":69.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg D-Dimer Quantititative Ref","code_information":[{"code":"60024041","type":"CDM"},{"code":"305","type":"RC"},{"code":"85379","type":"HCPCS"}],"standard_charges":[{"gross_charge":92.0,"discounted_cash":50.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Tumor Immunohistochem Her-2/Neu","code_information":[{"code":"60024080","type":"CDM"},{"code":"310","type":"RC"},{"code":"88360","type":"HCPCS"}],"standard_charges":[{"gross_charge":650.0,"discounted_cash":357.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Thrombin Time","code_information":[{"code":"60024170","type":"CDM"},{"code":"305","type":"RC"},{"code":"85670","type":"HCPCS"}],"standard_charges":[{"gross_charge":67.0,"discounted_cash":36.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Fibrinogen Activity","code_information":[{"code":"60024180","type":"CDM"},{"code":"305","type":"RC"},{"code":"85384","type":"HCPCS"}],"standard_charges":[{"gross_charge":100.0,"discounted_cash":55.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Fibrinogen Activity I","code_information":[{"code":"60024181","type":"CDM"},{"code":"305","type":"RC"},{"code":"85384","type":"HCPCS"}],"standard_charges":[{"gross_charge":100.0,"discounted_cash":55.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Factor Viii Assay","code_information":[{"code":"60024200","type":"CDM"},{"code":"305","type":"RC"},{"code":"85240","type":"HCPCS"}],"standard_charges":[{"gross_charge":107.0,"discounted_cash":58.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Factor Viii Assay Ii","code_information":[{"code":"60024202","type":"CDM"},{"code":"305","type":"RC"},{"code":"85240","type":"HCPCS"}],"standard_charges":[{"gross_charge":107.0,"discounted_cash":58.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Factor Ix Assay","code_information":[{"code":"60024210","type":"CDM"},{"code":"305","type":"RC"},{"code":"85250","type":"HCPCS"}],"standard_charges":[{"gross_charge":304.0,"discounted_cash":167.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Factor Ix Assay I","code_information":[{"code":"60024211","type":"CDM"},{"code":"305","type":"RC"},{"code":"85250","type":"HCPCS"}],"standard_charges":[{"gross_charge":304.0,"discounted_cash":167.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Factor Ix Assay Ii","code_information":[{"code":"60024212","type":"CDM"},{"code":"305","type":"RC"},{"code":"85250","type":"HCPCS"}],"standard_charges":[{"gross_charge":304.0,"discounted_cash":167.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Factor Viii Inhibitor","code_information":[{"code":"60024220","type":"CDM"},{"code":"305","type":"RC"},{"code":"85335","type":"HCPCS"}],"standard_charges":[{"gross_charge":240.0,"discounted_cash":132.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Factor Viii Inhibitor I","code_information":[{"code":"60024221","type":"CDM"},{"code":"305","type":"RC"},{"code":"85335","type":"HCPCS"}],"standard_charges":[{"gross_charge":240.0,"discounted_cash":132.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Fish Chromosome Dna Probe Ii","code_information":[{"code":"60024342","type":"CDM"},{"code":"310","type":"RC"},{"code":"88271","type":"HCPCS"}],"standard_charges":[{"gross_charge":142.0,"discounted_cash":78.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Platelet Neutralization","code_information":[{"code":"60024940","type":"CDM"},{"code":"305","type":"RC"},{"code":"85597","type":"HCPCS"}],"standard_charges":[{"gross_charge":59.0,"discounted_cash":32.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Lactoferrin Fecal Qualitative","code_information":[{"code":"60025210","type":"CDM"},{"code":"301","type":"RC"},{"code":"83630","type":"HCPCS"}],"standard_charges":[{"gross_charge":214.0,"discounted_cash":117.7,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Saccharomyces Antibody Igg","code_information":[{"code":"60025360","type":"CDM"},{"code":"302","type":"RC"},{"code":"86671","type":"HCPCS"}],"standard_charges":[{"gross_charge":76.0,"discounted_cash":41.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Saccharomyces Antibody Iga","code_information":[{"code":"60025370","type":"CDM"},{"code":"302","type":"RC"},{"code":"86671","type":"HCPCS"}],"standard_charges":[{"gross_charge":76.0,"discounted_cash":41.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Dna Antibody Ds Crithidia Titer","code_information":[{"code":"60025860","type":"CDM"},{"code":"302","type":"RC"},{"code":"86256","type":"HCPCS"}],"standard_charges":[{"gross_charge":110.0,"discounted_cash":60.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Testosterone Total Male","code_information":[{"code":"60025920","type":"CDM"},{"code":"301","type":"RC"},{"code":"84403","type":"HCPCS"}],"standard_charges":[{"gross_charge":397.0,"discounted_cash":218.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Quetiapine I","code_information":[{"code":"60026101","type":"CDM"},{"code":"301","type":"RC"},{"code":"80342","type":"HCPCS"}],"standard_charges":[{"gross_charge":268.0,"discounted_cash":147.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Bk Virus Pcr Quant Blood","code_information":[{"code":"60026160","type":"CDM"},{"code":"306","type":"RC"},{"code":"87799","type":"HCPCS"}],"standard_charges":[{"gross_charge":494.0,"discounted_cash":271.7,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Serotonin Release Assay","code_information":[{"code":"60026400","type":"CDM"},{"code":"302","type":"RC"},{"code":"86022","type":"HCPCS"}],"standard_charges":[{"gross_charge":493.0,"discounted_cash":271.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Epstein-Barr Virus Pcr Quant","code_information":[{"code":"60026460","type":"CDM"},{"code":"306","type":"RC"},{"code":"87799","type":"HCPCS"}],"standard_charges":[{"gross_charge":508.0,"discounted_cash":279.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Hiv-1 Dna Pcr Qualitative","code_information":[{"code":"60026580","type":"CDM"},{"code":"306","type":"RC"},{"code":"87535","type":"HCPCS"}],"standard_charges":[{"gross_charge":142.0,"discounted_cash":78.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Hiv-1 Dna Pcr Qualitative I","code_information":[{"code":"60026581","type":"CDM"},{"code":"306","type":"RC"},{"code":"87535","type":"HCPCS"}],"standard_charges":[{"gross_charge":308.0,"discounted_cash":169.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Beta-2 Transferrin Fluid","code_information":[{"code":"60026640","type":"CDM"},{"code":"302","type":"RC"},{"code":"86335","type":"HCPCS"}],"standard_charges":[{"gross_charge":339.0,"discounted_cash":186.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Noncdm Charge Record","code_information":[{"code":"60026651","type":"CDM"},{"code":"301","type":"RC"},{"code":"80323","type":"HCPCS"}],"standard_charges":[{"gross_charge":60.0,"discounted_cash":33.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Lchg Histoplasma Antigen Urine","code_information":[{"code":"60027040","type":"CDM"},{"code":"306","type":"RC"},{"code":"87385","type":"HCPCS"}],"standard_charges":[{"gross_charge":269.0,"discounted_cash":147.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Acylcarnitines Quantitative","code_information":[{"code":"60027050","type":"CDM"},{"code":"301","type":"RC"},{"code":"82017","type":"HCPCS"}],"standard_charges":[{"gross_charge":235.0,"discounted_cash":129.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Cortisol Blood Free","code_information":[{"code":"60027060","type":"CDM"},{"code":"301","type":"RC"},{"code":"82530","type":"HCPCS"}],"standard_charges":[{"gross_charge":262.0,"discounted_cash":144.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Factor Viii Vw Activity","code_information":[{"code":"60027200","type":"CDM"},{"code":"305","type":"RC"},{"code":"85240","type":"HCPCS"}],"standard_charges":[{"gross_charge":113.0,"discounted_cash":62.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Norovirus Stool Pcr","code_information":[{"code":"60027370","type":"CDM"},{"code":"306","type":"RC"},{"code":"87798","type":"HCPCS"}],"standard_charges":[{"gross_charge":702.0,"discounted_cash":386.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Intraconazole Level","code_information":[{"code":"60027380","type":"CDM"},{"code":"301","type":"RC"},{"code":"80299","type":"HCPCS"}],"standard_charges":[{"gross_charge":303.0,"discounted_cash":166.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Dengue Fever Virus Antibody Igg","code_information":[{"code":"60027390","type":"CDM"},{"code":"302","type":"RC"},{"code":"86790","type":"HCPCS"}],"standard_charges":[{"gross_charge":98.0,"discounted_cash":53.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Dengue Fever Virus Antibody Igm","code_information":[{"code":"60027400","type":"CDM"},{"code":"302","type":"RC"},{"code":"86790","type":"HCPCS"}],"standard_charges":[{"gross_charge":98.0,"discounted_cash":53.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Viral Tissue Cult Ip Stain","code_information":[{"code":"60028510","type":"CDM"},{"code":"306","type":"RC"},{"code":"87253","type":"HCPCS"}],"standard_charges":[{"gross_charge":174.0,"discounted_cash":95.7,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Allergen Peanut Ige","code_information":[{"code":"60028630","type":"CDM"},{"code":"302","type":"RC"},{"code":"86003","type":"HCPCS"}],"standard_charges":[{"gross_charge":48.0,"discounted_cash":26.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Allergen Derm Farinae Ige","code_information":[{"code":"60028910","type":"CDM"},{"code":"302","type":"RC"},{"code":"86003","type":"HCPCS"}],"standard_charges":[{"gross_charge":48.0,"discounted_cash":26.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Allergen Ragweed Ige","code_information":[{"code":"60028980","type":"CDM"},{"code":"302","type":"RC"},{"code":"86003","type":"HCPCS"}],"standard_charges":[{"gross_charge":48.0,"discounted_cash":26.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Pt Mix I","code_information":[{"code":"60029001","type":"CDM"},{"code":"305","type":"RC"},{"code":"85611","type":"HCPCS"}],"standard_charges":[{"gross_charge":41.0,"discounted_cash":22.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Ptt Mix","code_information":[{"code":"60029020","type":"CDM"},{"code":"305","type":"RC"},{"code":"85732","type":"HCPCS"}],"standard_charges":[{"gross_charge":98.0,"discounted_cash":53.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Ptt Mix I","code_information":[{"code":"60029021","type":"CDM"},{"code":"305","type":"RC"},{"code":"85732","type":"HCPCS"}],"standard_charges":[{"gross_charge":95.0,"discounted_cash":52.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Platelet Associated Antibody I","code_information":[{"code":"60029171","type":"CDM"},{"code":"302","type":"RC"},{"code":"86022","type":"HCPCS"}],"standard_charges":[{"gross_charge":151.0,"discounted_cash":83.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Alcohol Ethyl Urine Quant Ii","code_information":[{"code":"60029362","type":"CDM"},{"code":"301","type":"RC"},{"code":"80307","type":"HCPCS"}],"standard_charges":[{"gross_charge":255.0,"discounted_cash":140.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Culture Typing Nacd Seq Each","code_information":[{"code":"60029380","type":"CDM"},{"code":"306","type":"RC"},{"code":"87153","type":"HCPCS"}],"standard_charges":[{"gross_charge":926.0,"discounted_cash":509.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Culture Typing Nacd Seq Each Refer","code_information":[{"code":"60029381","type":"CDM"},{"code":"306","type":"RC"},{"code":"87153","type":"HCPCS"}],"standard_charges":[{"gross_charge":926.0,"discounted_cash":509.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Titin Antibody","code_information":[{"code":"60029640","type":"CDM"},{"code":"301","type":"RC"},{"code":"83516","type":"HCPCS"}],"standard_charges":[{"gross_charge":174.0,"discounted_cash":95.7,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Platelet Lr Irrad","code_information":[{"code":"60029840","type":"CDM"},{"code":"390","type":"RC"},{"code":"P9033","type":"HCPCS"}],"standard_charges":[{"gross_charge":655.0,"discounted_cash":360.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Lyme Disease C6 Peptide Antibodies","code_information":[{"code":"60029920","type":"CDM"},{"code":"302","type":"RC"},{"code":"86618","type":"HCPCS"}],"standard_charges":[{"gross_charge":128.0,"discounted_cash":70.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Blood Type Rh Only","code_information":[{"code":"60030110","type":"CDM"},{"code":"300","type":"RC"},{"code":"86901","type":"HCPCS"}],"standard_charges":[{"gross_charge":130.0,"discounted_cash":71.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Therapeutic Phlebotomy","code_information":[{"code":"60031410","type":"CDM"},{"code":"940","type":"RC"},{"code":"99195","type":"HCPCS"}],"standard_charges":[{"gross_charge":334.0,"discounted_cash":183.7,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Kleihauer Betke Stain","code_information":[{"code":"60031860","type":"CDM"},{"code":"305","type":"RC"},{"code":"85460","type":"HCPCS"}],"standard_charges":[{"gross_charge":128.0,"discounted_cash":70.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Aminolevulinic Acid Urine Random","code_information":[{"code":"60032970","type":"CDM"},{"code":"301","type":"RC"},{"code":"82135","type":"HCPCS"}],"standard_charges":[{"gross_charge":264.0,"discounted_cash":145.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Immunofixation Crypglobulin","code_information":[{"code":"60033130","type":"CDM"},{"code":"302","type":"RC"},{"code":"86334","type":"HCPCS"}],"standard_charges":[{"gross_charge":244.0,"discounted_cash":134.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Hemoglobin Eval Reflex Cascade","code_information":[{"code":"60033210","type":"CDM"},{"code":"301","type":"RC"},{"code":"83021","type":"HCPCS"}],"standard_charges":[{"gross_charge":285.0,"discounted_cash":156.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Cd15","code_information":[{"code":"60033290","type":"CDM"},{"code":"302","type":"RC"},{"code":"86356","type":"HCPCS"}],"standard_charges":[{"gross_charge":80.0,"discounted_cash":44.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Flaer","code_information":[{"code":"60033300","type":"CDM"},{"code":"302","type":"RC"},{"code":"86356","type":"HCPCS"}],"standard_charges":[{"gross_charge":80.0,"discounted_cash":44.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Flow Cell Alps Add Each Marker","code_information":[{"code":"60033311","type":"CDM"},{"code":"311","type":"RC"},{"code":"88185","type":"HCPCS"}],"standard_charges":[{"gross_charge":179.0,"discounted_cash":98.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Noncdm Charge Record","code_information":[{"code":"60033610","type":"CDM"},{"code":"311","type":"RC"},{"code":"88280","type":"HCPCS"}],"standard_charges":[{"gross_charge":100.0,"discounted_cash":55.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Lchg Fish Bcr-Abl1 I","code_information":[{"code":"60034841","type":"CDM"},{"code":"310","type":"RC"},{"code":"88271","type":"HCPCS"}],"standard_charges":[{"gross_charge":142.0,"discounted_cash":78.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Pt Pheno Other Ref","code_information":[{"code":"60037000","type":"CDM"},{"code":"300","type":"RC"},{"code":"86905","type":"HCPCS"}],"standard_charges":[{"gross_charge":113.0,"discounted_cash":62.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Antibody Elution Ref","code_information":[{"code":"60037010","type":"CDM"},{"code":"300","type":"RC"},{"code":"86860","type":"HCPCS"}],"standard_charges":[{"gross_charge":181.0,"discounted_cash":99.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Antibody Screen Ref I","code_information":[{"code":"60037021","type":"CDM"},{"code":"300","type":"RC"},{"code":"86850","type":"HCPCS"}],"standard_charges":[{"gross_charge":129.0,"discounted_cash":70.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Rbc Treatment Enzymes Ref","code_information":[{"code":"60037030","type":"CDM"},{"code":"300","type":"RC"},{"code":"86971","type":"HCPCS"}],"standard_charges":[{"gross_charge":812.0,"discounted_cash":446.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Rbc Pretreatment W Chem Or Drugs Ref","code_information":[{"code":"60037040","type":"CDM"},{"code":"300","type":"RC"},{"code":"86970","type":"HCPCS"}],"standard_charges":[{"gross_charge":812.0,"discounted_cash":446.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Rbc Pretreatment Incub W Drug Ref","code_information":[{"code":"60037050","type":"CDM"},{"code":"300","type":"RC"},{"code":"86975","type":"HCPCS"}],"standard_charges":[{"gross_charge":521.0,"discounted_cash":286.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Rbc Pretreatment Autoabsorb Ref","code_information":[{"code":"60037060","type":"CDM"},{"code":"300","type":"RC"},{"code":"86978","type":"HCPCS"}],"standard_charges":[{"gross_charge":168.0,"discounted_cash":92.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Rbc Pretreat Serum Diff Rbc Abso Ref","code_information":[{"code":"60037070","type":"CDM"},{"code":"300","type":"RC"},{"code":"86978","type":"HCPCS"}],"standard_charges":[{"gross_charge":208.0,"discounted_cash":114.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Rbc Pretreatment Serum Inhib Ref","code_information":[{"code":"60037090","type":"CDM"},{"code":"300","type":"RC"},{"code":"86977","type":"HCPCS"}],"standard_charges":[{"gross_charge":411.0,"discounted_cash":226.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Thaw Rare Rgt Ref","code_information":[{"code":"60037100","type":"CDM"},{"code":"300","type":"RC"},{"code":"86999","type":"HCPCS"}],"standard_charges":[{"gross_charge":134.0,"discounted_cash":73.7,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Antibody Titer Ref I","code_information":[{"code":"60037121","type":"CDM"},{"code":"300","type":"RC"},{"code":"86886","type":"HCPCS"}],"standard_charges":[{"gross_charge":411.0,"discounted_cash":226.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Antibody Titer Ref Ii","code_information":[{"code":"60037122","type":"CDM"},{"code":"300","type":"RC"},{"code":"86886","type":"HCPCS"}],"standard_charges":[{"gross_charge":411.0,"discounted_cash":226.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Rbc Pretreatment Density Grad Ref","code_information":[{"code":"60037140","type":"CDM"},{"code":"300","type":"RC"},{"code":"86972","type":"HCPCS"}],"standard_charges":[{"gross_charge":411.0,"discounted_cash":226.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Antigen Id Ref","code_information":[{"code":"60037170","type":"CDM"},{"code":"300","type":"RC"},{"code":"86902","type":"HCPCS"}],"standard_charges":[{"gross_charge":788.0,"discounted_cash":433.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Antigen Id Ref I","code_information":[{"code":"60037171","type":"CDM"},{"code":"302","type":"RC"},{"code":"86902","type":"HCPCS"}],"standard_charges":[{"gross_charge":108.0,"discounted_cash":59.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Antigen Id Ref Ii","code_information":[{"code":"60037172","type":"CDM"},{"code":"302","type":"RC"},{"code":"86902","type":"HCPCS"}],"standard_charges":[{"gross_charge":139.0,"discounted_cash":76.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Antigen Id Ref Iii","code_information":[{"code":"60037173","type":"CDM"},{"code":"302","type":"RC"},{"code":"86902","type":"HCPCS"}],"standard_charges":[{"gross_charge":172.0,"discounted_cash":94.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Antigen Id Ref Iv","code_information":[{"code":"60037174","type":"CDM"},{"code":"302","type":"RC"},{"code":"86902","type":"HCPCS"}],"standard_charges":[{"gross_charge":205.0,"discounted_cash":112.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Antigen Id Ref V","code_information":[{"code":"60037175","type":"CDM"},{"code":"302","type":"RC"},{"code":"86902","type":"HCPCS"}],"standard_charges":[{"gross_charge":238.0,"discounted_cash":130.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Antigen Id Ref Vi","code_information":[{"code":"60037176","type":"CDM"},{"code":"302","type":"RC"},{"code":"86902","type":"HCPCS"}],"standard_charges":[{"gross_charge":272.0,"discounted_cash":149.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Antigen Screen Patient Ref","code_information":[{"code":"60037180","type":"CDM"},{"code":"300","type":"RC"},{"code":"86904","type":"HCPCS"}],"standard_charges":[{"gross_charge":96.0,"discounted_cash":52.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Sickle Cell Test Reflex","code_information":[{"code":"60037200","type":"CDM"},{"code":"305","type":"RC"},{"code":"85660","type":"HCPCS"}],"standard_charges":[{"gross_charge":284.0,"discounted_cash":156.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Compatibility Test Immediate Spin Ref","code_information":[{"code":"60037330","type":"CDM"},{"code":"300","type":"RC"},{"code":"86920","type":"HCPCS"}],"standard_charges":[{"gross_charge":180.0,"discounted_cash":99.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Compatibility Test Each Incub Ref","code_information":[{"code":"60037340","type":"CDM"},{"code":"300","type":"RC"},{"code":"86921","type":"HCPCS"}],"standard_charges":[{"gross_charge":399.0,"discounted_cash":219.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Coombs Direct Igg","code_information":[{"code":"60037430","type":"CDM"},{"code":"300","type":"RC"},{"code":"86880","type":"HCPCS"}],"standard_charges":[{"gross_charge":120.0,"discounted_cash":66.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Ffp W/I 24Hrs","code_information":[{"code":"60037550","type":"CDM"},{"code":"390","type":"RC"},{"code":"P9059","type":"HCPCS"}],"standard_charges":[{"gross_charge":414.0,"discounted_cash":227.7,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Rbc Lr Frozen Deglyc Washed","code_information":[{"code":"60037700","type":"CDM"},{"code":"390","type":"RC"},{"code":"P9054","type":"HCPCS"}],"standard_charges":[{"gross_charge":453.0,"discounted_cash":249.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Ffp 24Hr <200Ml","code_information":[{"code":"60037930","type":"CDM"},{"code":"390","type":"RC"},{"code":"P9059","type":"HCPCS"}],"standard_charges":[{"gross_charge":414.0,"discounted_cash":227.7,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Antibody Id Refer","code_information":[{"code":"60038070","type":"CDM"},{"code":"302","type":"RC"},{"code":"86870","type":"HCPCS"}],"standard_charges":[{"gross_charge":117.0,"discounted_cash":64.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Antibody Id Refer I","code_information":[{"code":"60038071","type":"CDM"},{"code":"302","type":"RC"},{"code":"86870","type":"HCPCS"}],"standard_charges":[{"gross_charge":117.0,"discounted_cash":64.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Coombs Direct Refer","code_information":[{"code":"60038370","type":"CDM"},{"code":"300","type":"RC"},{"code":"86880","type":"HCPCS"}],"standard_charges":[{"gross_charge":80.0,"discounted_cash":44.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Rbc Lr","code_information":[{"code":"60038480","type":"CDM"},{"code":"390","type":"RC"},{"code":"P9016","type":"HCPCS"}],"standard_charges":[{"gross_charge":983.0,"discounted_cash":540.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Rbc Lr I","code_information":[{"code":"60038481","type":"CDM"},{"code":"390","type":"RC"},{"code":"P9016","type":"HCPCS"}],"standard_charges":[{"gross_charge":983.0,"discounted_cash":540.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Platelet Pheresis Lr","code_information":[{"code":"60038540","type":"CDM"},{"code":"390","type":"RC"},{"code":"P9035","type":"HCPCS"}],"standard_charges":[{"gross_charge":1282.0,"discounted_cash":705.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Platelet Lr","code_information":[{"code":"60038830","type":"CDM"},{"code":"390","type":"RC"},{"code":"P9031","type":"HCPCS"}],"standard_charges":[{"gross_charge":392.0,"discounted_cash":215.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Platelet Lr I","code_information":[{"code":"60038831","type":"CDM"},{"code":"390","type":"RC"},{"code":"P9031","type":"HCPCS"}],"standard_charges":[{"gross_charge":392.0,"discounted_cash":215.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Rbc Lr Irrad","code_information":[{"code":"60038850","type":"CDM"},{"code":"390","type":"RC"},{"code":"P9040","type":"HCPCS"}],"standard_charges":[{"gross_charge":674.0,"discounted_cash":370.7,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Platelet Pheresis Lr Irrad","code_information":[{"code":"60038860","type":"CDM"},{"code":"390","type":"RC"},{"code":"P9037","type":"HCPCS"}],"standard_charges":[{"gross_charge":655.0,"discounted_cash":360.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Platelet Pheresis Match Lr Irrad","code_information":[{"code":"60038930","type":"CDM"},{"code":"390","type":"RC"},{"code":"P9052","type":"HCPCS"}],"standard_charges":[{"gross_charge":1033.0,"discounted_cash":568.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Blood Type Only Ref","code_information":[{"code":"60038970","type":"CDM"},{"code":"300","type":"RC"},{"code":"86900","type":"HCPCS"}],"standard_charges":[{"gross_charge":303.0,"discounted_cash":166.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Blood Type Rh Only Ref","code_information":[{"code":"60038980","type":"CDM"},{"code":"300","type":"RC"},{"code":"86901","type":"HCPCS"}],"standard_charges":[{"gross_charge":22.0,"discounted_cash":12.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Blood Type Rh Phenotype Ref","code_information":[{"code":"60038990","type":"CDM"},{"code":"300","type":"RC"},{"code":"86906","type":"HCPCS"}],"standard_charges":[{"gross_charge":79.0,"discounted_cash":43.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Blood Type Rh Phenotype Ref I","code_information":[{"code":"60038991","type":"CDM"},{"code":"300","type":"RC"},{"code":"86906","type":"HCPCS"}],"standard_charges":[{"gross_charge":79.0,"discounted_cash":43.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Blood Type Abo","code_information":[{"code":"60039030","type":"CDM"},{"code":"302","type":"RC"},{"code":"86900","type":"HCPCS"}],"standard_charges":[{"gross_charge":49.0,"discounted_cash":26.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Blood Type Abo I","code_information":[{"code":"60039031","type":"CDM"},{"code":"302","type":"RC"},{"code":"86900","type":"HCPCS"}],"standard_charges":[{"gross_charge":67.0,"discounted_cash":36.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Blood Type Rh I","code_information":[{"code":"60039040","type":"CDM"},{"code":"302","type":"RC"},{"code":"86901","type":"HCPCS"}],"standard_charges":[{"gross_charge":14.0,"discounted_cash":7.7,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Blood Type Rh Ii","code_information":[{"code":"60039041","type":"CDM"},{"code":"302","type":"RC"},{"code":"86905","type":"HCPCS"}],"standard_charges":[{"gross_charge":21.0,"discounted_cash":11.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Blood Type Rh Iii","code_information":[{"code":"60039042","type":"CDM"},{"code":"302","type":"RC"},{"code":"86901","type":"HCPCS"}],"standard_charges":[{"gross_charge":45.0,"discounted_cash":24.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Compatibility Test Immediate Spin","code_information":[{"code":"60039100","type":"CDM"},{"code":"302","type":"RC"},{"code":"86920","type":"HCPCS"}],"standard_charges":[{"gross_charge":180.0,"discounted_cash":99.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Compatibility Test Immediate Spin I","code_information":[{"code":"60039101","type":"CDM"},{"code":"302","type":"RC"},{"code":"86920","type":"HCPCS"}],"standard_charges":[{"gross_charge":180.0,"discounted_cash":99.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Compatibility Test Antiglobulin","code_information":[{"code":"60039120","type":"CDM"},{"code":"300","type":"RC"},{"code":"86922","type":"HCPCS"}],"standard_charges":[{"gross_charge":188.0,"discounted_cash":103.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Compatibility Test Antiglobulin I","code_information":[{"code":"60039121","type":"CDM"},{"code":"300","type":"RC"},{"code":"86922","type":"HCPCS"}],"standard_charges":[{"gross_charge":289.0,"discounted_cash":158.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Compatibility Test Antglob Ii","code_information":[{"code":"60039122","type":"CDM"},{"code":"300","type":"RC"},{"code":"86922","type":"HCPCS"}],"standard_charges":[{"gross_charge":289.0,"discounted_cash":158.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Fetal Screen","code_information":[{"code":"60039140","type":"CDM"},{"code":"305","type":"RC"},{"code":"85461","type":"HCPCS"}],"standard_charges":[{"gross_charge":133.0,"discounted_cash":73.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Blood Prod Irrad","code_information":[{"code":"60039150","type":"CDM"},{"code":"300","type":"RC"},{"code":"86945","type":"HCPCS"}],"standard_charges":[{"gross_charge":187.0,"discounted_cash":102.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Blood Prod Irrad I","code_information":[{"code":"60039151","type":"CDM"},{"code":"300","type":"RC"},{"code":"86945","type":"HCPCS"}],"standard_charges":[{"gross_charge":187.0,"discounted_cash":102.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Cmv Neg Unit","code_information":[{"code":"60039250","type":"CDM"},{"code":"302","type":"RC"},{"code":"86644","type":"HCPCS"}],"standard_charges":[{"gross_charge":124.0,"discounted_cash":68.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Rbc Lr Frozen Deglyc","code_information":[{"code":"60039370","type":"CDM"},{"code":"390","type":"RC"},{"code":"P9039","type":"HCPCS"}],"standard_charges":[{"gross_charge":791.0,"discounted_cash":435.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Cryoprecipitate","code_information":[{"code":"60039490","type":"CDM"},{"code":"390","type":"RC"},{"code":"P9012","type":"HCPCS"}],"standard_charges":[{"gross_charge":373.0,"discounted_cash":205.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Cryoprecipitate I","code_information":[{"code":"60039491","type":"CDM"},{"code":"390","type":"RC"},{"code":"P9012","type":"HCPCS"}],"standard_charges":[{"gross_charge":373.0,"discounted_cash":205.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Cryoprecipitate Ii","code_information":[{"code":"60039492","type":"CDM"},{"code":"390","type":"RC"},{"code":"P9012","type":"HCPCS"}],"standard_charges":[{"gross_charge":373.0,"discounted_cash":205.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Cryoprecipitate Iii","code_information":[{"code":"60039493","type":"CDM"},{"code":"390","type":"RC"},{"code":"P9012","type":"HCPCS"}],"standard_charges":[{"gross_charge":373.0,"discounted_cash":205.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Washed Cells","code_information":[{"code":"60039570","type":"CDM"},{"code":"390","type":"RC"},{"code":"P9022","type":"HCPCS"}],"standard_charges":[{"gross_charge":975.0,"discounted_cash":536.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Transfusion Reaction","code_information":[{"code":"60039610","type":"CDM"},{"code":"305","type":"RC"},{"code":"86078","type":"HCPCS"}],"standard_charges":[{"gross_charge":220.0,"discounted_cash":121.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Antibody Screen","code_information":[{"code":"60039710","type":"CDM"},{"code":"302","type":"RC"},{"code":"86850","type":"HCPCS"}],"standard_charges":[{"gross_charge":139.0,"discounted_cash":76.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Antibody Screen I","code_information":[{"code":"60039711","type":"CDM"},{"code":"302","type":"RC"},{"code":"86850","type":"HCPCS"}],"standard_charges":[{"gross_charge":139.0,"discounted_cash":76.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Antibody Screen Ii","code_information":[{"code":"60039712","type":"CDM"},{"code":"302","type":"RC"},{"code":"86850","type":"HCPCS"}],"standard_charges":[{"gross_charge":139.0,"discounted_cash":76.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Antibody Elution","code_information":[{"code":"60039720","type":"CDM"},{"code":"300","type":"RC"},{"code":"86860","type":"HCPCS"}],"standard_charges":[{"gross_charge":181.0,"discounted_cash":99.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Antibody Id","code_information":[{"code":"60039730","type":"CDM"},{"code":"302","type":"RC"},{"code":"86870","type":"HCPCS"}],"standard_charges":[{"gross_charge":201.0,"discounted_cash":110.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Coombs Direct","code_information":[{"code":"60039740","type":"CDM"},{"code":"302","type":"RC"},{"code":"86880","type":"HCPCS"}],"standard_charges":[{"gross_charge":40.0,"discounted_cash":22.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Coombs Direct I","code_information":[{"code":"60039741","type":"CDM"},{"code":"302","type":"RC"},{"code":"86880","type":"HCPCS"}],"standard_charges":[{"gross_charge":40.0,"discounted_cash":22.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Coombs Direct Ii","code_information":[{"code":"60039742","type":"CDM"},{"code":"302","type":"RC"},{"code":"86880","type":"HCPCS"}],"standard_charges":[{"gross_charge":40.0,"discounted_cash":22.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Transfusion Service Fee","code_information":[{"code":"60039910","type":"CDM"},{"code":"391","type":"RC"},{"code":"36430","type":"HCPCS"}],"standard_charges":[{"gross_charge":999.0,"discounted_cash":549.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Culture Fluid","code_information":[{"code":"60040070","type":"CDM"},{"code":"306","type":"RC"},{"code":"87070","type":"HCPCS"}],"standard_charges":[{"gross_charge":183.0,"discounted_cash":100.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Culture Bronchial Brush Qnt","code_information":[{"code":"60040111","type":"CDM"},{"code":"306","type":"RC"},{"code":"87071","type":"HCPCS"}],"standard_charges":[{"gross_charge":183.0,"discounted_cash":100.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Culture Csf","code_information":[{"code":"60040130","type":"CDM"},{"code":"306","type":"RC"},{"code":"87070","type":"HCPCS"}],"standard_charges":[{"gross_charge":183.0,"discounted_cash":100.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Culture Respiratory","code_information":[{"code":"60040140","type":"CDM"},{"code":"306","type":"RC"},{"code":"87070","type":"HCPCS"}],"standard_charges":[{"gross_charge":183.0,"discounted_cash":100.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Culture Genital","code_information":[{"code":"60040160","type":"CDM"},{"code":"306","type":"RC"},{"code":"87070","type":"HCPCS"}],"standard_charges":[{"gross_charge":183.0,"discounted_cash":100.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Culture Abscess","code_information":[{"code":"60040170","type":"CDM"},{"code":"306","type":"RC"},{"code":"87070","type":"HCPCS"}],"standard_charges":[{"gross_charge":152.0,"discounted_cash":83.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Culture Cath Tip","code_information":[{"code":"60040180","type":"CDM"},{"code":"306","type":"RC"},{"code":"87070","type":"HCPCS"}],"standard_charges":[{"gross_charge":183.0,"discounted_cash":100.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Culture Environmental","code_information":[{"code":"60040200","type":"CDM"},{"code":"306","type":"RC"},{"code":"87070","type":"HCPCS"}],"standard_charges":[{"gross_charge":175.0,"discounted_cash":96.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Culture Afb","code_information":[{"code":"60040230","type":"CDM"},{"code":"306","type":"RC"},{"code":"87116","type":"HCPCS"}],"standard_charges":[{"gross_charge":225.0,"discounted_cash":123.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Culture Blood Afb","code_information":[{"code":"60040300","type":"CDM"},{"code":"306","type":"RC"},{"code":"87116","type":"HCPCS"}],"standard_charges":[{"gross_charge":219.0,"discounted_cash":120.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Culture Anaerobe","code_information":[{"code":"60040310","type":"CDM"},{"code":"306","type":"RC"},{"code":"87075","type":"HCPCS"}],"standard_charges":[{"gross_charge":224.0,"discounted_cash":123.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Culture Strep A","code_information":[{"code":"60040360","type":"CDM"},{"code":"306","type":"RC"},{"code":"87081","type":"HCPCS"}],"standard_charges":[{"gross_charge":150.0,"discounted_cash":82.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Culture Strep B","code_information":[{"code":"60040380","type":"CDM"},{"code":"306","type":"RC"},{"code":"87081","type":"HCPCS"}],"standard_charges":[{"gross_charge":150.0,"discounted_cash":82.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Culture Yersinia I","code_information":[{"code":"60040401","type":"CDM"},{"code":"306","type":"RC"},{"code":"87046","type":"HCPCS"}],"standard_charges":[{"gross_charge":133.0,"discounted_cash":73.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Culture Mrsa","code_information":[{"code":"60040410","type":"CDM"},{"code":"306","type":"RC"},{"code":"87081","type":"HCPCS"}],"standard_charges":[{"gross_charge":194.0,"discounted_cash":106.7,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Culture Bordetella Pertussis","code_information":[{"code":"60040420","type":"CDM"},{"code":"306","type":"RC"},{"code":"87081","type":"HCPCS"}],"standard_charges":[{"gross_charge":194.0,"discounted_cash":106.7,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Culture Cystic Fibrosis Pulmonary","code_information":[{"code":"60040440","type":"CDM"},{"code":"306","type":"RC"},{"code":"87070","type":"HCPCS"}],"standard_charges":[{"gross_charge":148.0,"discounted_cash":81.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Culture Legionella","code_information":[{"code":"60040450","type":"CDM"},{"code":"306","type":"RC"},{"code":"87081","type":"HCPCS"}],"standard_charges":[{"gross_charge":151.0,"discounted_cash":83.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Culture Urine","code_information":[{"code":"60040470","type":"CDM"},{"code":"306","type":"RC"},{"code":"87086","type":"HCPCS"}],"standard_charges":[{"gross_charge":160.0,"discounted_cash":88.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Culture Fungus Skin Hair Nails","code_information":[{"code":"60040500","type":"CDM"},{"code":"306","type":"RC"},{"code":"87101","type":"HCPCS"}],"standard_charges":[{"gross_charge":229.0,"discounted_cash":125.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Susceptibility Beta Lactamase","code_information":[{"code":"60040570","type":"CDM"},{"code":"306","type":"RC"},{"code":"87185","type":"HCPCS"}],"standard_charges":[{"gross_charge":94.0,"discounted_cash":51.7,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Fungus Koh Smear Skin Hair Nail","code_information":[{"code":"60040640","type":"CDM"},{"code":"306","type":"RC"},{"code":"87220","type":"HCPCS"}],"standard_charges":[{"gross_charge":76.0,"discounted_cash":41.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Gram Stain Smear","code_information":[{"code":"60040720","type":"CDM"},{"code":"306","type":"RC"},{"code":"87205","type":"HCPCS"}],"standard_charges":[{"gross_charge":86.0,"discounted_cash":47.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Afb Smear","code_information":[{"code":"60040750","type":"CDM"},{"code":"306","type":"RC"},{"code":"87206","type":"HCPCS"}],"standard_charges":[{"gross_charge":117.0,"discounted_cash":64.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Pinworms Smear","code_information":[{"code":"60040780","type":"CDM"},{"code":"306","type":"RC"},{"code":"87172","type":"HCPCS"}],"standard_charges":[{"gross_charge":82.0,"discounted_cash":45.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Fungus Koh Smear Ii","code_information":[{"code":"60040811","type":"CDM"},{"code":"306","type":"RC"},{"code":"87210","type":"HCPCS"}],"standard_charges":[{"gross_charge":94.0,"discounted_cash":51.7,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Clostridium Difficile Toxin","code_information":[{"code":"60040820","type":"CDM"},{"code":"306","type":"RC"},{"code":"87230","type":"HCPCS"}],"standard_charges":[{"gross_charge":80.0,"discounted_cash":44.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Culture Blood","code_information":[{"code":"60040840","type":"CDM"},{"code":"306","type":"RC"},{"code":"87040","type":"HCPCS"}],"standard_charges":[{"gross_charge":230.0,"discounted_cash":126.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Gc Dna Probe","code_information":[{"code":"60040940","type":"CDM"},{"code":"306","type":"RC"},{"code":"87591","type":"HCPCS"}],"standard_charges":[{"gross_charge":611.0,"discounted_cash":336.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Culture Bronchoalveolar Lavage","code_information":[{"code":"60041000","type":"CDM"},{"code":"306","type":"RC"},{"code":"87070","type":"HCPCS"}],"standard_charges":[{"gross_charge":152.0,"discounted_cash":83.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Culture Tissue","code_information":[{"code":"60041020","type":"CDM"},{"code":"306","type":"RC"},{"code":"87070","type":"HCPCS"}],"standard_charges":[{"gross_charge":183.0,"discounted_cash":100.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Culture Throat","code_information":[{"code":"60041070","type":"CDM"},{"code":"306","type":"RC"},{"code":"87070","type":"HCPCS"}],"standard_charges":[{"gross_charge":188.0,"discounted_cash":103.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Rotavirus Antigen Feces I","code_information":[{"code":"60041171","type":"CDM"},{"code":"306","type":"RC"},{"code":"87425","type":"HCPCS"}],"standard_charges":[{"gross_charge":162.0,"discounted_cash":89.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Epstein-Barr Virus Antibody Igg","code_information":[{"code":"60041430","type":"CDM"},{"code":"302","type":"RC"},{"code":"86665","type":"HCPCS"}],"standard_charges":[{"gross_charge":183.0,"discounted_cash":100.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Epstein-Barr Virus Antibody Igm","code_information":[{"code":"60041440","type":"CDM"},{"code":"302","type":"RC"},{"code":"86665","type":"HCPCS"}],"standard_charges":[{"gross_charge":183.0,"discounted_cash":100.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Culture Blood Fungus Quant","code_information":[{"code":"60041540","type":"CDM"},{"code":"306","type":"RC"},{"code":"87103","type":"HCPCS"}],"standard_charges":[{"gross_charge":170.0,"discounted_cash":93.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Culture Routine","code_information":[{"code":"60041600","type":"CDM"},{"code":"306","type":"RC"},{"code":"87070","type":"HCPCS"}],"standard_charges":[{"gross_charge":183.0,"discounted_cash":100.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Culture Blood Quant","code_information":[{"code":"60041660","type":"CDM"},{"code":"306","type":"RC"},{"code":"87040","type":"HCPCS"}],"standard_charges":[{"gross_charge":230.0,"discounted_cash":126.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Cryptococcus Antigen Blood Ii","code_information":[{"code":"60041812","type":"CDM"},{"code":"306","type":"RC"},{"code":"87899","type":"HCPCS"}],"standard_charges":[{"gross_charge":138.0,"discounted_cash":75.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Culture Fungus Other","code_information":[{"code":"60041830","type":"CDM"},{"code":"306","type":"RC"},{"code":"87102","type":"HCPCS"}],"standard_charges":[{"gross_charge":202.0,"discounted_cash":111.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg O+P","code_information":[{"code":"60041890","type":"CDM"},{"code":"306","type":"RC"},{"code":"87177","type":"HCPCS"}],"standard_charges":[{"gross_charge":165.0,"discounted_cash":90.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Wet Prep Smear","code_information":[{"code":"60041940","type":"CDM"},{"code":"306","type":"RC"},{"code":"87210","type":"HCPCS"}],"standard_charges":[{"gross_charge":88.0,"discounted_cash":48.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Bacterial Vaginosis Smear","code_information":[{"code":"60041970","type":"CDM"},{"code":"306","type":"RC"},{"code":"87205","type":"HCPCS"}],"standard_charges":[{"gross_charge":86.0,"discounted_cash":47.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Culture Vre","code_information":[{"code":"60042170","type":"CDM"},{"code":"306","type":"RC"},{"code":"87081","type":"HCPCS"}],"standard_charges":[{"gross_charge":194.0,"discounted_cash":106.7,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Cryptosporidium Antigen","code_information":[{"code":"60042300","type":"CDM"},{"code":"306","type":"RC"},{"code":"87328","type":"HCPCS"}],"standard_charges":[{"gross_charge":246.0,"discounted_cash":135.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Chlamydia Trachomatis By Pcr","code_information":[{"code":"60042390","type":"CDM"},{"code":"306","type":"RC"},{"code":"87491","type":"HCPCS"}],"standard_charges":[{"gross_charge":312.0,"discounted_cash":171.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Special Stain Incl Bdy/Parasites Pc","code_information":[{"code":"60042680","type":"CDM"},{"code":"971","type":"RC"},{"code":"87207","type":"HCPCS"}],"standard_charges":[{"gross_charge":46.0,"discounted_cash":25.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Clostridium Difficile Toxin By Eia","code_information":[{"code":"60042790","type":"CDM"},{"code":"306","type":"RC"},{"code":"87324","type":"HCPCS"}],"standard_charges":[{"gross_charge":148.0,"discounted_cash":81.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Clostridium Diff Pcr","code_information":[{"code":"60042800","type":"CDM"},{"code":"306","type":"RC"},{"code":"87493","type":"HCPCS"}],"standard_charges":[{"gross_charge":147.0,"discounted_cash":80.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Gc Amplified Probe","code_information":[{"code":"60042830","type":"CDM"},{"code":"306","type":"RC"},{"code":"87591","type":"HCPCS"}],"standard_charges":[{"gross_charge":142.0,"discounted_cash":78.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Quantiferon Tb-Gold","code_information":[{"code":"60042850","type":"CDM"},{"code":"302","type":"RC"},{"code":"86480","type":"HCPCS"}],"standard_charges":[{"gross_charge":368.0,"discounted_cash":202.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Chlamydia Pneumoniae Amplified Probe I","code_information":[{"code":"60043181","type":"CDM"},{"code":"306","type":"RC"},{"code":"87486","type":"HCPCS"}],"standard_charges":[{"gross_charge":688.0,"discounted_cash":378.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Blastomyces Antigen","code_information":[{"code":"60043200","type":"CDM"},{"code":"302","type":"RC"},{"code":"87449","type":"HCPCS"}],"standard_charges":[{"gross_charge":251.0,"discounted_cash":138.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Culture Mssa","code_information":[{"code":"60043220","type":"CDM"},{"code":"306","type":"RC"},{"code":"87081","type":"HCPCS"}],"standard_charges":[{"gross_charge":194.0,"discounted_cash":106.7,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Mrsa Amplified Probe","code_information":[{"code":"60043290","type":"CDM"},{"code":"306","type":"RC"},{"code":"87641","type":"HCPCS"}],"standard_charges":[{"gross_charge":275.0,"discounted_cash":151.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Strep B Amplified Probe","code_information":[{"code":"60043450","type":"CDM"},{"code":"306","type":"RC"},{"code":"87653","type":"HCPCS"}],"standard_charges":[{"gross_charge":367.0,"discounted_cash":201.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Staph Aureus Amplified Probe","code_information":[{"code":"60043670","type":"CDM"},{"code":"306","type":"RC"},{"code":"87640","type":"HCPCS"}],"standard_charges":[{"gross_charge":275.0,"discounted_cash":151.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Noncdm Charge Record","code_information":[{"code":"60044141","type":"CDM"},{"code":"305","type":"RC"},{"code":"85245","type":"HCPCS"}],"standard_charges":[{"gross_charge":176.0,"discounted_cash":96.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Lchg Pth Intact W/O Calcium","code_information":[{"code":"60044330","type":"CDM"},{"code":"301","type":"RC"},{"code":"83970","type":"HCPCS"}],"standard_charges":[{"gross_charge":135.0,"discounted_cash":74.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Lyme Disease Pcr Tick I","code_information":[{"code":"60044371","type":"CDM"},{"code":"306","type":"RC"},{"code":"87801","type":"HCPCS"}],"standard_charges":[{"gross_charge":295.0,"discounted_cash":162.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Tick Id W Reflx Lyme Dna Ql Rt Pcr","code_information":[{"code":"60044590","type":"CDM"},{"code":"306","type":"RC"},{"code":"87168","type":"HCPCS"}],"standard_charges":[{"gross_charge":19.0,"discounted_cash":10.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Methadone Blood Quantitative I","code_information":[{"code":"60044621","type":"CDM"},{"code":"301","type":"RC"},{"code":"80358","type":"HCPCS"}],"standard_charges":[{"gross_charge":233.0,"discounted_cash":128.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Organic Acid Urine Qual Each Spec","code_information":[{"code":"60044660","type":"CDM"},{"code":"301","type":"RC"},{"code":"83919","type":"HCPCS"}],"standard_charges":[{"gross_charge":269.0,"discounted_cash":147.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Cystatin C Level","code_information":[{"code":"60045020","type":"CDM"},{"code":"301","type":"RC"},{"code":"82610","type":"HCPCS"}],"standard_charges":[{"gross_charge":110.0,"discounted_cash":60.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Influenza Pcr Multiple Types","code_information":[{"code":"60045030","type":"CDM"},{"code":"306","type":"RC"},{"code":"87502","type":"HCPCS"}],"standard_charges":[{"gross_charge":663.0,"discounted_cash":364.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Anti-Mullerian Hormone","code_information":[{"code":"60045370","type":"CDM"},{"code":"301","type":"RC"},{"code":"83520","type":"HCPCS"}],"standard_charges":[{"gross_charge":141.0,"discounted_cash":77.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Neutrophil Associated Antibodies","code_information":[{"code":"60045660","type":"CDM"},{"code":"302","type":"RC"},{"code":"86021","type":"HCPCS"}],"standard_charges":[{"gross_charge":45.0,"discounted_cash":24.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Adamts13 Activity","code_information":[{"code":"60046090","type":"CDM"},{"code":"305","type":"RC"},{"code":"85397","type":"HCPCS"}],"standard_charges":[{"gross_charge":197.0,"discounted_cash":108.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Procalcitonin Level","code_information":[{"code":"60046110","type":"CDM"},{"code":"301","type":"RC"},{"code":"84145","type":"HCPCS"}],"standard_charges":[{"gross_charge":205.0,"discounted_cash":112.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Lacosamide I","code_information":[{"code":"60046121","type":"CDM"},{"code":"301","type":"RC"},{"code":"80339","type":"HCPCS"}],"standard_charges":[{"gross_charge":283.0,"discounted_cash":155.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Buprenorphine+Metabolite Urine Confirm I","code_information":[{"code":"60046481","type":"CDM"},{"code":"301","type":"RC"},{"code":"80348","type":"HCPCS"}],"standard_charges":[{"gross_charge":139.0,"discounted_cash":76.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Celiac Disease Dual Ag Screen","code_information":[{"code":"60046510","type":"CDM"},{"code":"301","type":"RC"},{"code":"83516","type":"HCPCS"}],"standard_charges":[{"gross_charge":181.0,"discounted_cash":99.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Ethyl Glucuronide Urine Qual I","code_information":[{"code":"60046541","type":"CDM"},{"code":"301","type":"RC"},{"code":"80321","type":"HCPCS"}],"standard_charges":[{"gross_charge":353.0,"discounted_cash":194.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Ethyl Glucuronide Urine Qual Iv","code_information":[{"code":"60046544","type":"CDM"},{"code":"301","type":"RC"},{"code":"80307","type":"HCPCS"}],"standard_charges":[{"gross_charge":248.0,"discounted_cash":136.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Babesia Microti Amplified Probe Each","code_information":[{"code":"60046571","type":"CDM"},{"code":"306","type":"RC"},{"code":"87798","type":"HCPCS"}],"standard_charges":[{"gross_charge":432.0,"discounted_cash":237.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Cortisol Saliva","code_information":[{"code":"60047270","type":"CDM"},{"code":"301","type":"RC"},{"code":"82533","type":"HCPCS"}],"standard_charges":[{"gross_charge":260.0,"discounted_cash":143.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Allergen Derm Pteronyssinus Ige","code_information":[{"code":"60047490","type":"CDM"},{"code":"302","type":"RC"},{"code":"86003","type":"HCPCS"}],"standard_charges":[{"gross_charge":48.0,"discounted_cash":26.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Cd 24","code_information":[{"code":"60047571","type":"CDM"},{"code":"302","type":"RC"},{"code":"86356","type":"HCPCS"}],"standard_charges":[{"gross_charge":80.0,"discounted_cash":44.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Aspergillus Galactomannan Antibody","code_information":[{"code":"60047590","type":"CDM"},{"code":"302","type":"RC"},{"code":"87305","type":"HCPCS"}],"standard_charges":[{"gross_charge":147.0,"discounted_cash":80.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Aspergillus Galactomannan Ag","code_information":[{"code":"60047591","type":"CDM"},{"code":"306","type":"RC"},{"code":"87305","type":"HCPCS"}],"standard_charges":[{"gross_charge":147.0,"discounted_cash":80.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Aspergillus Galactomannan Ag I","code_information":[{"code":"60047592","type":"CDM"},{"code":"306","type":"RC"},{"code":"87305","type":"HCPCS"}],"standard_charges":[{"gross_charge":142.0,"discounted_cash":78.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Ia-2 Antibody I","code_information":[{"code":"60047621","type":"CDM"},{"code":"302","type":"RC"},{"code":"86341","type":"HCPCS"}],"standard_charges":[{"gross_charge":74.0,"discounted_cash":40.7,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Basic Metabolic Panel Fasting","code_information":[{"code":"60047790","type":"CDM"},{"code":"301","type":"RC"},{"code":"80048","type":"HCPCS"}],"standard_charges":[{"gross_charge":177.0,"discounted_cash":97.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Occult Blood Feces 1-3 Immuno","code_information":[{"code":"60047870","type":"CDM"},{"code":"301","type":"RC"},{"code":"82274","type":"HCPCS"}],"standard_charges":[{"gross_charge":162.0,"discounted_cash":89.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Protein Electrophoresis Urine Random","code_information":[{"code":"60047880","type":"CDM"},{"code":"301","type":"RC"},{"code":"84166","type":"HCPCS"}],"standard_charges":[{"gross_charge":204.0,"discounted_cash":112.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Calcium Channel Vgcc Antibody","code_information":[{"code":"60047890","type":"CDM"},{"code":"301","type":"RC"},{"code":"83519","type":"HCPCS"}],"standard_charges":[{"gross_charge":169.0,"discounted_cash":92.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Immunoassay Analyte Quant Nos Nonab Ibd","code_information":[{"code":"60048170","type":"CDM"},{"code":"301","type":"RC"},{"code":"83520","type":"HCPCS"}],"standard_charges":[{"gross_charge":198.0,"discounted_cash":108.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Thyrotropin Binding Inhibit Immun I","code_information":[{"code":"60048291","type":"CDM"},{"code":"301","type":"RC"},{"code":"83520","type":"HCPCS"}],"standard_charges":[{"gross_charge":203.0,"discounted_cash":111.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Anca Titer","code_information":[{"code":"60048420","type":"CDM"},{"code":"302","type":"RC"},{"code":"86256","type":"HCPCS"}],"standard_charges":[{"gross_charge":110.0,"discounted_cash":60.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Strep Pneumo Antigen Csf I","code_information":[{"code":"60048571","type":"CDM"},{"code":"306","type":"RC"},{"code":"87899","type":"HCPCS"}],"standard_charges":[{"gross_charge":170.0,"discounted_cash":93.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Amplified Probe Each Organism","code_information":[{"code":"60048820","type":"CDM"},{"code":"306","type":"RC"},{"code":"87798","type":"HCPCS"}],"standard_charges":[{"gross_charge":518.0,"discounted_cash":284.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Amplified Probe Each Organism I","code_information":[{"code":"60048821","type":"CDM"},{"code":"306","type":"RC"},{"code":"87798","type":"HCPCS"}],"standard_charges":[{"gross_charge":508.0,"discounted_cash":279.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Shiga-Like Toxin","code_information":[{"code":"60048830","type":"CDM"},{"code":"306","type":"RC"},{"code":"87427","type":"HCPCS"}],"standard_charges":[{"gross_charge":163.0,"discounted_cash":89.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Mycobacterium Tb Ampl Probe","code_information":[{"code":"60048860","type":"CDM"},{"code":"306","type":"RC"},{"code":"87556","type":"HCPCS"}],"standard_charges":[{"gross_charge":169.0,"discounted_cash":92.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Susceptibility Disc Method","code_information":[{"code":"60049020","type":"CDM"},{"code":"306","type":"RC"},{"code":"87184","type":"HCPCS"}],"standard_charges":[{"gross_charge":141.0,"discounted_cash":77.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Susceptibility Mic","code_information":[{"code":"60049040","type":"CDM"},{"code":"306","type":"RC"},{"code":"87186","type":"HCPCS"}],"standard_charges":[{"gross_charge":216.0,"discounted_cash":118.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Susceptibility Fungus Mic","code_information":[{"code":"60049060","type":"CDM"},{"code":"306","type":"RC"},{"code":"87186","type":"HCPCS"}],"standard_charges":[{"gross_charge":52.0,"discounted_cash":28.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Gram Stain Smear I","code_information":[{"code":"60049090","type":"CDM"},{"code":"306","type":"RC"},{"code":"87205","type":"HCPCS"}],"standard_charges":[{"gross_charge":86.0,"discounted_cash":47.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Stain Trichrome","code_information":[{"code":"60049130","type":"CDM"},{"code":"306","type":"RC"},{"code":"87209","type":"HCPCS"}],"standard_charges":[{"gross_charge":292.0,"discounted_cash":160.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Fungus Smear","code_information":[{"code":"60049160","type":"CDM"},{"code":"306","type":"RC"},{"code":"87206","type":"HCPCS"}],"standard_charges":[{"gross_charge":92.0,"discounted_cash":50.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Concentration Any Infectious Agent","code_information":[{"code":"60049220","type":"CDM"},{"code":"306","type":"RC"},{"code":"87015","type":"HCPCS"}],"standard_charges":[{"gross_charge":62.0,"discounted_cash":34.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Organism Id Anaerobe","code_information":[{"code":"60049230","type":"CDM"},{"code":"306","type":"RC"},{"code":"87076","type":"HCPCS"}],"standard_charges":[{"gross_charge":195.0,"discounted_cash":107.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Organism Id Anaerobe Refer","code_information":[{"code":"60049231","type":"CDM"},{"code":"306","type":"RC"},{"code":"87076","type":"HCPCS"}],"standard_charges":[{"gross_charge":153.0,"discounted_cash":84.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Organism Id Afb","code_information":[{"code":"60049280","type":"CDM"},{"code":"306","type":"RC"},{"code":"87118","type":"HCPCS"}],"standard_charges":[{"gross_charge":290.0,"discounted_cash":159.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Culture Anaerobe I","code_information":[{"code":"60049520","type":"CDM"},{"code":"306","type":"RC"},{"code":"87075","type":"HCPCS"}],"standard_charges":[{"gross_charge":224.0,"discounted_cash":123.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Organism Id Urine","code_information":[{"code":"60049530","type":"CDM"},{"code":"306","type":"RC"},{"code":"87088","type":"HCPCS"}],"standard_charges":[{"gross_charge":110.0,"discounted_cash":60.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Organism Id Fungus","code_information":[{"code":"60049590","type":"CDM"},{"code":"306","type":"RC"},{"code":"87106","type":"HCPCS"}],"standard_charges":[{"gross_charge":204.0,"discounted_cash":112.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Organism Id Parasite","code_information":[{"code":"60049730","type":"CDM"},{"code":"306","type":"RC"},{"code":"87169","type":"HCPCS"}],"standard_charges":[{"gross_charge":107.0,"discounted_cash":58.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Organism Id Parasite I","code_information":[{"code":"60049731","type":"CDM"},{"code":"306","type":"RC"},{"code":"87169","type":"HCPCS"}],"standard_charges":[{"gross_charge":107.0,"discounted_cash":58.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Organism Id Mold","code_information":[{"code":"60049800","type":"CDM"},{"code":"306","type":"RC"},{"code":"87107","type":"HCPCS"}],"standard_charges":[{"gross_charge":201.0,"discounted_cash":110.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Susceptibility E-Test","code_information":[{"code":"60049930","type":"CDM"},{"code":"306","type":"RC"},{"code":"87181","type":"HCPCS"}],"standard_charges":[{"gross_charge":56.0,"discounted_cash":30.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Organism Id Strep Latex","code_information":[{"code":"60049980","type":"CDM"},{"code":"306","type":"RC"},{"code":"87147","type":"HCPCS"}],"standard_charges":[{"gross_charge":66.0,"discounted_cash":36.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Dna Ploidy/Cell Kinetics","code_information":[{"code":"60050110","type":"CDM"},{"code":"310","type":"RC"},{"code":"88182","type":"HCPCS"}],"standard_charges":[{"gross_charge":207.0,"discounted_cash":113.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Her-2 Fish I","code_information":[{"code":"60050132","type":"CDM"},{"code":"310","type":"RC"},{"code":"88377","type":"HCPCS"}],"standard_charges":[{"gross_charge":956.0,"discounted_cash":525.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Egfr Gene Common Variants","code_information":[{"code":"60050870","type":"CDM"},{"code":"310","type":"RC"},{"code":"81235","type":"HCPCS"}],"standard_charges":[{"gross_charge":1886.0,"discounted_cash":1037.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Egfr Gene Common Variants I","code_information":[{"code":"60050871","type":"CDM"},{"code":"310","type":"RC"},{"code":"81235","type":"HCPCS"}],"standard_charges":[{"gross_charge":1886.0,"discounted_cash":1037.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Cell Block","code_information":[{"code":"60051390","type":"CDM"},{"code":"310","type":"RC"},{"code":"88305","type":"HCPCS"}],"standard_charges":[{"gross_charge":494.0,"discounted_cash":271.7,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Histochemistry Enzyme Pc","code_information":[{"code":"60051690","type":"CDM"},{"code":"971","type":"RC"},{"code":"88319","type":"HCPCS"}],"standard_charges":[{"gross_charge":252.0,"discounted_cash":138.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Histochemistry Enzyme","code_information":[{"code":"60051700","type":"CDM"},{"code":"312","type":"RC"},{"code":"88319","type":"HCPCS"}],"standard_charges":[{"gross_charge":384.0,"discounted_cash":211.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Histochemistry Enzyme Tc Nl","code_information":[{"code":"60051701","type":"CDM"},{"code":"310","type":"RC"},{"code":"88319","type":"HCPCS"}],"standard_charges":[{"gross_charge":384.0,"discounted_cash":211.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Immunofluorescent Study Tc Nl","code_information":[{"code":"60052002","type":"CDM"},{"code":"310","type":"RC"},{"code":"88346","type":"HCPCS"}],"standard_charges":[{"gross_charge":139.0,"discounted_cash":76.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Immunohisto Tumor","code_information":[{"code":"60052020","type":"CDM"},{"code":"310","type":"RC"},{"code":"88360","type":"HCPCS"}],"standard_charges":[{"gross_charge":381.0,"discounted_cash":209.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Sp Stain Frozen","code_information":[{"code":"60052040","type":"CDM"},{"code":"310","type":"RC"},{"code":"88314","type":"HCPCS"}],"standard_charges":[{"gross_charge":178.0,"discounted_cash":97.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Sp Gross Level I Tc Nl","code_information":[{"code":"60052351","type":"CDM"},{"code":"310","type":"RC"},{"code":"88300","type":"HCPCS"}],"standard_charges":[{"gross_charge":228.0,"discounted_cash":125.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Ihc 1St Stn Pc","code_information":[{"code":"60052480","type":"CDM"},{"code":"971","type":"RC"},{"code":"88342","type":"HCPCS"}],"standard_charges":[{"gross_charge":314.0,"discounted_cash":172.7,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Sp Stain Frozen I","code_information":[{"code":"60052540","type":"CDM"},{"code":"310","type":"RC"},{"code":"88314","type":"HCPCS"}],"standard_charges":[{"gross_charge":178.0,"discounted_cash":97.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Sp G+M Level Ii Tc Nl","code_information":[{"code":"60052741","type":"CDM"},{"code":"310","type":"RC"},{"code":"88302","type":"HCPCS"}],"standard_charges":[{"gross_charge":239.0,"discounted_cash":131.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Sp G+M Level Iii Tc Nl","code_information":[{"code":"60052751","type":"CDM"},{"code":"310","type":"RC"},{"code":"88304","type":"HCPCS"}],"standard_charges":[{"gross_charge":499.0,"discounted_cash":274.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Sp G+M Level V Tc Nl","code_information":[{"code":"60052771","type":"CDM"},{"code":"310","type":"RC"},{"code":"88307","type":"HCPCS"}],"standard_charges":[{"gross_charge":699.0,"discounted_cash":384.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Sp G+M Level Vi Tc Nl","code_information":[{"code":"60052781","type":"CDM"},{"code":"310","type":"RC"},{"code":"88309","type":"HCPCS"}],"standard_charges":[{"gross_charge":677.0,"discounted_cash":372.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Decal Tc Nl","code_information":[{"code":"60052791","type":"CDM"},{"code":"310","type":"RC"},{"code":"88311","type":"HCPCS"}],"standard_charges":[{"gross_charge":207.0,"discounted_cash":113.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Sp Stain Group I Tc","code_information":[{"code":"60052800","type":"CDM"},{"code":"310","type":"RC"},{"code":"88312","type":"HCPCS"}],"standard_charges":[{"gross_charge":232.0,"discounted_cash":127.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Sp Stain Group I Tc Nl","code_information":[{"code":"60052801","type":"CDM"},{"code":"310","type":"RC"},{"code":"88312","type":"HCPCS"}],"standard_charges":[{"gross_charge":232.0,"discounted_cash":127.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Sp Stain Group Ii Tc","code_information":[{"code":"60052810","type":"CDM"},{"code":"310","type":"RC"},{"code":"88313","type":"HCPCS"}],"standard_charges":[{"gross_charge":204.0,"discounted_cash":112.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Sp Stain Group Ii Tc Nl","code_information":[{"code":"60052811","type":"CDM"},{"code":"310","type":"RC"},{"code":"88313","type":"HCPCS"}],"standard_charges":[{"gross_charge":228.0,"discounted_cash":125.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Sp Stain Group Ii Tc Ap Ltl","code_information":[{"code":"60052812","type":"CDM"},{"code":"310","type":"RC"},{"code":"88313","type":"HCPCS"}],"standard_charges":[{"gross_charge":228.0,"discounted_cash":125.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Noncdm Charge Record","code_information":[{"code":"60052820","type":"CDM"},{"code":"310","type":"RC"},{"code":"88314","type":"HCPCS"}],"standard_charges":[{"gross_charge":59.4,"discounted_cash":32.67,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Lchg Sp Stain Group Iv Tc","code_information":[{"code":"60052830","type":"CDM"},{"code":"312","type":"RC"},{"code":"88319","type":"HCPCS"}],"standard_charges":[{"gross_charge":384.0,"discounted_cash":211.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Path Consult W Surg Frozen Tc Nl","code_information":[{"code":"60052861","type":"CDM"},{"code":"310","type":"RC"},{"code":"88331","type":"HCPCS"}],"standard_charges":[{"gross_charge":470.0,"discounted_cash":258.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Path Consult W Surg Frozen Each Add Tc Nl","code_information":[{"code":"60052871","type":"CDM"},{"code":"310","type":"RC"},{"code":"88332","type":"HCPCS"}],"standard_charges":[{"gross_charge":182.0,"discounted_cash":100.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Immunoperoxidase Tc","code_information":[{"code":"60052880","type":"CDM"},{"code":"310","type":"RC"},{"code":"88342","type":"HCPCS"}],"standard_charges":[{"gross_charge":479.0,"discounted_cash":263.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Histochemical Stain Add-On Tc","code_information":[{"code":"60052890","type":"CDM"},{"code":"310","type":"RC"},{"code":"88314","type":"HCPCS"}],"standard_charges":[{"gross_charge":178.0,"discounted_cash":97.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Noncdm Charge Record","code_information":[{"code":"60053030","type":"CDM"},{"code":"310","type":"RC"},{"code":"88342","type":"HCPCS"}],"standard_charges":[{"gross_charge":492.0,"discounted_cash":270.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Lchg Immunohistochemistry Each Ab","code_information":[{"code":"60053400","type":"CDM"},{"code":"310","type":"RC"},{"code":"88342","type":"HCPCS"}],"standard_charges":[{"gross_charge":489.0,"discounted_cash":268.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Path Consult W Surg Cyto Tc Nl","code_information":[{"code":"60053441","type":"CDM"},{"code":"310","type":"RC"},{"code":"88333","type":"HCPCS"}],"standard_charges":[{"gross_charge":280.0,"discounted_cash":154.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Path Consult Cyto Each Tc Nl","code_information":[{"code":"60053452","type":"CDM"},{"code":"310","type":"RC"},{"code":"88334","type":"HCPCS"}],"standard_charges":[{"gross_charge":182.0,"discounted_cash":100.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Sodium Chloride Irrigation Soln 0.9%","drug_information":{"unit":1000.0,"type":"ML"},"code_information":[{"code":"600536","type":"CDM"},{"code":"338004802","type":"NDC"}],"standard_charges":[{"gross_charge":133.35,"discounted_cash":73.34,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Sodium Chloride Irrigation Soln 0.9%","drug_information":{"unit":1000.0,"type":"ML"},"code_information":[{"code":"600536","type":"CDM"},{"code":"409613822","type":"NDC"}],"standard_charges":[{"gross_charge":142.25,"discounted_cash":78.24,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Sodium Chloride Irrigation Soln 0.9%","drug_information":{"unit":1000.0,"type":"ML"},"code_information":[{"code":"600536","type":"CDM"},{"code":"264220110","type":"NDC"}],"standard_charges":[{"gross_charge":71.05,"discounted_cash":39.08,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Sodium Chloride Irrigation Soln 0.9%","drug_information":{"unit":1000.0,"type":"ML"},"code_information":[{"code":"600536","type":"CDM"},{"code":"264220100","type":"NDC"}],"standard_charges":[{"gross_charge":53.25,"discounted_cash":29.29,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Lchg Cyto Path Imaging Tc Nl","code_information":[{"code":"60053633","type":"CDM"},{"code":"310","type":"RC"},{"code":"88175","type":"HCPCS"}],"standard_charges":[{"gross_charge":386.0,"discounted_cash":212.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Cftr Gene Full Sequence","code_information":[{"code":"60053720","type":"CDM"},{"code":"310","type":"RC"},{"code":"81223","type":"HCPCS"}],"standard_charges":[{"gross_charge":2414.0,"discounted_cash":1327.7,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Mopath Procedure Level 4","code_information":[{"code":"60053730","type":"CDM"},{"code":"310","type":"RC"},{"code":"81403","type":"HCPCS"}],"standard_charges":[{"gross_charge":898.0,"discounted_cash":493.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Trg Gene Rearrange Anal","code_information":[{"code":"60053750","type":"CDM"},{"code":"310","type":"RC"},{"code":"81342","type":"HCPCS"}],"standard_charges":[{"gross_charge":977.0,"discounted_cash":537.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Mopath Procedure Level 6","code_information":[{"code":"60053770","type":"CDM"},{"code":"310","type":"RC"},{"code":"81405","type":"HCPCS"}],"standard_charges":[{"gross_charge":1457.0,"discounted_cash":801.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Factor Ii Gene G20210A Prothrombin","code_information":[{"code":"60053820","type":"CDM"},{"code":"310","type":"RC"},{"code":"81240","type":"HCPCS"}],"standard_charges":[{"gross_charge":574.0,"discounted_cash":315.7,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Factor Ii Gene G20210A Prothrombin I","code_information":[{"code":"60053821","type":"CDM"},{"code":"310","type":"RC"},{"code":"81240","type":"HCPCS"}],"standard_charges":[{"gross_charge":574.0,"discounted_cash":315.7,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Mthfr Gene","code_information":[{"code":"60053840","type":"CDM"},{"code":"310","type":"RC"},{"code":"81291","type":"HCPCS"}],"standard_charges":[{"gross_charge":926.0,"discounted_cash":509.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Mopath Procedure Level 2","code_information":[{"code":"60053850","type":"CDM"},{"code":"310","type":"RC"},{"code":"81401","type":"HCPCS"}],"standard_charges":[{"gross_charge":1376.0,"discounted_cash":756.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Kras Gene","code_information":[{"code":"60053860","type":"CDM"},{"code":"300","type":"RC"},{"code":"81275","type":"HCPCS"}],"standard_charges":[{"gross_charge":1555.0,"discounted_cash":855.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Kras Gene I","code_information":[{"code":"60053861","type":"CDM"},{"code":"310","type":"RC"},{"code":"81275","type":"HCPCS"}],"standard_charges":[{"gross_charge":1555.0,"discounted_cash":855.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Jak2 Gene V6172F","code_information":[{"code":"60053870","type":"CDM"},{"code":"310","type":"RC"},{"code":"81270","type":"HCPCS"}],"standard_charges":[{"gross_charge":898.0,"discounted_cash":493.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Hfe Gene Hemochromatosis","code_information":[{"code":"60053880","type":"CDM"},{"code":"310","type":"RC"},{"code":"81256","type":"HCPCS"}],"standard_charges":[{"gross_charge":964.0,"discounted_cash":530.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Cytogen Micrarray Copy Nmbr+Snp Gene","code_information":[{"code":"60053890","type":"CDM"},{"code":"310","type":"RC"},{"code":"81229","type":"HCPCS"}],"standard_charges":[{"gross_charge":5614.0,"discounted_cash":3087.7,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Cytogen Micrarray Cpy Nbr+Snp Gene Ii","code_information":[{"code":"60053895","type":"CDM"},{"code":"310","type":"RC"},{"code":"81229","type":"HCPCS"}],"standard_charges":[{"gross_charge":5610.0,"discounted_cash":3085.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Cytogen Micrarray Cpy Nbr+Snp Gene Iv","code_information":[{"code":"60053897","type":"CDM"},{"code":"310","type":"RC"},{"code":"81229","type":"HCPCS"}],"standard_charges":[{"gross_charge":5614.0,"discounted_cash":3087.7,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Factor V Gene Leiden","code_information":[{"code":"60053920","type":"CDM"},{"code":"310","type":"RC"},{"code":"81241","type":"HCPCS"}],"standard_charges":[{"gross_charge":790.0,"discounted_cash":434.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Factor V Gene Leiden I","code_information":[{"code":"60053921","type":"CDM"},{"code":"310","type":"RC"},{"code":"81241","type":"HCPCS"}],"standard_charges":[{"gross_charge":790.0,"discounted_cash":434.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Cftr Gene Cystic Fibrosis","code_information":[{"code":"60053930","type":"CDM"},{"code":"310","type":"RC"},{"code":"81220","type":"HCPCS"}],"standard_charges":[{"gross_charge":2405.0,"discounted_cash":1322.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Bcr-Abl1 Gene Major Bp","code_information":[{"code":"60053940","type":"CDM"},{"code":"310","type":"RC"},{"code":"81206","type":"HCPCS"}],"standard_charges":[{"gross_charge":818.0,"discounted_cash":449.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Serpina1 Gene Common Variants","code_information":[{"code":"60053950","type":"CDM"},{"code":"310","type":"RC"},{"code":"81332","type":"HCPCS"}],"standard_charges":[{"gross_charge":211.0,"discounted_cash":116.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Braf Gene","code_information":[{"code":"60053960","type":"CDM"},{"code":"310","type":"RC"},{"code":"81210","type":"HCPCS"}],"standard_charges":[{"gross_charge":848.0,"discounted_cash":466.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Braf Gene I","code_information":[{"code":"60053961","type":"CDM"},{"code":"310","type":"RC"},{"code":"81210","type":"HCPCS"}],"standard_charges":[{"gross_charge":848.0,"discounted_cash":466.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Noncdm Charge Record","code_information":[{"code":"60054120","type":"CDM"},{"code":"311","type":"RC"},{"code":"88112","type":"HCPCS"}],"standard_charges":[{"gross_charge":263.0,"discounted_cash":144.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Lchg Cd4 (Absolute T4)","code_information":[{"code":"60054260","type":"CDM"},{"code":"302","type":"RC"},{"code":"86361","type":"HCPCS"}],"standard_charges":[{"gross_charge":361.0,"discounted_cash":198.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Norovirus 1 Rt Pcr","code_information":[{"code":"60054790","type":"CDM"},{"code":"306","type":"RC"},{"code":"87798","type":"HCPCS"}],"standard_charges":[{"gross_charge":508.0,"discounted_cash":279.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Bordetella Pertussis Pcr","code_information":[{"code":"60054810","type":"CDM"},{"code":"306","type":"RC"},{"code":"87798","type":"HCPCS"}],"standard_charges":[{"gross_charge":508.0,"discounted_cash":279.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Bordetella Parapertussis Pcr","code_information":[{"code":"60054820","type":"CDM"},{"code":"306","type":"RC"},{"code":"87798","type":"HCPCS"}],"standard_charges":[{"gross_charge":508.0,"discounted_cash":279.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Cytopath Othr Sourc Scrn Intrp Tc Nl","code_information":[{"code":"60055111","type":"CDM"},{"code":"311","type":"RC"},{"code":"88112","type":"HCPCS"}],"standard_charges":[{"gross_charge":336.0,"discounted_cash":184.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Fine Needle Evaluation Tc","code_information":[{"code":"60055270","type":"CDM"},{"code":"311","type":"RC"},{"code":"88172","type":"HCPCS"}],"standard_charges":[{"gross_charge":478.0,"discounted_cash":262.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Cytopath Cerv/Vag Thin Layer Nl","code_information":[{"code":"60055331","type":"CDM"},{"code":"311","type":"RC"},{"code":"88142","type":"HCPCS"}],"standard_charges":[{"gross_charge":313.0,"discounted_cash":172.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Cytopath Cell Enhance Tech W Interp Tc Nl","code_information":[{"code":"60055411","type":"CDM"},{"code":"311","type":"RC"},{"code":"88112","type":"HCPCS"}],"standard_charges":[{"gross_charge":452.0,"discounted_cash":248.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Fine Needle Aspiration Each Addl","code_information":[{"code":"60055470","type":"CDM"},{"code":"310","type":"RC"},{"code":"88177","type":"HCPCS"}],"standard_charges":[{"gross_charge":112.0,"discounted_cash":61.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Hla Ii Typing 1 Allele Hr","code_information":[{"code":"60055530","type":"CDM"},{"code":"300","type":"RC"},{"code":"81383","type":"HCPCS"}],"standard_charges":[{"gross_charge":527.0,"discounted_cash":289.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Protein 14-3-3 Western Blot","code_information":[{"code":"60055550","type":"CDM"},{"code":"301","type":"RC"},{"code":"84182","type":"HCPCS"}],"standard_charges":[{"gross_charge":99.0,"discounted_cash":54.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Protein 14-3-3 Immunoassay","code_information":[{"code":"60055560","type":"CDM"},{"code":"302","type":"RC"},{"code":"86317","type":"HCPCS"}],"standard_charges":[{"gross_charge":46.0,"discounted_cash":25.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Glomerular Base Membrane Ab Qual","code_information":[{"code":"60055580","type":"CDM"},{"code":"301","type":"RC"},{"code":"83516","type":"HCPCS"}],"standard_charges":[{"gross_charge":187.0,"discounted_cash":102.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Cytospin","code_information":[{"code":"60055610","type":"CDM"},{"code":"311","type":"RC"},{"code":"88108","type":"HCPCS"}],"standard_charges":[{"gross_charge":322.0,"discounted_cash":177.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Cd59 I","code_information":[{"code":"60055660","type":"CDM"},{"code":"302","type":"RC"},{"code":"86356","type":"HCPCS"}],"standard_charges":[{"gross_charge":80.0,"discounted_cash":44.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Glycophorin","code_information":[{"code":"60055670","type":"CDM"},{"code":"302","type":"RC"},{"code":"86356","type":"HCPCS"}],"standard_charges":[{"gross_charge":80.0,"discounted_cash":44.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Flow Add Each Marker Refer","code_information":[{"code":"60055750","type":"CDM"},{"code":"311","type":"RC"},{"code":"88185","type":"HCPCS"}],"standard_charges":[{"gross_charge":179.0,"discounted_cash":98.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Flow Add Each Marker Refer I","code_information":[{"code":"60055751","type":"CDM"},{"code":"311","type":"RC"},{"code":"88185","type":"HCPCS"}],"standard_charges":[{"gross_charge":175.0,"discounted_cash":96.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Flow 1 Marker Refer","code_information":[{"code":"60055760","type":"CDM"},{"code":"311","type":"RC"},{"code":"88184","type":"HCPCS"}],"standard_charges":[{"gross_charge":185.0,"discounted_cash":101.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Microdissection Manual","code_information":[{"code":"60055810","type":"CDM"},{"code":"310","type":"RC"},{"code":"88381","type":"HCPCS"}],"standard_charges":[{"gross_charge":217.0,"discounted_cash":119.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Ana Ii","code_information":[{"code":"60055980","type":"CDM"},{"code":"302","type":"RC"},{"code":"86038","type":"HCPCS"}],"standard_charges":[{"gross_charge":162.0,"discounted_cash":89.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Testosterone Total Ii","code_information":[{"code":"60056070","type":"CDM"},{"code":"301","type":"RC"},{"code":"84403","type":"HCPCS"}],"standard_charges":[{"gross_charge":404.0,"discounted_cash":222.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Light Chains Free Ea","code_information":[{"code":"60056130","type":"CDM"},{"code":"301","type":"RC"},{"code":"83883","type":"HCPCS"}],"standard_charges":[{"gross_charge":212.0,"discounted_cash":116.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Anaplasma Phg Igm","code_information":[{"code":"60056140","type":"CDM"},{"code":"302","type":"RC"},{"code":"86666","type":"HCPCS"}],"standard_charges":[{"gross_charge":202.0,"discounted_cash":111.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Anaplasma Phg Igg","code_information":[{"code":"60056350","type":"CDM"},{"code":"302","type":"RC"},{"code":"86666","type":"HCPCS"}],"standard_charges":[{"gross_charge":196.0,"discounted_cash":107.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Purkinje Cell Antibody Titer","code_information":[{"code":"60056390","type":"CDM"},{"code":"302","type":"RC"},{"code":"86256","type":"HCPCS"}],"standard_charges":[{"gross_charge":110.0,"discounted_cash":60.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Allergen Ige","code_information":[{"code":"60056600","type":"CDM"},{"code":"301","type":"RC"},{"code":"82785","type":"HCPCS"}],"standard_charges":[{"gross_charge":274.0,"discounted_cash":150.7,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Albumin I","code_information":[{"code":"60056920","type":"CDM"},{"code":"301","type":"RC"},{"code":"82040","type":"HCPCS"}],"standard_charges":[{"gross_charge":60.0,"discounted_cash":33.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Chr Cytogen Interp/Report","code_information":[{"code":"60057210","type":"CDM"},{"code":"310","type":"RC"},{"code":"88291","type":"HCPCS"}],"standard_charges":[{"gross_charge":114.0,"discounted_cash":62.7,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Chr Cytogen Interp/Report I","code_information":[{"code":"60057211","type":"CDM"},{"code":"310","type":"RC"},{"code":"88291","type":"HCPCS"}],"standard_charges":[{"gross_charge":116.0,"discounted_cash":63.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Chr Lymph Tissue","code_information":[{"code":"60058040","type":"CDM"},{"code":"311","type":"RC"},{"code":"88230","type":"HCPCS"}],"standard_charges":[{"gross_charge":399.0,"discounted_cash":219.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Chr Tissue Culture Lymphocyte Gene","code_information":[{"code":"60058041","type":"CDM"},{"code":"311","type":"RC"},{"code":"88230","type":"HCPCS"}],"standard_charges":[{"gross_charge":831.0,"discounted_cash":457.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Chr Tissue Culture Lymphocyte Blood","code_information":[{"code":"60058060","type":"CDM"},{"code":"310","type":"RC"},{"code":"88230","type":"HCPCS"}],"standard_charges":[{"gross_charge":566.0,"discounted_cash":311.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Noncdm Charge Record","code_information":[{"code":"60058120","type":"CDM"},{"code":"311","type":"RC"},{"code":"88237","type":"HCPCS"}],"standard_charges":[{"gross_charge":366.29,"discounted_cash":201.46,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Lchg Chr (15-20Ct/2K/Bd)","code_information":[{"code":"60058180","type":"CDM"},{"code":"311","type":"RC"},{"code":"88262","type":"HCPCS"}],"standard_charges":[{"gross_charge":429.0,"discounted_cash":235.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Chr (15-20Ct/2K/Bd) Gene","code_information":[{"code":"60058181","type":"CDM"},{"code":"311","type":"RC"},{"code":"88262","type":"HCPCS"}],"standard_charges":[{"gross_charge":1400.0,"discounted_cash":770.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Dna Probe Fish Gene","code_information":[{"code":"60058660","type":"CDM"},{"code":"310","type":"RC"},{"code":"88271","type":"HCPCS"}],"standard_charges":[{"gross_charge":229.0,"discounted_cash":125.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Dna Probe Fish Gene","code_information":[{"code":"60058661","type":"CDM"},{"code":"311","type":"RC"},{"code":"88271","type":"HCPCS"}],"standard_charges":[{"gross_charge":142.0,"discounted_cash":78.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Interphase Hybrid 100-300 Gene","code_information":[{"code":"60058710","type":"CDM"},{"code":"311","type":"RC"},{"code":"88275","type":"HCPCS"}],"standard_charges":[{"gross_charge":469.0,"discounted_cash":257.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Interphase Hybrid 100-300","code_information":[{"code":"60058940","type":"CDM"},{"code":"310","type":"RC"},{"code":"88275","type":"HCPCS"}],"standard_charges":[{"gross_charge":469.0,"discounted_cash":257.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Noncdm Charge Record","code_information":[{"code":"60058960","type":"CDM"},{"code":"311","type":"RC"},{"code":"88264","type":"HCPCS"}],"standard_charges":[{"gross_charge":310.25,"discounted_cash":170.64,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Lchg Cd14","code_information":[{"code":"60059030","type":"CDM"},{"code":"302","type":"RC"},{"code":"86356","type":"HCPCS"}],"standard_charges":[{"gross_charge":80.0,"discounted_cash":44.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg B Lymphocyte Subset Count (Cd19)","code_information":[{"code":"60059050","type":"CDM"},{"code":"310","type":"RC"},{"code":"88184","type":"HCPCS"}],"standard_charges":[{"gross_charge":179.0,"discounted_cash":98.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Cd 33","code_information":[{"code":"60059090","type":"CDM"},{"code":"302","type":"RC"},{"code":"86356","type":"HCPCS"}],"standard_charges":[{"gross_charge":80.0,"discounted_cash":44.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Nk Total Count","code_information":[{"code":"60059500","type":"CDM"},{"code":"302","type":"RC"},{"code":"86357","type":"HCPCS"}],"standard_charges":[{"gross_charge":569.0,"discounted_cash":312.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Cyclic Citrul Peptide Ab Igg (Ccp)","code_information":[{"code":"60059560","type":"CDM"},{"code":"302","type":"RC"},{"code":"86200","type":"HCPCS"}],"standard_charges":[{"gross_charge":197.0,"discounted_cash":108.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Porphyrins Urine Random Fractionation","code_information":[{"code":"60059730","type":"CDM"},{"code":"301","type":"RC"},{"code":"84120","type":"HCPCS"}],"standard_charges":[{"gross_charge":235.0,"discounted_cash":129.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Trypanosoma Cruzi Ab Igg","code_information":[{"code":"60059770","type":"CDM"},{"code":"302","type":"RC"},{"code":"86753","type":"HCPCS"}],"standard_charges":[{"gross_charge":37.0,"discounted_cash":20.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg West Nile Virus Pcr","code_information":[{"code":"60059800","type":"CDM"},{"code":"306","type":"RC"},{"code":"87798","type":"HCPCS"}],"standard_charges":[{"gross_charge":702.0,"discounted_cash":386.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Hexagonal Phospholipid Neutralize","code_information":[{"code":"60059840","type":"CDM"},{"code":"305","type":"RC"},{"code":"85598","type":"HCPCS"}],"standard_charges":[{"gross_charge":169.0,"discounted_cash":92.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Apc Resistance","code_information":[{"code":"60059860","type":"CDM"},{"code":"305","type":"RC"},{"code":"85307","type":"HCPCS"}],"standard_charges":[{"gross_charge":171.0,"discounted_cash":94.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Zolpidem Level I","code_information":[{"code":"60059871","type":"CDM"},{"code":"301","type":"RC"},{"code":"80368","type":"HCPCS"}],"standard_charges":[{"gross_charge":343.0,"discounted_cash":188.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Immunoassay Analyte Quantitative Ria","code_information":[{"code":"60059900","type":"CDM"},{"code":"301","type":"RC"},{"code":"83519","type":"HCPCS"}],"standard_charges":[{"gross_charge":175.0,"discounted_cash":96.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Thiopurine Meth Transferase","code_information":[{"code":"60059970","type":"CDM"},{"code":"301","type":"RC"},{"code":"82657","type":"HCPCS"}],"standard_charges":[{"gross_charge":288.0,"discounted_cash":158.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Aldolase","code_information":[{"code":"60060050","type":"CDM"},{"code":"301","type":"RC"},{"code":"82085","type":"HCPCS"}],"standard_charges":[{"gross_charge":154.0,"discounted_cash":84.7,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Complement C2","code_information":[{"code":"60060080","type":"CDM"},{"code":"302","type":"RC"},{"code":"86160","type":"HCPCS"}],"standard_charges":[{"gross_charge":181.0,"discounted_cash":99.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Aldosterone","code_information":[{"code":"60060100","type":"CDM"},{"code":"301","type":"RC"},{"code":"82088","type":"HCPCS"}],"standard_charges":[{"gross_charge":668.0,"discounted_cash":367.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Complement C1 Esteras Inhib Ag I","code_information":[{"code":"60060161","type":"CDM"},{"code":"302","type":"RC"},{"code":"86160","type":"HCPCS"}],"standard_charges":[{"gross_charge":159.0,"discounted_cash":87.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Complement C1Q","code_information":[{"code":"60060180","type":"CDM"},{"code":"302","type":"RC"},{"code":"86160","type":"HCPCS"}],"standard_charges":[{"gross_charge":180.0,"discounted_cash":99.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Alpha-1-Antitrypsin Blood","code_information":[{"code":"60060200","type":"CDM"},{"code":"301","type":"RC"},{"code":"82103","type":"HCPCS"}],"standard_charges":[{"gross_charge":218.0,"discounted_cash":119.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Alpha-1-Antitrypsin Blood Phenotype","code_information":[{"code":"60060210","type":"CDM"},{"code":"301","type":"RC"},{"code":"82104","type":"HCPCS"}],"standard_charges":[{"gross_charge":214.0,"discounted_cash":117.7,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Coccidiodes Antibody Cf","code_information":[{"code":"60060230","type":"CDM"},{"code":"302","type":"RC"},{"code":"86635","type":"HCPCS"}],"standard_charges":[{"gross_charge":38.0,"discounted_cash":20.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Alpha Fetoprotein Blood Tumor","code_information":[{"code":"60060250","type":"CDM"},{"code":"301","type":"RC"},{"code":"82105","type":"HCPCS"}],"standard_charges":[{"gross_charge":265.0,"discounted_cash":145.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Aluminum","code_information":[{"code":"60060270","type":"CDM"},{"code":"301","type":"RC"},{"code":"82108","type":"HCPCS"}],"standard_charges":[{"gross_charge":703.0,"discounted_cash":386.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Amiodarone Level","code_information":[{"code":"60060300","type":"CDM"},{"code":"301","type":"RC"},{"code":"80299","type":"HCPCS"}],"standard_charges":[{"gross_charge":301.0,"discounted_cash":165.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Amino Acid Blood Quantiative","code_information":[{"code":"60060310","type":"CDM"},{"code":"301","type":"RC"},{"code":"82139","type":"HCPCS"}],"standard_charges":[{"gross_charge":231.0,"discounted_cash":127.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Angiotensin Convert Enzyme Blood","code_information":[{"code":"60060350","type":"CDM"},{"code":"301","type":"RC"},{"code":"82164","type":"HCPCS"}],"standard_charges":[{"gross_charge":238.0,"discounted_cash":130.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Androstenedione","code_information":[{"code":"60060390","type":"CDM"},{"code":"301","type":"RC"},{"code":"82157","type":"HCPCS"}],"standard_charges":[{"gross_charge":477.0,"discounted_cash":262.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Arsenic Blood","code_information":[{"code":"60060420","type":"CDM"},{"code":"301","type":"RC"},{"code":"82175","type":"HCPCS"}],"standard_charges":[{"gross_charge":302.0,"discounted_cash":166.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Beta-2-Microglobulin","code_information":[{"code":"60060430","type":"CDM"},{"code":"301","type":"RC"},{"code":"82232","type":"HCPCS"}],"standard_charges":[{"gross_charge":254.0,"discounted_cash":139.7,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Dnase Antibody B","code_information":[{"code":"60060450","type":"CDM"},{"code":"302","type":"RC"},{"code":"86215","type":"HCPCS"}],"standard_charges":[{"gross_charge":210.0,"discounted_cash":115.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Bile Acids I","code_information":[{"code":"60060461","type":"CDM"},{"code":"301","type":"RC"},{"code":"82239","type":"HCPCS"}],"standard_charges":[{"gross_charge":133.0,"discounted_cash":73.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Cadmium","code_information":[{"code":"60060471","type":"CDM"},{"code":"301","type":"RC"},{"code":"82300","type":"HCPCS"}],"standard_charges":[{"gross_charge":377.0,"discounted_cash":207.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Vitamin D 25-Hydroxy","code_information":[{"code":"60060480","type":"CDM"},{"code":"301","type":"RC"},{"code":"82306","type":"HCPCS"}],"standard_charges":[{"gross_charge":384.0,"discounted_cash":211.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Jo-1 Antibody","code_information":[{"code":"60060520","type":"CDM"},{"code":"302","type":"RC"},{"code":"86235","type":"HCPCS"}],"standard_charges":[{"gross_charge":269.0,"discounted_cash":147.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Jo-1 Antibody I","code_information":[{"code":"60060521","type":"CDM"},{"code":"302","type":"RC"},{"code":"86235","type":"HCPCS"}],"standard_charges":[{"gross_charge":269.0,"discounted_cash":147.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Citric Acid Urine Timed","code_information":[{"code":"60060530","type":"CDM"},{"code":"301","type":"RC"},{"code":"82507","type":"HCPCS"}],"standard_charges":[{"gross_charge":91.0,"discounted_cash":50.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Mitochondrial Antibody Titer Elisa","code_information":[{"code":"60060551","type":"CDM"},{"code":"301","type":"RC"},{"code":"83516","type":"HCPCS"}],"standard_charges":[{"gross_charge":181.0,"discounted_cash":99.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Dna Antibody Double Stranded","code_information":[{"code":"60060570","type":"CDM"},{"code":"302","type":"RC"},{"code":"86225","type":"HCPCS"}],"standard_charges":[{"gross_charge":210.0,"discounted_cash":115.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Cyanide","code_information":[{"code":"60060580","type":"CDM"},{"code":"301","type":"RC"},{"code":"82600","type":"HCPCS"}],"standard_charges":[{"gross_charge":63.0,"discounted_cash":34.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Scl70 Antibody","code_information":[{"code":"60060590","type":"CDM"},{"code":"302","type":"RC"},{"code":"86235","type":"HCPCS"}],"standard_charges":[{"gross_charge":269.0,"discounted_cash":147.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Sm/Rnp Antibody","code_information":[{"code":"60060610","type":"CDM"},{"code":"302","type":"RC"},{"code":"86235","type":"HCPCS"}],"standard_charges":[{"gross_charge":269.0,"discounted_cash":147.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Dhea","code_information":[{"code":"60060640","type":"CDM"},{"code":"301","type":"RC"},{"code":"82626","type":"HCPCS"}],"standard_charges":[{"gross_charge":83.0,"discounted_cash":45.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Noncdm Charge Record","code_information":[{"code":"60060685","type":"CDM"},{"code":"301","type":"RC"},{"code":"82642","type":"HCPCS"}],"standard_charges":[{"gross_charge":70.0,"discounted_cash":38.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Lchg Vitamin D 1 25 Dihydroxy","code_information":[{"code":"60060690","type":"CDM"},{"code":"301","type":"RC"},{"code":"82652","type":"HCPCS"}],"standard_charges":[{"gross_charge":559.0,"discounted_cash":307.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Erythropoietin","code_information":[{"code":"60060710","type":"CDM"},{"code":"301","type":"RC"},{"code":"82668","type":"HCPCS"}],"standard_charges":[{"gross_charge":288.0,"discounted_cash":158.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Ss-A Antibody","code_information":[{"code":"60060730","type":"CDM"},{"code":"302","type":"RC"},{"code":"86235","type":"HCPCS"}],"standard_charges":[{"gross_charge":269.0,"discounted_cash":147.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Fat Qualitative Feces Random","code_information":[{"code":"60060740","type":"CDM"},{"code":"301","type":"RC"},{"code":"82705","type":"HCPCS"}],"standard_charges":[{"gross_charge":76.0,"discounted_cash":41.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Vitamin C","code_information":[{"code":"60060750","type":"CDM"},{"code":"301","type":"RC"},{"code":"82180","type":"HCPCS"}],"standard_charges":[{"gross_charge":33.0,"discounted_cash":18.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Ss-B Antibody","code_information":[{"code":"60060770","type":"CDM"},{"code":"302","type":"RC"},{"code":"86235","type":"HCPCS"}],"standard_charges":[{"gross_charge":269.0,"discounted_cash":147.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Fatty Acids Nonesterified Free","code_information":[{"code":"60060780","type":"CDM"},{"code":"301","type":"RC"},{"code":"82725","type":"HCPCS"}],"standard_charges":[{"gross_charge":61.0,"discounted_cash":33.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Folate Rbc","code_information":[{"code":"60060810","type":"CDM"},{"code":"301","type":"RC"},{"code":"82747","type":"HCPCS"}],"standard_charges":[{"gross_charge":177.0,"discounted_cash":97.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Centromere Antibody Ia","code_information":[{"code":"60060861","type":"CDM"},{"code":"301","type":"RC"},{"code":"83516","type":"HCPCS"}],"standard_charges":[{"gross_charge":160.0,"discounted_cash":88.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Centromere Antibody Quant","code_information":[{"code":"60060862","type":"CDM"},{"code":"301","type":"RC"},{"code":"83520","type":"HCPCS"}],"standard_charges":[{"gross_charge":165.0,"discounted_cash":90.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Glucagon","code_information":[{"code":"60060870","type":"CDM"},{"code":"301","type":"RC"},{"code":"82943","type":"HCPCS"}],"standard_charges":[{"gross_charge":49.0,"discounted_cash":26.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg G6Pd Quantitative","code_information":[{"code":"60060880","type":"CDM"},{"code":"301","type":"RC"},{"code":"82955","type":"HCPCS"}],"standard_charges":[{"gross_charge":153.0,"discounted_cash":84.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Calcitonin","code_information":[{"code":"60060900","type":"CDM"},{"code":"301","type":"RC"},{"code":"82308","type":"HCPCS"}],"standard_charges":[{"gross_charge":419.0,"discounted_cash":230.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Parietal Cell Antibody Screen I","code_information":[{"code":"60060921","type":"CDM"},{"code":"301","type":"RC"},{"code":"83516","type":"HCPCS"}],"standard_charges":[{"gross_charge":187.0,"discounted_cash":102.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Rocky Mt Spotted Fever Antibody Igm","code_information":[{"code":"60060990","type":"CDM"},{"code":"302","type":"RC"},{"code":"86757","type":"HCPCS"}],"standard_charges":[{"gross_charge":58.0,"discounted_cash":31.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Carotene Total","code_information":[{"code":"60061000","type":"CDM"},{"code":"301","type":"RC"},{"code":"82380","type":"HCPCS"}],"standard_charges":[{"gross_charge":31.0,"discounted_cash":17.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Homocysteine Blood Quant","code_information":[{"code":"60061010","type":"CDM"},{"code":"301","type":"RC"},{"code":"83090","type":"HCPCS"}],"standard_charges":[{"gross_charge":262.0,"discounted_cash":144.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Enolase Neuron Specific","code_information":[{"code":"60061040","type":"CDM"},{"code":"302","type":"RC"},{"code":"86316","type":"HCPCS"}],"standard_charges":[{"gross_charge":316.0,"discounted_cash":173.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Catecholamines Urine Fractionated","code_information":[{"code":"60061100","type":"CDM"},{"code":"301","type":"RC"},{"code":"82384","type":"HCPCS"}],"standard_charges":[{"gross_charge":343.0,"discounted_cash":188.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Catecholamines Blood Fract","code_information":[{"code":"60061110","type":"CDM"},{"code":"301","type":"RC"},{"code":"82384","type":"HCPCS"}],"standard_charges":[{"gross_charge":343.0,"discounted_cash":188.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Ceruloplasmin","code_information":[{"code":"60061200","type":"CDM"},{"code":"301","type":"RC"},{"code":"82390","type":"HCPCS"}],"standard_charges":[{"gross_charge":165.0,"discounted_cash":90.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Tryptase","code_information":[{"code":"60061280","type":"CDM"},{"code":"301","type":"RC"},{"code":"83520","type":"HCPCS"}],"standard_charges":[{"gross_charge":159.0,"discounted_cash":87.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Trazodone Level I","code_information":[{"code":"60061411","type":"CDM"},{"code":"301","type":"RC"},{"code":"80338","type":"HCPCS"}],"standard_charges":[{"gross_charge":342.0,"discounted_cash":188.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Clomipramine Level Ii","code_information":[{"code":"60061523","type":"CDM"},{"code":"301","type":"RC"},{"code":"80335","type":"HCPCS"}],"standard_charges":[{"gross_charge":279.0,"discounted_cash":153.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Complement Total","code_information":[{"code":"60061550","type":"CDM"},{"code":"302","type":"RC"},{"code":"86162","type":"HCPCS"}],"standard_charges":[{"gross_charge":259.0,"discounted_cash":142.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Caffeine Level I","code_information":[{"code":"60061571","type":"CDM"},{"code":"301","type":"RC"},{"code":"80155","type":"HCPCS"}],"standard_charges":[{"gross_charge":116.0,"discounted_cash":63.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Copper Blood","code_information":[{"code":"60061600","type":"CDM"},{"code":"301","type":"RC"},{"code":"82525","type":"HCPCS"}],"standard_charges":[{"gross_charge":163.0,"discounted_cash":89.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Clozapine Level Ii","code_information":[{"code":"60061632","type":"CDM"},{"code":"301","type":"RC"},{"code":"80159","type":"HCPCS"}],"standard_charges":[{"gross_charge":148.0,"discounted_cash":81.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Copper Urine","code_information":[{"code":"60061650","type":"CDM"},{"code":"301","type":"RC"},{"code":"82525","type":"HCPCS"}],"standard_charges":[{"gross_charge":159.0,"discounted_cash":87.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Ethylene Glycol","code_information":[{"code":"60061670","type":"CDM"},{"code":"301","type":"RC"},{"code":"82693","type":"HCPCS"}],"standard_charges":[{"gross_charge":241.0,"discounted_cash":132.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Felbamate Level I","code_information":[{"code":"60061681","type":"CDM"},{"code":"301","type":"RC"},{"code":"80339","type":"HCPCS"}],"standard_charges":[{"gross_charge":283.0,"discounted_cash":155.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Coxsackie B","code_information":[{"code":"60061700","type":"CDM"},{"code":"302","type":"RC"},{"code":"86658","type":"HCPCS"}],"standard_charges":[{"gross_charge":33.0,"discounted_cash":18.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Fluoxetine Level I","code_information":[{"code":"60061711","type":"CDM"},{"code":"301","type":"RC"},{"code":"80332","type":"HCPCS"}],"standard_charges":[{"gross_charge":273.0,"discounted_cash":150.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Fluphenazine Level I","code_information":[{"code":"60061721","type":"CDM"},{"code":"301","type":"RC"},{"code":"80342","type":"HCPCS"}],"standard_charges":[{"gross_charge":273.0,"discounted_cash":150.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Ibuprofen Level I","code_information":[{"code":"60061731","type":"CDM"},{"code":"301","type":"RC"},{"code":"80329","type":"HCPCS"}],"standard_charges":[{"gross_charge":63.0,"discounted_cash":34.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Porphyrins Total Blood","code_information":[{"code":"60061950","type":"CDM"},{"code":"301","type":"RC"},{"code":"84311","type":"HCPCS"}],"standard_charges":[{"gross_charge":114.0,"discounted_cash":62.7,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Porphyrins Total Blood I","code_information":[{"code":"60061951","type":"CDM"},{"code":"301","type":"RC"},{"code":"84311","type":"HCPCS"}],"standard_charges":[{"gross_charge":25.0,"discounted_cash":13.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Sertraline Level I","code_information":[{"code":"60061961","type":"CDM"},{"code":"301","type":"RC"},{"code":"80332","type":"HCPCS"}],"standard_charges":[{"gross_charge":343.0,"discounted_cash":188.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Mycophenolic Acid Ii","code_information":[{"code":"60061982","type":"CDM"},{"code":"301","type":"RC"},{"code":"80180","type":"HCPCS"}],"standard_charges":[{"gross_charge":244.0,"discounted_cash":134.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Striated Muscle Ab Iv","code_information":[{"code":"60062032","type":"CDM"},{"code":"301","type":"RC"},{"code":"83520","type":"HCPCS"}],"standard_charges":[{"gross_charge":204.0,"discounted_cash":112.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Purkinje Cell Antibody Titer Csf","code_information":[{"code":"60062034","type":"CDM"},{"code":"302","type":"RC"},{"code":"86256","type":"HCPCS"}],"standard_charges":[{"gross_charge":110.0,"discounted_cash":60.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Striated Muscle Ab I","code_information":[{"code":"60062041","type":"CDM"},{"code":"302","type":"RC"},{"code":"86255","type":"HCPCS"}],"standard_charges":[{"gross_charge":124.0,"discounted_cash":68.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Histone Antibody","code_information":[{"code":"60062060","type":"CDM"},{"code":"301","type":"RC"},{"code":"83516","type":"HCPCS"}],"standard_charges":[{"gross_charge":294.0,"discounted_cash":161.7,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Herpes Simplex 2 Antibody Igg","code_information":[{"code":"60062150","type":"CDM"},{"code":"302","type":"RC"},{"code":"86696","type":"HCPCS"}],"standard_charges":[{"gross_charge":459.0,"discounted_cash":252.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Alpha Subunit I","code_information":[{"code":"60062171","type":"CDM"},{"code":"300","type":"RC"},{"code":"83520","type":"HCPCS"}],"standard_charges":[{"gross_charge":57.0,"discounted_cash":31.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Alpha Subunit Ii","code_information":[{"code":"60062172","type":"CDM"},{"code":"301","type":"RC"},{"code":"82397","type":"HCPCS"}],"standard_charges":[{"gross_charge":226.0,"discounted_cash":124.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Sex Hormone Binding Globulin","code_information":[{"code":"60062240","type":"CDM"},{"code":"301","type":"RC"},{"code":"84270","type":"HCPCS"}],"standard_charges":[{"gross_charge":381.0,"discounted_cash":209.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Microalbumin Urine Timed Quant","code_information":[{"code":"60062260","type":"CDM"},{"code":"301","type":"RC"},{"code":"82043","type":"HCPCS"}],"standard_charges":[{"gross_charge":80.0,"discounted_cash":44.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Alpha Fetoprotein Blood Maternal","code_information":[{"code":"60062270","type":"CDM"},{"code":"301","type":"RC"},{"code":"82105","type":"HCPCS"}],"standard_charges":[{"gross_charge":269.0,"discounted_cash":147.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Cholesterol Fluid","code_information":[{"code":"60062320","type":"CDM"},{"code":"301","type":"RC"},{"code":"82465","type":"HCPCS"}],"standard_charges":[{"gross_charge":81.0,"discounted_cash":44.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Estrogen Fractionate","code_information":[{"code":"60062430","type":"CDM"},{"code":"301","type":"RC"},{"code":"82671","type":"HCPCS"}],"standard_charges":[{"gross_charge":106.0,"discounted_cash":58.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Fsh","code_information":[{"code":"60062600","type":"CDM"},{"code":"301","type":"RC"},{"code":"83001","type":"HCPCS"}],"standard_charges":[{"gross_charge":195.0,"discounted_cash":107.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Fta Antibody","code_information":[{"code":"60062650","type":"CDM"},{"code":"302","type":"RC"},{"code":"86780","type":"HCPCS"}],"standard_charges":[{"gross_charge":385.0,"discounted_cash":211.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Gastrin","code_information":[{"code":"60062700","type":"CDM"},{"code":"301","type":"RC"},{"code":"82941","type":"HCPCS"}],"standard_charges":[{"gross_charge":276.0,"discounted_cash":151.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Growth Hormone Human","code_information":[{"code":"60062750","type":"CDM"},{"code":"301","type":"RC"},{"code":"83003","type":"HCPCS"}],"standard_charges":[{"gross_charge":225.0,"discounted_cash":123.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Fructosamine","code_information":[{"code":"60062840","type":"CDM"},{"code":"301","type":"RC"},{"code":"82985","type":"HCPCS"}],"standard_charges":[{"gross_charge":183.0,"discounted_cash":100.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Hemoglobin A1C","code_information":[{"code":"60062850","type":"CDM"},{"code":"301","type":"RC"},{"code":"83036","type":"HCPCS"}],"standard_charges":[{"gross_charge":157.0,"discounted_cash":86.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Apt Fetal Hemoglobin","code_information":[{"code":"60062930","type":"CDM"},{"code":"301","type":"RC"},{"code":"83033","type":"HCPCS"}],"standard_charges":[{"gross_charge":26.0,"discounted_cash":14.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Epstein-Barr Virus Antibody To Early Ag","code_information":[{"code":"60062940","type":"CDM"},{"code":"302","type":"RC"},{"code":"86663","type":"HCPCS"}],"standard_charges":[{"gross_charge":202.0,"discounted_cash":111.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Hemoglobin Plasma","code_information":[{"code":"60062950","type":"CDM"},{"code":"301","type":"RC"},{"code":"83051","type":"HCPCS"}],"standard_charges":[{"gross_charge":24.0,"discounted_cash":13.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Epstein-Barr Virus Antibody Nuclear Ag","code_information":[{"code":"60062980","type":"CDM"},{"code":"302","type":"RC"},{"code":"86664","type":"HCPCS"}],"standard_charges":[{"gross_charge":234.0,"discounted_cash":128.7,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Epstein-Barr Virus Antibody Vca","code_information":[{"code":"60062990","type":"CDM"},{"code":"302","type":"RC"},{"code":"86665","type":"HCPCS"}],"standard_charges":[{"gross_charge":183.0,"discounted_cash":100.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Entamoeba Histolytica Antibody","code_information":[{"code":"60063020","type":"CDM"},{"code":"302","type":"RC"},{"code":"86753","type":"HCPCS"}],"standard_charges":[{"gross_charge":71.0,"discounted_cash":39.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Neutrophil Oxidase Burst Assay (Cell)","code_information":[{"code":"60063050","type":"CDM"},{"code":"302","type":"RC"},{"code":"86352","type":"HCPCS"}],"standard_charges":[{"gross_charge":408.0,"discounted_cash":224.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Heterophile Antibody Titer","code_information":[{"code":"60063090","type":"CDM"},{"code":"302","type":"RC"},{"code":"86309","type":"HCPCS"}],"standard_charges":[{"gross_charge":20.0,"discounted_cash":11.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Hydroxyprogesterone 17-","code_information":[{"code":"60063210","type":"CDM"},{"code":"301","type":"RC"},{"code":"83498","type":"HCPCS"}],"standard_charges":[{"gross_charge":443.0,"discounted_cash":243.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Histoplasma Antibody","code_information":[{"code":"60063250","type":"CDM"},{"code":"302","type":"RC"},{"code":"86698","type":"HCPCS"}],"standard_charges":[{"gross_charge":78.0,"discounted_cash":42.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Allergen Latex Ige","code_information":[{"code":"60063260","type":"CDM"},{"code":"302","type":"RC"},{"code":"86003","type":"HCPCS"}],"standard_charges":[{"gross_charge":48.0,"discounted_cash":26.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Histoplasma Antigen","code_information":[{"code":"60063330","type":"CDM"},{"code":"306","type":"RC"},{"code":"87385","type":"HCPCS"}],"standard_charges":[{"gross_charge":269.0,"discounted_cash":147.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Histoplasma Antigen I","code_information":[{"code":"60063331","type":"CDM"},{"code":"306","type":"RC"},{"code":"87385","type":"HCPCS"}],"standard_charges":[{"gross_charge":269.0,"discounted_cash":147.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Hla Typing B27","code_information":[{"code":"60063350","type":"CDM"},{"code":"302","type":"RC"},{"code":"86812","type":"HCPCS"}],"standard_charges":[{"gross_charge":77.0,"discounted_cash":42.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Somatomedin C (Igf-1)","code_information":[{"code":"60063360","type":"CDM"},{"code":"301","type":"RC"},{"code":"84305","type":"HCPCS"}],"standard_charges":[{"gross_charge":279.0,"discounted_cash":153.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Hydroxybutyrate Beta I","code_information":[{"code":"60063391","type":"CDM"},{"code":"301","type":"RC"},{"code":"82010","type":"HCPCS"}],"standard_charges":[{"gross_charge":80.0,"discounted_cash":44.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Flecainide Level","code_information":[{"code":"60063420","type":"CDM"},{"code":"301","type":"RC"},{"code":"80299","type":"HCPCS"}],"standard_charges":[{"gross_charge":303.0,"discounted_cash":166.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Gm1 Auto Antibody","code_information":[{"code":"60063430","type":"CDM"},{"code":"301","type":"RC"},{"code":"83516","type":"HCPCS"}],"standard_charges":[{"gross_charge":159.0,"discounted_cash":87.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Oxalate Urine Timed","code_information":[{"code":"60063450","type":"CDM"},{"code":"301","type":"RC"},{"code":"83945","type":"HCPCS"}],"standard_charges":[{"gross_charge":47.0,"discounted_cash":25.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Legionella Antigen Urine","code_information":[{"code":"60063510","type":"CDM"},{"code":"306","type":"RC"},{"code":"87449","type":"HCPCS"}],"standard_charges":[{"gross_charge":251.0,"discounted_cash":138.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Myeloperoxidase Antibody I","code_information":[{"code":"60063541","type":"CDM"},{"code":"301","type":"RC"},{"code":"83516","type":"HCPCS"}],"standard_charges":[{"gross_charge":151.0,"discounted_cash":83.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Pth Related Peptide I","code_information":[{"code":"60063571","type":"CDM"},{"code":"301","type":"RC"},{"code":"82542","type":"HCPCS"}],"standard_charges":[{"gross_charge":223.0,"discounted_cash":122.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Insulin Level","code_information":[{"code":"60063600","type":"CDM"},{"code":"301","type":"RC"},{"code":"83525","type":"HCPCS"}],"standard_charges":[{"gross_charge":182.0,"discounted_cash":100.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Myoglobin Urine Quantitative","code_information":[{"code":"60063640","type":"CDM"},{"code":"301","type":"RC"},{"code":"83874","type":"HCPCS"}],"standard_charges":[{"gross_charge":182.0,"discounted_cash":100.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Iga Csf","code_information":[{"code":"60063660","type":"CDM"},{"code":"301","type":"RC"},{"code":"82784","type":"HCPCS"}],"standard_charges":[{"gross_charge":152.0,"discounted_cash":83.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Kappa Light Chains","code_information":[{"code":"60063680","type":"CDM"},{"code":"301","type":"RC"},{"code":"83883","type":"HCPCS"}],"standard_charges":[{"gross_charge":212.0,"discounted_cash":116.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Lambda Light Chains","code_information":[{"code":"60063720","type":"CDM"},{"code":"301","type":"RC"},{"code":"83883","type":"HCPCS"}],"standard_charges":[{"gross_charge":212.0,"discounted_cash":116.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Parvovirus Pcr I","code_information":[{"code":"60063741","type":"CDM"},{"code":"306","type":"RC"},{"code":"87799","type":"HCPCS"}],"standard_charges":[{"gross_charge":494.0,"discounted_cash":271.7,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Lead Blood","code_information":[{"code":"60063800","type":"CDM"},{"code":"301","type":"RC"},{"code":"83655","type":"HCPCS"}],"standard_charges":[{"gross_charge":124.0,"discounted_cash":68.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Noncdm Charge Record","code_information":[{"code":"60063811","type":"CDM"},{"code":"301","type":"RC"},{"code":"83520","type":"HCPCS"}],"standard_charges":[{"gross_charge":117.0,"discounted_cash":64.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Lchg Carnitine Blood","code_information":[{"code":"60063820","type":"CDM"},{"code":"301","type":"RC"},{"code":"82379","type":"HCPCS"}],"standard_charges":[{"gross_charge":231.0,"discounted_cash":127.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Lead Urine","code_information":[{"code":"60063850","type":"CDM"},{"code":"301","type":"RC"},{"code":"83655","type":"HCPCS"}],"standard_charges":[{"gross_charge":128.0,"discounted_cash":70.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg T3 Free","code_information":[{"code":"60063920","type":"CDM"},{"code":"301","type":"RC"},{"code":"84481","type":"HCPCS"}],"standard_charges":[{"gross_charge":194.0,"discounted_cash":106.7,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Vasoactive Intestine Peptide","code_information":[{"code":"60063960","type":"CDM"},{"code":"301","type":"RC"},{"code":"84586","type":"HCPCS"}],"standard_charges":[{"gross_charge":191.0,"discounted_cash":105.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Zinc Urine","code_information":[{"code":"60063970","type":"CDM"},{"code":"301","type":"RC"},{"code":"84630","type":"HCPCS"}],"standard_charges":[{"gross_charge":164.0,"discounted_cash":90.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Lipoprotein Electrophoresis","code_information":[{"code":"60064000","type":"CDM"},{"code":"301","type":"RC"},{"code":"83700","type":"HCPCS"}],"standard_charges":[{"gross_charge":210.0,"discounted_cash":115.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Ca 125 Blood","code_information":[{"code":"60064040","type":"CDM"},{"code":"302","type":"RC"},{"code":"86304","type":"HCPCS"}],"standard_charges":[{"gross_charge":303.0,"discounted_cash":166.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Lh","code_information":[{"code":"60064050","type":"CDM"},{"code":"301","type":"RC"},{"code":"83002","type":"HCPCS"}],"standard_charges":[{"gross_charge":278.0,"discounted_cash":152.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Ca 15-3","code_information":[{"code":"60064060","type":"CDM"},{"code":"302","type":"RC"},{"code":"86300","type":"HCPCS"}],"standard_charges":[{"gross_charge":298.0,"discounted_cash":163.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Ca 19-9","code_information":[{"code":"60064070","type":"CDM"},{"code":"302","type":"RC"},{"code":"86301","type":"HCPCS"}],"standard_charges":[{"gross_charge":306.0,"discounted_cash":168.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Noncdm Charge Record","code_information":[{"code":"60064090","type":"CDM"},{"code":"302","type":"RC"},{"code":"86317","type":"HCPCS"}],"standard_charges":[{"gross_charge":103.0,"discounted_cash":56.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Lchg Mercury Urine","code_information":[{"code":"60064100","type":"CDM"},{"code":"301","type":"RC"},{"code":"83825","type":"HCPCS"}],"standard_charges":[{"gross_charge":266.0,"discounted_cash":146.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Mercury Blood","code_information":[{"code":"60064110","type":"CDM"},{"code":"301","type":"RC"},{"code":"83825","type":"HCPCS"}],"standard_charges":[{"gross_charge":264.0,"discounted_cash":145.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Metanephrines Urine","code_information":[{"code":"60064150","type":"CDM"},{"code":"301","type":"RC"},{"code":"83835","type":"HCPCS"}],"standard_charges":[{"gross_charge":271.0,"discounted_cash":149.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Metanephrines Urine Frac","code_information":[{"code":"60064160","type":"CDM"},{"code":"301","type":"RC"},{"code":"83835","type":"HCPCS"}],"standard_charges":[{"gross_charge":253.0,"discounted_cash":139.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Cysticercosis Antibodies","code_information":[{"code":"60064210","type":"CDM"},{"code":"302","type":"RC"},{"code":"86682","type":"HCPCS"}],"standard_charges":[{"gross_charge":117.0,"discounted_cash":64.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Aspergillus Antibody","code_information":[{"code":"60064220","type":"CDM"},{"code":"302","type":"RC"},{"code":"86606","type":"HCPCS"}],"standard_charges":[{"gross_charge":87.0,"discounted_cash":47.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Aspergillus Antibody I","code_information":[{"code":"60064221","type":"CDM"},{"code":"302","type":"RC"},{"code":"86606","type":"HCPCS"}],"standard_charges":[{"gross_charge":84.0,"discounted_cash":46.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Igg Subclasses","code_information":[{"code":"60064240","type":"CDM"},{"code":"301","type":"RC"},{"code":"82787","type":"HCPCS"}],"standard_charges":[{"gross_charge":148.0,"discounted_cash":81.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Ife Blood","code_information":[{"code":"60064290","type":"CDM"},{"code":"302","type":"RC"},{"code":"86334","type":"HCPCS"}],"standard_charges":[{"gross_charge":244.0,"discounted_cash":134.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Noncdm Charge Record","code_information":[{"code":"60064291","type":"CDM"},{"code":"301","type":"RC"},{"code":"84160","type":"HCPCS"}],"standard_charges":[{"gross_charge":45.0,"discounted_cash":24.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Lchg Ife Blood Ii","code_information":[{"code":"60064292","type":"CDM"},{"code":"302","type":"RC"},{"code":"86334","type":"HCPCS"}],"standard_charges":[{"gross_charge":244.0,"discounted_cash":134.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Myelin Basic Protein Csf","code_information":[{"code":"60064300","type":"CDM"},{"code":"301","type":"RC"},{"code":"83873","type":"HCPCS"}],"standard_charges":[{"gross_charge":254.0,"discounted_cash":139.7,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Ife Urine","code_information":[{"code":"60064310","type":"CDM"},{"code":"302","type":"RC"},{"code":"86335","type":"HCPCS"}],"standard_charges":[{"gross_charge":339.0,"discounted_cash":186.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Intrinsic Factor Ab","code_information":[{"code":"60064340","type":"CDM"},{"code":"302","type":"RC"},{"code":"86340","type":"HCPCS"}],"standard_charges":[{"gross_charge":152.0,"discounted_cash":83.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Myoglobin Blood","code_information":[{"code":"60064350","type":"CDM"},{"code":"301","type":"RC"},{"code":"83874","type":"HCPCS"}],"standard_charges":[{"gross_charge":205.0,"discounted_cash":112.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Nucleotidase 5-","code_information":[{"code":"60064400","type":"CDM"},{"code":"301","type":"RC"},{"code":"83915","type":"HCPCS"}],"standard_charges":[{"gross_charge":36.0,"discounted_cash":19.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Rubella Antibody Igg","code_information":[{"code":"60064510","type":"CDM"},{"code":"302","type":"RC"},{"code":"86762","type":"HCPCS"}],"standard_charges":[{"gross_charge":218.0,"discounted_cash":119.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Porphobilinogen Urine Quantitative","code_information":[{"code":"60064560","type":"CDM"},{"code":"301","type":"RC"},{"code":"84110","type":"HCPCS"}],"standard_charges":[{"gross_charge":28.0,"discounted_cash":15.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Porphobilinogen Blood","code_information":[{"code":"60064570","type":"CDM"},{"code":"301","type":"RC"},{"code":"82657","type":"HCPCS"}],"standard_charges":[{"gross_charge":63.0,"discounted_cash":34.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Porphyrins Urine Timed Fractionation","code_information":[{"code":"60064610","type":"CDM"},{"code":"301","type":"RC"},{"code":"84120","type":"HCPCS"}],"standard_charges":[{"gross_charge":235.0,"discounted_cash":129.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Allergen Individual","code_information":[{"code":"60064680","type":"CDM"},{"code":"302","type":"RC"},{"code":"86003","type":"HCPCS"}],"standard_charges":[{"gross_charge":48.0,"discounted_cash":26.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Prolactin","code_information":[{"code":"60064700","type":"CDM"},{"code":"301","type":"RC"},{"code":"84146","type":"HCPCS"}],"standard_charges":[{"gross_charge":318.0,"discounted_cash":174.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Prolactin I","code_information":[{"code":"60064701","type":"CDM"},{"code":"301","type":"RC"},{"code":"84146","type":"HCPCS"}],"standard_charges":[{"gross_charge":318.0,"discounted_cash":174.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Prostate Specific Antigen Diag","code_information":[{"code":"60064750","type":"CDM"},{"code":"301","type":"RC"},{"code":"84153","type":"HCPCS"}],"standard_charges":[{"gross_charge":218.0,"discounted_cash":119.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Musk Antibody","code_information":[{"code":"60064810","type":"CDM"},{"code":"301","type":"RC"},{"code":"83519","type":"HCPCS"}],"standard_charges":[{"gross_charge":175.0,"discounted_cash":96.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Hiv-2 Antibody","code_information":[{"code":"60064840","type":"CDM"},{"code":"302","type":"RC"},{"code":"86702","type":"HCPCS"}],"standard_charges":[{"gross_charge":42.0,"discounted_cash":23.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Legionella Antibody","code_information":[{"code":"60064880","type":"CDM"},{"code":"302","type":"RC"},{"code":"86713","type":"HCPCS"}],"standard_charges":[{"gross_charge":46.0,"discounted_cash":25.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Leptospira Antibody","code_information":[{"code":"60064890","type":"CDM"},{"code":"302","type":"RC"},{"code":"86720","type":"HCPCS"}],"standard_charges":[{"gross_charge":87.0,"discounted_cash":47.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Renin","code_information":[{"code":"60064900","type":"CDM"},{"code":"301","type":"RC"},{"code":"84244","type":"HCPCS"}],"standard_charges":[{"gross_charge":345.0,"discounted_cash":189.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Oligoclonal Bands Csf I","code_information":[{"code":"60064931","type":"CDM"},{"code":"301","type":"RC"},{"code":"83916","type":"HCPCS"}],"standard_charges":[{"gross_charge":227.0,"discounted_cash":124.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Serotonin","code_information":[{"code":"60065000","type":"CDM"},{"code":"301","type":"RC"},{"code":"84260","type":"HCPCS"}],"standard_charges":[{"gross_charge":450.0,"discounted_cash":247.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Adenovirus Antibody Titer Blood","code_information":[{"code":"60065020","type":"CDM"},{"code":"302","type":"RC"},{"code":"86603","type":"HCPCS"}],"standard_charges":[{"gross_charge":40.0,"discounted_cash":22.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Ehrlichia Antibody","code_information":[{"code":"60065040","type":"CDM"},{"code":"302","type":"RC"},{"code":"86666","type":"HCPCS"}],"standard_charges":[{"gross_charge":202.0,"discounted_cash":111.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Stone Analysis Quant Infrared Spec","code_information":[{"code":"60065051","type":"CDM"},{"code":"301","type":"RC"},{"code":"82365","type":"HCPCS"}],"standard_charges":[{"gross_charge":44.0,"discounted_cash":24.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Blastomyces Antibody","code_information":[{"code":"60065060","type":"CDM"},{"code":"302","type":"RC"},{"code":"86612","type":"HCPCS"}],"standard_charges":[{"gross_charge":36.0,"discounted_cash":19.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Noncdm Charge Record","code_information":[{"code":"60065080","type":"CDM"},{"code":"302","type":"RC"},{"code":"86790","type":"HCPCS"}],"standard_charges":[{"gross_charge":68.0,"discounted_cash":37.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Lchg Hepatitis E Antibody Igm","code_information":[{"code":"60065100","type":"CDM"},{"code":"302","type":"RC"},{"code":"86790","type":"HCPCS"}],"standard_charges":[{"gross_charge":22.0,"discounted_cash":12.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Pth Intact","code_information":[{"code":"60065140","type":"CDM"},{"code":"301","type":"RC"},{"code":"83970","type":"HCPCS"}],"standard_charges":[{"gross_charge":1507.0,"discounted_cash":828.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Lyme Disease Ab Igm","code_information":[{"code":"60065160","type":"CDM"},{"code":"302","type":"RC"},{"code":"86618","type":"HCPCS"}],"standard_charges":[{"gross_charge":247.0,"discounted_cash":135.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Testosterone Total","code_information":[{"code":"60065200","type":"CDM"},{"code":"301","type":"RC"},{"code":"84403","type":"HCPCS"}],"standard_charges":[{"gross_charge":397.0,"discounted_cash":218.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Proinsulin","code_information":[{"code":"60065270","type":"CDM"},{"code":"301","type":"RC"},{"code":"84206","type":"HCPCS"}],"standard_charges":[{"gross_charge":285.0,"discounted_cash":156.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Vitamin B6","code_information":[{"code":"60065280","type":"CDM"},{"code":"301","type":"RC"},{"code":"84207","type":"HCPCS"}],"standard_charges":[{"gross_charge":439.0,"discounted_cash":241.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Pyruvate Blood","code_information":[{"code":"60065290","type":"CDM"},{"code":"301","type":"RC"},{"code":"84210","type":"HCPCS"}],"standard_charges":[{"gross_charge":173.0,"discounted_cash":95.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Brucella Antibody","code_information":[{"code":"60065330","type":"CDM"},{"code":"302","type":"RC"},{"code":"86622","type":"HCPCS"}],"standard_charges":[{"gross_charge":27.0,"discounted_cash":14.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Candida Antibody","code_information":[{"code":"60065340","type":"CDM"},{"code":"302","type":"RC"},{"code":"86628","type":"HCPCS"}],"standard_charges":[{"gross_charge":74.0,"discounted_cash":40.7,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Tsi","code_information":[{"code":"60065380","type":"CDM"},{"code":"301","type":"RC"},{"code":"84445","type":"HCPCS"}],"standard_charges":[{"gross_charge":350.0,"discounted_cash":192.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Vitamin B2","code_information":[{"code":"60065390","type":"CDM"},{"code":"301","type":"RC"},{"code":"84252","type":"HCPCS"}],"standard_charges":[{"gross_charge":67.0,"discounted_cash":36.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Selenium","code_information":[{"code":"60065410","type":"CDM"},{"code":"301","type":"RC"},{"code":"84255","type":"HCPCS"}],"standard_charges":[{"gross_charge":86.0,"discounted_cash":47.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Testosterone Free","code_information":[{"code":"60065420","type":"CDM"},{"code":"301","type":"RC"},{"code":"84402","type":"HCPCS"}],"standard_charges":[{"gross_charge":361.0,"discounted_cash":198.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Testosterone Free I","code_information":[{"code":"60065421","type":"CDM"},{"code":"301","type":"RC"},{"code":"84402","type":"HCPCS"}],"standard_charges":[{"gross_charge":361.0,"discounted_cash":198.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Vitamin B1","code_information":[{"code":"60065440","type":"CDM"},{"code":"301","type":"RC"},{"code":"84425","type":"HCPCS"}],"standard_charges":[{"gross_charge":332.0,"discounted_cash":182.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Toxoplasma Antibody Igg","code_information":[{"code":"60065450","type":"CDM"},{"code":"302","type":"RC"},{"code":"86777","type":"HCPCS"}],"standard_charges":[{"gross_charge":195.0,"discounted_cash":107.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Vitamin E","code_information":[{"code":"60065460","type":"CDM"},{"code":"301","type":"RC"},{"code":"84446","type":"HCPCS"}],"standard_charges":[{"gross_charge":221.0,"discounted_cash":121.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg T3 Reverse","code_information":[{"code":"60065470","type":"CDM"},{"code":"301","type":"RC"},{"code":"84482","type":"HCPCS"}],"standard_charges":[{"gross_charge":51.0,"discounted_cash":28.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Transferrin","code_information":[{"code":"60065500","type":"CDM"},{"code":"301","type":"RC"},{"code":"84466","type":"HCPCS"}],"standard_charges":[{"gross_charge":186.0,"discounted_cash":102.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Chlamydia Antibody Igg","code_information":[{"code":"60065510","type":"CDM"},{"code":"302","type":"RC"},{"code":"86631","type":"HCPCS"}],"standard_charges":[{"gross_charge":108.0,"discounted_cash":59.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Chlamydia Antibody Igm","code_information":[{"code":"60065570","type":"CDM"},{"code":"302","type":"RC"},{"code":"86632","type":"HCPCS"}],"standard_charges":[{"gross_charge":64.0,"discounted_cash":35.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Vasopressin","code_information":[{"code":"60065580","type":"CDM"},{"code":"301","type":"RC"},{"code":"84588","type":"HCPCS"}],"standard_charges":[{"gross_charge":296.0,"discounted_cash":162.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Vitamin A","code_information":[{"code":"60065590","type":"CDM"},{"code":"301","type":"RC"},{"code":"84590","type":"HCPCS"}],"standard_charges":[{"gross_charge":187.0,"discounted_cash":102.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Coccidioides Antibody Id","code_information":[{"code":"60065600","type":"CDM"},{"code":"302","type":"RC"},{"code":"86635","type":"HCPCS"}],"standard_charges":[{"gross_charge":38.0,"discounted_cash":20.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Russell Viper Venom Diluted","code_information":[{"code":"60065610","type":"CDM"},{"code":"305","type":"RC"},{"code":"85613","type":"HCPCS"}],"standard_charges":[{"gross_charge":145.0,"discounted_cash":79.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Russell Viper Venom Diluted I","code_information":[{"code":"60065611","type":"CDM"},{"code":"305","type":"RC"},{"code":"85613","type":"HCPCS"}],"standard_charges":[{"gross_charge":145.0,"discounted_cash":79.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Alcohol Isopropyl Blood Iv","code_information":[{"code":"60065634","type":"CDM"},{"code":"301","type":"RC"},{"code":"80320","type":"HCPCS"}],"standard_charges":[{"gross_charge":354.0,"discounted_cash":194.7,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Zinc Blood","code_information":[{"code":"60065650","type":"CDM"},{"code":"301","type":"RC"},{"code":"84630","type":"HCPCS"}],"standard_charges":[{"gross_charge":145.0,"discounted_cash":79.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg C-Peptide","code_information":[{"code":"60065670","type":"CDM"},{"code":"301","type":"RC"},{"code":"84681","type":"HCPCS"}],"standard_charges":[{"gross_charge":80.0,"discounted_cash":44.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Rocky Mt Spotted Fever Antibody Igg","code_information":[{"code":"60065700","type":"CDM"},{"code":"302","type":"RC"},{"code":"86757","type":"HCPCS"}],"standard_charges":[{"gross_charge":58.0,"discounted_cash":31.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Heparin Assay","code_information":[{"code":"60065800","type":"CDM"},{"code":"305","type":"RC"},{"code":"85520","type":"HCPCS"}],"standard_charges":[{"gross_charge":137.0,"discounted_cash":75.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Factor Ii Assay I","code_information":[{"code":"60065801","type":"CDM"},{"code":"305","type":"RC"},{"code":"85210","type":"HCPCS"}],"standard_charges":[{"gross_charge":96.0,"discounted_cash":52.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Factor Ii Assay","code_information":[{"code":"60065810","type":"CDM"},{"code":"305","type":"RC"},{"code":"85210","type":"HCPCS"}],"standard_charges":[{"gross_charge":96.0,"discounted_cash":52.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Factor V Assay","code_information":[{"code":"60065820","type":"CDM"},{"code":"305","type":"RC"},{"code":"85220","type":"HCPCS"}],"standard_charges":[{"gross_charge":276.0,"discounted_cash":151.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Factor V Assay Ii","code_information":[{"code":"60065821","type":"CDM"},{"code":"305","type":"RC"},{"code":"85220","type":"HCPCS"}],"standard_charges":[{"gross_charge":276.0,"discounted_cash":151.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Factor Vii Assay","code_information":[{"code":"60065830","type":"CDM"},{"code":"305","type":"RC"},{"code":"85230","type":"HCPCS"}],"standard_charges":[{"gross_charge":285.0,"discounted_cash":156.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Factor Vii Assay Ii","code_information":[{"code":"60065831","type":"CDM"},{"code":"305","type":"RC"},{"code":"85230","type":"HCPCS"}],"standard_charges":[{"gross_charge":285.0,"discounted_cash":156.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Factor Viii Ristocetin Cofactor","code_information":[{"code":"60065840","type":"CDM"},{"code":"305","type":"RC"},{"code":"85245","type":"HCPCS"}],"standard_charges":[{"gross_charge":353.0,"discounted_cash":194.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Factor Viii Vw Antigen","code_information":[{"code":"60065850","type":"CDM"},{"code":"305","type":"RC"},{"code":"85246","type":"HCPCS"}],"standard_charges":[{"gross_charge":396.0,"discounted_cash":217.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Factor Viii Vw Antigen I","code_information":[{"code":"60065851","type":"CDM"},{"code":"305","type":"RC"},{"code":"85246","type":"HCPCS"}],"standard_charges":[{"gross_charge":342.0,"discounted_cash":188.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Factor Viii Multimeric","code_information":[{"code":"60065860","type":"CDM"},{"code":"305","type":"RC"},{"code":"85247","type":"HCPCS"}],"standard_charges":[{"gross_charge":364.0,"discounted_cash":200.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Factor X Assay","code_information":[{"code":"60065870","type":"CDM"},{"code":"305","type":"RC"},{"code":"85260","type":"HCPCS"}],"standard_charges":[{"gross_charge":59.0,"discounted_cash":32.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Factor X Assay I","code_information":[{"code":"60065871","type":"CDM"},{"code":"305","type":"RC"},{"code":"85260","type":"HCPCS"}],"standard_charges":[{"gross_charge":59.0,"discounted_cash":32.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Factor Xi Assay","code_information":[{"code":"60065880","type":"CDM"},{"code":"305","type":"RC"},{"code":"85270","type":"HCPCS"}],"standard_charges":[{"gross_charge":285.0,"discounted_cash":156.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Factor Xi Assay I","code_information":[{"code":"60065881","type":"CDM"},{"code":"305","type":"RC"},{"code":"85270","type":"HCPCS"}],"standard_charges":[{"gross_charge":285.0,"discounted_cash":156.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Factor Xii Assay","code_information":[{"code":"60065890","type":"CDM"},{"code":"305","type":"RC"},{"code":"85280","type":"HCPCS"}],"standard_charges":[{"gross_charge":308.0,"discounted_cash":169.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Factor Xii Assay I","code_information":[{"code":"60065891","type":"CDM"},{"code":"305","type":"RC"},{"code":"85280","type":"HCPCS"}],"standard_charges":[{"gross_charge":308.0,"discounted_cash":169.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Factor Xiii Screen Solubility","code_information":[{"code":"60065900","type":"CDM"},{"code":"305","type":"RC"},{"code":"85291","type":"HCPCS"}],"standard_charges":[{"gross_charge":29.0,"discounted_cash":15.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Antithrombin Iii Antigen","code_information":[{"code":"60065910","type":"CDM"},{"code":"305","type":"RC"},{"code":"85301","type":"HCPCS"}],"standard_charges":[{"gross_charge":177.0,"discounted_cash":97.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Antithrombin Iii Antigen I","code_information":[{"code":"60065911","type":"CDM"},{"code":"305","type":"RC"},{"code":"85301","type":"HCPCS"}],"standard_charges":[{"gross_charge":177.0,"discounted_cash":97.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Protein C Antigen","code_information":[{"code":"60065920","type":"CDM"},{"code":"305","type":"RC"},{"code":"85302","type":"HCPCS"}],"standard_charges":[{"gross_charge":189.0,"discounted_cash":103.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Protein C Antigen I","code_information":[{"code":"60065921","type":"CDM"},{"code":"305","type":"RC"},{"code":"85302","type":"HCPCS"}],"standard_charges":[{"gross_charge":189.0,"discounted_cash":103.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Protein C Activity","code_information":[{"code":"60065930","type":"CDM"},{"code":"305","type":"RC"},{"code":"85303","type":"HCPCS"}],"standard_charges":[{"gross_charge":164.0,"discounted_cash":90.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Protein C Activity I","code_information":[{"code":"60065931","type":"CDM"},{"code":"305","type":"RC"},{"code":"85303","type":"HCPCS"}],"standard_charges":[{"gross_charge":216.0,"discounted_cash":118.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Protein S Total","code_information":[{"code":"60065940","type":"CDM"},{"code":"305","type":"RC"},{"code":"85305","type":"HCPCS"}],"standard_charges":[{"gross_charge":184.0,"discounted_cash":101.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Protein S Total I","code_information":[{"code":"60065941","type":"CDM"},{"code":"305","type":"RC"},{"code":"85305","type":"HCPCS"}],"standard_charges":[{"gross_charge":184.0,"discounted_cash":101.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Q Fever Antibody","code_information":[{"code":"60065950","type":"CDM"},{"code":"302","type":"RC"},{"code":"86638","type":"HCPCS"}],"standard_charges":[{"gross_charge":37.0,"discounted_cash":20.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Protein S Free","code_information":[{"code":"60065960","type":"CDM"},{"code":"305","type":"RC"},{"code":"85306","type":"HCPCS"}],"standard_charges":[{"gross_charge":170.0,"discounted_cash":93.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Protein S Free I","code_information":[{"code":"60065961","type":"CDM"},{"code":"305","type":"RC"},{"code":"85306","type":"HCPCS"}],"standard_charges":[{"gross_charge":170.0,"discounted_cash":93.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Coagulopathy Interp+Report Pc","code_information":[{"code":"60065990","type":"CDM"},{"code":"971","type":"RC"},{"code":"85390","type":"HCPCS"}],"standard_charges":[{"gross_charge":47.0,"discounted_cash":25.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Encephalitis East Equine Antibody","code_information":[{"code":"60066010","type":"CDM"},{"code":"302","type":"RC"},{"code":"86652","type":"HCPCS"}],"standard_charges":[{"gross_charge":62.0,"discounted_cash":34.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Encephalitis St Louis Antibody","code_information":[{"code":"60066020","type":"CDM"},{"code":"302","type":"RC"},{"code":"86653","type":"HCPCS"}],"standard_charges":[{"gross_charge":62.0,"discounted_cash":34.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Encephalitis West Equine Antibody","code_information":[{"code":"60066030","type":"CDM"},{"code":"302","type":"RC"},{"code":"86654","type":"HCPCS"}],"standard_charges":[{"gross_charge":64.0,"discounted_cash":35.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Ana Titer Ii","code_information":[{"code":"60066050","type":"CDM"},{"code":"302","type":"RC"},{"code":"86039","type":"HCPCS"}],"standard_charges":[{"gross_charge":171.0,"discounted_cash":94.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Varicella Zoster Antibody Igg","code_information":[{"code":"60066060","type":"CDM"},{"code":"302","type":"RC"},{"code":"86787","type":"HCPCS"}],"standard_charges":[{"gross_charge":337.0,"discounted_cash":185.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Varicella Zoster Antibody Igm","code_information":[{"code":"60066070","type":"CDM"},{"code":"302","type":"RC"},{"code":"86787","type":"HCPCS"}],"standard_charges":[{"gross_charge":87.0,"discounted_cash":47.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Varicella Zoster Antibody Igm I","code_information":[{"code":"60066071","type":"CDM"},{"code":"302","type":"RC"},{"code":"86787","type":"HCPCS"}],"standard_charges":[{"gross_charge":87.0,"discounted_cash":47.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Mumps Antibody Igm","code_information":[{"code":"60066110","type":"CDM"},{"code":"302","type":"RC"},{"code":"86735","type":"HCPCS"}],"standard_charges":[{"gross_charge":209.0,"discounted_cash":114.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Mumps Antibody Igg","code_information":[{"code":"60066120","type":"CDM"},{"code":"302","type":"RC"},{"code":"86735","type":"HCPCS"}],"standard_charges":[{"gross_charge":209.0,"discounted_cash":114.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Parvovirus B19 Antibody Igg","code_information":[{"code":"60066170","type":"CDM"},{"code":"302","type":"RC"},{"code":"86747","type":"HCPCS"}],"standard_charges":[{"gross_charge":202.0,"discounted_cash":111.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Beta-2 Glycoprotein 1 Ab Iga","code_information":[{"code":"60066210","type":"CDM"},{"code":"302","type":"RC"},{"code":"86146","type":"HCPCS"}],"standard_charges":[{"gross_charge":61.0,"discounted_cash":33.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Rubeola Antibody Igm","code_information":[{"code":"60066220","type":"CDM"},{"code":"302","type":"RC"},{"code":"86765","type":"HCPCS"}],"standard_charges":[{"gross_charge":192.0,"discounted_cash":105.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Rubeola Antibody Igg","code_information":[{"code":"60066230","type":"CDM"},{"code":"302","type":"RC"},{"code":"86765","type":"HCPCS"}],"standard_charges":[{"gross_charge":192.0,"discounted_cash":105.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Rubeola Antibody Igg I","code_information":[{"code":"60066231","type":"CDM"},{"code":"302","type":"RC"},{"code":"86765","type":"HCPCS"}],"standard_charges":[{"gross_charge":192.0,"discounted_cash":105.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Vitamin K1","code_information":[{"code":"60066290","type":"CDM"},{"code":"301","type":"RC"},{"code":"84597","type":"HCPCS"}],"standard_charges":[{"gross_charge":221.0,"discounted_cash":121.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Chlamydia Dna Probe","code_information":[{"code":"60066300","type":"CDM"},{"code":"306","type":"RC"},{"code":"87491","type":"HCPCS"}],"standard_charges":[{"gross_charge":130.0,"discounted_cash":71.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Mycoplasma Dna Pcr","code_information":[{"code":"60066310","type":"CDM"},{"code":"306","type":"RC"},{"code":"87581","type":"HCPCS"}],"standard_charges":[{"gross_charge":340.0,"discounted_cash":187.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Herpes Simplex Pcr","code_information":[{"code":"60066340","type":"CDM"},{"code":"306","type":"RC"},{"code":"87529","type":"HCPCS"}],"standard_charges":[{"gross_charge":685.0,"discounted_cash":376.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Herpes Simplex Pcr I","code_information":[{"code":"60066341","type":"CDM"},{"code":"306","type":"RC"},{"code":"87529","type":"HCPCS"}],"standard_charges":[{"gross_charge":685.0,"discounted_cash":376.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Herpes Simplex Amplified Probe Iii","code_information":[{"code":"60066343","type":"CDM"},{"code":"306","type":"RC"},{"code":"87529","type":"HCPCS"}],"standard_charges":[{"gross_charge":685.0,"discounted_cash":376.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Herpes Simplex Amplified Probe Iv","code_information":[{"code":"60066344","type":"CDM"},{"code":"306","type":"RC"},{"code":"87529","type":"HCPCS"}],"standard_charges":[{"gross_charge":685.0,"discounted_cash":376.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Herpes Simplex Pcr V","code_information":[{"code":"60066345","type":"CDM"},{"code":"306","type":"RC"},{"code":"87529","type":"HCPCS"}],"standard_charges":[{"gross_charge":685.0,"discounted_cash":376.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Encephalitis Calif Antibody","code_information":[{"code":"60066430","type":"CDM"},{"code":"302","type":"RC"},{"code":"86651","type":"HCPCS"}],"standard_charges":[{"gross_charge":62.0,"discounted_cash":34.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Cyclic Citrul Peptide Ab Igg (Ccp) I","code_information":[{"code":"60066460","type":"CDM"},{"code":"302","type":"RC"},{"code":"86200","type":"HCPCS"}],"standard_charges":[{"gross_charge":197.0,"discounted_cash":108.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Dhea Sulfate","code_information":[{"code":"60066590","type":"CDM"},{"code":"301","type":"RC"},{"code":"82627","type":"HCPCS"}],"standard_charges":[{"gross_charge":316.0,"discounted_cash":173.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Thyroglobulin Antibody","code_information":[{"code":"60066700","type":"CDM"},{"code":"302","type":"RC"},{"code":"86800","type":"HCPCS"}],"standard_charges":[{"gross_charge":252.0,"discounted_cash":138.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Thyroid Peroxidase Antibody","code_information":[{"code":"60066750","type":"CDM"},{"code":"302","type":"RC"},{"code":"86376","type":"HCPCS"}],"standard_charges":[{"gross_charge":178.0,"discounted_cash":97.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Noncdm Charge Record","code_information":[{"code":"60066910","type":"CDM"},{"code":"301","type":"RC"},{"code":"82657","type":"HCPCS"}],"standard_charges":[{"gross_charge":301.0,"discounted_cash":165.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Lchg Cocaine + Metabolites Urine I","code_information":[{"code":"60067141","type":"CDM"},{"code":"301","type":"RC"},{"code":"80353","type":"HCPCS"}],"standard_charges":[{"gross_charge":136.0,"discounted_cash":74.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Acth","code_information":[{"code":"60067160","type":"CDM"},{"code":"301","type":"RC"},{"code":"82024","type":"HCPCS"}],"standard_charges":[{"gross_charge":592.0,"discounted_cash":325.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Alkaline Phosphatase Isoenzymes","code_information":[{"code":"60067180","type":"CDM"},{"code":"301","type":"RC"},{"code":"84080","type":"HCPCS"}],"standard_charges":[{"gross_charge":97.0,"discounted_cash":53.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Herpes-6-Human Antibody Igg","code_information":[{"code":"60067270","type":"CDM"},{"code":"302","type":"RC"},{"code":"86790","type":"HCPCS"}],"standard_charges":[{"gross_charge":98.0,"discounted_cash":53.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Cortisol Urine Timed","code_information":[{"code":"60067280","type":"CDM"},{"code":"301","type":"RC"},{"code":"82530","type":"HCPCS"}],"standard_charges":[{"gross_charge":270.0,"discounted_cash":148.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Cryoglobulin Qualitative","code_information":[{"code":"60067330","type":"CDM"},{"code":"301","type":"RC"},{"code":"82595","type":"HCPCS"}],"standard_charges":[{"gross_charge":91.0,"discounted_cash":50.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Noncdm Charge Record","code_information":[{"code":"60067340","type":"CDM"},{"code":"301","type":"RC"},{"code":"82172","type":"HCPCS"}],"standard_charges":[{"gross_charge":117.0,"discounted_cash":64.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Lchg Pancreatic Elastase Feces I","code_information":[{"code":"60067391","type":"CDM"},{"code":"301","type":"RC"},{"code":"83520","type":"HCPCS"}],"standard_charges":[{"gross_charge":186.0,"discounted_cash":102.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Hepatitis Be Antigen","code_information":[{"code":"60067400","type":"CDM"},{"code":"306","type":"RC"},{"code":"87350","type":"HCPCS"}],"standard_charges":[{"gross_charge":48.0,"discounted_cash":26.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Testosterone Total I","code_information":[{"code":"60067550","type":"CDM"},{"code":"301","type":"RC"},{"code":"84403","type":"HCPCS"}],"standard_charges":[{"gross_charge":406.0,"discounted_cash":223.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Newborn Screen","code_information":[{"code":"60067700","type":"CDM"},{"code":"300","type":"RC"},{"code":"S3620","type":"HCPCS"}],"standard_charges":[{"gross_charge":502.0,"discounted_cash":276.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Coxsackie A","code_information":[{"code":"60067770","type":"CDM"},{"code":"302","type":"RC"},{"code":"86658","type":"HCPCS"}],"standard_charges":[{"gross_charge":33.0,"discounted_cash":18.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Carbamazepine Level Total I","code_information":[{"code":"60067890","type":"CDM"},{"code":"301","type":"RC"},{"code":"80156","type":"HCPCS"}],"standard_charges":[{"gross_charge":247.0,"discounted_cash":135.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Igd","code_information":[{"code":"60067920","type":"CDM"},{"code":"301","type":"RC"},{"code":"82784","type":"HCPCS"}],"standard_charges":[{"gross_charge":178.0,"discounted_cash":97.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Microsomal Antibody Liver/Kidney","code_information":[{"code":"60067930","type":"CDM"},{"code":"302","type":"RC"},{"code":"86376","type":"HCPCS"}],"standard_charges":[{"gross_charge":140.0,"discounted_cash":77.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Parvovirus B19 Antibody Igm","code_information":[{"code":"60067960","type":"CDM"},{"code":"302","type":"RC"},{"code":"86747","type":"HCPCS"}],"standard_charges":[{"gross_charge":202.0,"discounted_cash":111.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Platelet Antibody Indirect","code_information":[{"code":"60067970","type":"CDM"},{"code":"302","type":"RC"},{"code":"86022","type":"HCPCS"}],"standard_charges":[{"gross_charge":151.0,"discounted_cash":83.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Toxoplasma Antibody Igm","code_information":[{"code":"60068040","type":"CDM"},{"code":"302","type":"RC"},{"code":"86778","type":"HCPCS"}],"standard_charges":[{"gross_charge":172.0,"discounted_cash":94.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Tularemia Antibody","code_information":[{"code":"60068050","type":"CDM"},{"code":"302","type":"RC"},{"code":"86668","type":"HCPCS"}],"standard_charges":[{"gross_charge":43.0,"discounted_cash":23.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Protein Total Blood I","code_information":[{"code":"60068150","type":"CDM"},{"code":"301","type":"RC"},{"code":"84155","type":"HCPCS"}],"standard_charges":[{"gross_charge":96.0,"discounted_cash":52.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Cadmium Urine","code_information":[{"code":"60068180","type":"CDM"},{"code":"301","type":"RC"},{"code":"82300","type":"HCPCS"}],"standard_charges":[{"gross_charge":377.0,"discounted_cash":207.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Viscosity","code_information":[{"code":"60068250","type":"CDM"},{"code":"305","type":"RC"},{"code":"85810","type":"HCPCS"}],"standard_charges":[{"gross_charge":189.0,"discounted_cash":103.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Hla Screen","code_information":[{"code":"60068380","type":"CDM"},{"code":"302","type":"RC"},{"code":"86807","type":"HCPCS"}],"standard_charges":[{"gross_charge":236.0,"discounted_cash":129.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Platelet Antibody (Pla-1)","code_information":[{"code":"60068390","type":"CDM"},{"code":"302","type":"RC"},{"code":"86022","type":"HCPCS"}],"standard_charges":[{"gross_charge":151.0,"discounted_cash":83.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Hydroxypregnenolone 17-","code_information":[{"code":"60068440","type":"CDM"},{"code":"301","type":"RC"},{"code":"84143","type":"HCPCS"}],"standard_charges":[{"gross_charge":85.0,"discounted_cash":46.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Iron Tissue","code_information":[{"code":"60068510","type":"CDM"},{"code":"301","type":"RC"},{"code":"83540","type":"HCPCS"}],"standard_charges":[{"gross_charge":100.0,"discounted_cash":55.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Arsenic Urine","code_information":[{"code":"60068550","type":"CDM"},{"code":"301","type":"RC"},{"code":"82175","type":"HCPCS"}],"standard_charges":[{"gross_charge":309.0,"discounted_cash":169.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Neutrophil Cytoplasmic Antibody Igg","code_information":[{"code":"60068890","type":"CDM"},{"code":"302","type":"RC"},{"code":"86255","type":"HCPCS"}],"standard_charges":[{"gross_charge":110.0,"discounted_cash":60.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Methylmalonic Acid Blood","code_information":[{"code":"60068970","type":"CDM"},{"code":"301","type":"RC"},{"code":"83921","type":"HCPCS"}],"standard_charges":[{"gross_charge":225.0,"discounted_cash":123.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Gabapentin Level I","code_information":[{"code":"60068991","type":"CDM"},{"code":"301","type":"RC"},{"code":"80171","type":"HCPCS"}],"standard_charges":[{"gross_charge":267.0,"discounted_cash":146.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Gabapentin Level Iii","code_information":[{"code":"60068993","type":"CDM"},{"code":"301","type":"RC"},{"code":"80355","type":"HCPCS"}],"standard_charges":[{"gross_charge":262.0,"discounted_cash":144.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Gabapentin Level Iv","code_information":[{"code":"60068994","type":"CDM"},{"code":"301","type":"RC"},{"code":"80355","type":"HCPCS"}],"standard_charges":[{"gross_charge":343.0,"discounted_cash":188.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Sp Stain Group Iv","code_information":[{"code":"60069370","type":"CDM"},{"code":"312","type":"RC"},{"code":"88319","type":"HCPCS"}],"standard_charges":[{"gross_charge":384.0,"discounted_cash":211.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Sp G+M Level Iv Refer","code_information":[{"code":"60069400","type":"CDM"},{"code":"310","type":"RC"},{"code":"88305","type":"HCPCS"}],"standard_charges":[{"gross_charge":494.0,"discounted_cash":271.7,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Cytopath Fluids Nongyn Tc Nl","code_information":[{"code":"60069441","type":"CDM"},{"code":"310","type":"RC"},{"code":"88104","type":"HCPCS"}],"standard_charges":[{"gross_charge":436.0,"discounted_cash":239.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Drvvt Confirm I","code_information":[{"code":"60069581","type":"CDM"},{"code":"305","type":"RC"},{"code":"85613","type":"HCPCS"}],"standard_charges":[{"gross_charge":145.0,"discounted_cash":79.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Serine Protease 3 Antibody","code_information":[{"code":"60069690","type":"CDM"},{"code":"301","type":"RC"},{"code":"83516","type":"HCPCS"}],"standard_charges":[{"gross_charge":151.0,"discounted_cash":83.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Pt I","code_information":[{"code":"60069730","type":"CDM"},{"code":"305","type":"RC"},{"code":"85610","type":"HCPCS"}],"standard_charges":[{"gross_charge":41.0,"discounted_cash":22.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Pt Ii","code_information":[{"code":"60069731","type":"CDM"},{"code":"305","type":"RC"},{"code":"85610","type":"HCPCS"}],"standard_charges":[{"gross_charge":41.0,"discounted_cash":22.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Pt Iii","code_information":[{"code":"60069732","type":"CDM"},{"code":"305","type":"RC"},{"code":"85610","type":"HCPCS"}],"standard_charges":[{"gross_charge":41.0,"discounted_cash":22.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Ptt I","code_information":[{"code":"60069740","type":"CDM"},{"code":"305","type":"RC"},{"code":"85730","type":"HCPCS"}],"standard_charges":[{"gross_charge":36.0,"discounted_cash":19.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Estradiol Iii","code_information":[{"code":"60069862","type":"CDM"},{"code":"301","type":"RC"},{"code":"82670","type":"HCPCS"}],"standard_charges":[{"gross_charge":453.0,"discounted_cash":249.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Fungus Identification","code_information":[{"code":"60069870","type":"CDM"},{"code":"306","type":"RC"},{"code":"87106","type":"HCPCS"}],"standard_charges":[{"gross_charge":131.0,"discounted_cash":72.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Immunoglobulin","code_information":[{"code":"60069880","type":"CDM"},{"code":"301","type":"RC"},{"code":"82784","type":"HCPCS"}],"standard_charges":[{"gross_charge":106.0,"discounted_cash":58.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Hepatitis B Surface Antibody I","code_information":[{"code":"60069910","type":"CDM"},{"code":"302","type":"RC"},{"code":"86706","type":"HCPCS"}],"standard_charges":[{"gross_charge":176.0,"discounted_cash":96.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Hepatitis B Surface Antibody Np","code_information":[{"code":"60069911","type":"CDM"},{"code":"302","type":"RC"},{"code":"86706","type":"HCPCS"}],"standard_charges":[{"gross_charge":176.0,"discounted_cash":96.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Volume Measure Urine","code_information":[{"code":"60069980","type":"CDM"},{"code":"307","type":"RC"},{"code":"81050","type":"HCPCS"}],"standard_charges":[{"gross_charge":47.0,"discounted_cash":25.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Ana Blood Screen","code_information":[{"code":"60070000","type":"CDM"},{"code":"302","type":"RC"},{"code":"86038","type":"HCPCS"}],"standard_charges":[{"gross_charge":153.0,"discounted_cash":84.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Ana Blood Screen I","code_information":[{"code":"60070001","type":"CDM"},{"code":"302","type":"RC"},{"code":"86038","type":"HCPCS"}],"standard_charges":[{"gross_charge":158.0,"discounted_cash":86.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Ana Blood Titer","code_information":[{"code":"60070010","type":"CDM"},{"code":"302","type":"RC"},{"code":"86039","type":"HCPCS"}],"standard_charges":[{"gross_charge":171.0,"discounted_cash":94.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Aso Titer","code_information":[{"code":"60070050","type":"CDM"},{"code":"302","type":"RC"},{"code":"86060","type":"HCPCS"}],"standard_charges":[{"gross_charge":114.0,"discounted_cash":62.7,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg C-Reactive Protein","code_information":[{"code":"60070100","type":"CDM"},{"code":"302","type":"RC"},{"code":"86140","type":"HCPCS"}],"standard_charges":[{"gross_charge":81.0,"discounted_cash":44.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg C-Reactive Protein I","code_information":[{"code":"60070110","type":"CDM"},{"code":"302","type":"RC"},{"code":"86140","type":"HCPCS"}],"standard_charges":[{"gross_charge":81.0,"discounted_cash":44.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg C-Reactive Protein Ii","code_information":[{"code":"60070111","type":"CDM"},{"code":"302","type":"RC"},{"code":"86140","type":"HCPCS"}],"standard_charges":[{"gross_charge":81.0,"discounted_cash":44.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Herpes Simplex 1 Antibody Igg","code_information":[{"code":"60070260","type":"CDM"},{"code":"302","type":"RC"},{"code":"86695","type":"HCPCS"}],"standard_charges":[{"gross_charge":203.0,"discounted_cash":111.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Hiv-1 Ag W Hiv-1+Hiv-2 Ab","code_information":[{"code":"60070271","type":"CDM"},{"code":"306","type":"RC"},{"code":"87389","type":"HCPCS"}],"standard_charges":[{"gross_charge":188.0,"discounted_cash":103.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Cryptococcus Antigen Fluid Ii","code_information":[{"code":"60070282","type":"CDM"},{"code":"306","type":"RC"},{"code":"87899","type":"HCPCS"}],"standard_charges":[{"gross_charge":246.0,"discounted_cash":135.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Cardiolipin Antibody","code_information":[{"code":"60070290","type":"CDM"},{"code":"302","type":"RC"},{"code":"86147","type":"HCPCS"}],"standard_charges":[{"gross_charge":65.0,"discounted_cash":35.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Smooth Muscle Antibody I","code_information":[{"code":"60070311","type":"CDM"},{"code":"301","type":"RC"},{"code":"83516","type":"HCPCS"}],"standard_charges":[{"gross_charge":181.0,"discounted_cash":99.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Strep A Screen Direct By Eia","code_information":[{"code":"60070340","type":"CDM"},{"code":"306","type":"RC"},{"code":"87430","type":"HCPCS"}],"standard_charges":[{"gross_charge":225.0,"discounted_cash":123.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Strep A Screen Direct Immuno","code_information":[{"code":"60070341","type":"CDM"},{"code":"306","type":"RC"},{"code":"87880","type":"HCPCS"}],"standard_charges":[{"gross_charge":225.0,"discounted_cash":123.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Cmv Antibody Igg Blood","code_information":[{"code":"60070370","type":"CDM"},{"code":"302","type":"RC"},{"code":"86644","type":"HCPCS"}],"standard_charges":[{"gross_charge":152.0,"discounted_cash":83.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Cmv Antibody Igg Blood I","code_information":[{"code":"60070371","type":"CDM"},{"code":"302","type":"RC"},{"code":"86644","type":"HCPCS"}],"standard_charges":[{"gross_charge":138.0,"discounted_cash":75.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Cmv Antibody Igm Blood","code_information":[{"code":"60070380","type":"CDM"},{"code":"302","type":"RC"},{"code":"86645","type":"HCPCS"}],"standard_charges":[{"gross_charge":1265.0,"discounted_cash":695.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Mononucleosis Screen","code_information":[{"code":"60070400","type":"CDM"},{"code":"302","type":"RC"},{"code":"86308","type":"HCPCS"}],"standard_charges":[{"gross_charge":87.0,"discounted_cash":47.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Rheumatoid Factor Blood Quant","code_information":[{"code":"60070460","type":"CDM"},{"code":"302","type":"RC"},{"code":"86431","type":"HCPCS"}],"standard_charges":[{"gross_charge":91.0,"discounted_cash":50.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Rheumatoid Factor Blood Quant I","code_information":[{"code":"60070461","type":"CDM"},{"code":"302","type":"RC"},{"code":"86431","type":"HCPCS"}],"standard_charges":[{"gross_charge":91.0,"discounted_cash":50.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Rpr I","code_information":[{"code":"60070501","type":"CDM"},{"code":"302","type":"RC"},{"code":"86592","type":"HCPCS"}],"standard_charges":[{"gross_charge":63.0,"discounted_cash":34.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Vdrl Blood","code_information":[{"code":"60070550","type":"CDM"},{"code":"302","type":"RC"},{"code":"86592","type":"HCPCS"}],"standard_charges":[{"gross_charge":63.0,"discounted_cash":34.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Aso Titer I","code_information":[{"code":"60070551","type":"CDM"},{"code":"302","type":"RC"},{"code":"86060","type":"HCPCS"}],"standard_charges":[{"gross_charge":114.0,"discounted_cash":62.7,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Vdrl Csf","code_information":[{"code":"60070570","type":"CDM"},{"code":"302","type":"RC"},{"code":"86592","type":"HCPCS"}],"standard_charges":[{"gross_charge":63.0,"discounted_cash":34.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Rnp Antibody","code_information":[{"code":"60070830","type":"CDM"},{"code":"302","type":"RC"},{"code":"86235","type":"HCPCS"}],"standard_charges":[{"gross_charge":269.0,"discounted_cash":147.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Rnp Antibody Quant","code_information":[{"code":"60070831","type":"CDM"},{"code":"301","type":"RC"},{"code":"83520","type":"HCPCS"}],"standard_charges":[{"gross_charge":151.0,"discounted_cash":83.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Sm Antibody Ena","code_information":[{"code":"60070840","type":"CDM"},{"code":"302","type":"RC"},{"code":"86235","type":"HCPCS"}],"standard_charges":[{"gross_charge":265.0,"discounted_cash":145.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Rubella Immune Status","code_information":[{"code":"60070930","type":"CDM"},{"code":"302","type":"RC"},{"code":"86762","type":"HCPCS"}],"standard_charges":[{"gross_charge":218.0,"discounted_cash":119.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Rpr W Reflex Confirm","code_information":[{"code":"60071010","type":"CDM"},{"code":"302","type":"RC"},{"code":"86592","type":"HCPCS"}],"standard_charges":[{"gross_charge":64.0,"discounted_cash":35.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Hepatitis B Virus Dna Quant","code_information":[{"code":"60071090","type":"CDM"},{"code":"306","type":"RC"},{"code":"87517","type":"HCPCS"}],"standard_charges":[{"gross_charge":850.0,"discounted_cash":467.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg C-Reactive Protein Sensitive","code_information":[{"code":"60071170","type":"CDM"},{"code":"302","type":"RC"},{"code":"86141","type":"HCPCS"}],"standard_charges":[{"gross_charge":141.0,"discounted_cash":77.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Strep Pneumo Antigen Urine","code_information":[{"code":"60071190","type":"CDM"},{"code":"306","type":"RC"},{"code":"87449","type":"HCPCS"}],"standard_charges":[{"gross_charge":138.0,"discounted_cash":75.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Mi-2 Autoantibodies","code_information":[{"code":"60071640","type":"CDM"},{"code":"302","type":"RC"},{"code":"86235","type":"HCPCS"}],"standard_charges":[{"gross_charge":269.0,"discounted_cash":147.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Myositis Autoantibodies","code_information":[{"code":"60071670","type":"CDM"},{"code":"301","type":"RC"},{"code":"83516","type":"HCPCS"}],"standard_charges":[{"gross_charge":142.0,"discounted_cash":78.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Chromatin Antibody I","code_information":[{"code":"60071681","type":"CDM"},{"code":"301","type":"RC"},{"code":"83516","type":"HCPCS"}],"standard_charges":[{"gross_charge":138.0,"discounted_cash":75.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Viral Culture Cmv","code_information":[{"code":"60073030","type":"CDM"},{"code":"306","type":"RC"},{"code":"87254","type":"HCPCS"}],"standard_charges":[{"gross_charge":222.0,"discounted_cash":122.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Viral Culture Cmv I","code_information":[{"code":"60073031","type":"CDM"},{"code":"306","type":"RC"},{"code":"87252","type":"HCPCS"}],"standard_charges":[{"gross_charge":530.0,"discounted_cash":291.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Viral Culture","code_information":[{"code":"60073060","type":"CDM"},{"code":"306","type":"RC"},{"code":"87252","type":"HCPCS"}],"standard_charges":[{"gross_charge":530.0,"discounted_cash":291.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Viral Culture I","code_information":[{"code":"60073061","type":"CDM"},{"code":"306","type":"RC"},{"code":"87253","type":"HCPCS"}],"standard_charges":[{"gross_charge":174.0,"discounted_cash":95.7,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Viral Culture Misc","code_information":[{"code":"60073270","type":"CDM"},{"code":"306","type":"RC"},{"code":"87252","type":"HCPCS"}],"standard_charges":[{"gross_charge":530.0,"discounted_cash":291.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Viral Culture Tissue","code_information":[{"code":"60073300","type":"CDM"},{"code":"306","type":"RC"},{"code":"87252","type":"HCPCS"}],"standard_charges":[{"gross_charge":530.0,"discounted_cash":291.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Rsv Pcr","code_information":[{"code":"60073970","type":"CDM"},{"code":"306","type":"RC"},{"code":"87798","type":"HCPCS"}],"standard_charges":[{"gross_charge":508.0,"discounted_cash":279.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Pregabalin Iii","code_information":[{"code":"60074323","type":"CDM"},{"code":"301","type":"RC"},{"code":"80366","type":"HCPCS"}],"standard_charges":[{"gross_charge":343.0,"discounted_cash":188.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Blood Collection/Port","code_information":[{"code":"60074420","type":"CDM"},{"code":"300","type":"RC"},{"code":"36591","type":"HCPCS"}],"standard_charges":[{"gross_charge":200.0,"discounted_cash":110.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Voriconazole Level","code_information":[{"code":"60074870","type":"CDM"},{"code":"301","type":"RC"},{"code":"80299","type":"HCPCS"}],"standard_charges":[{"gross_charge":272.0,"discounted_cash":149.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Urinalysis Routine Auto W Microscopic","code_information":[{"code":"60075030","type":"CDM"},{"code":"307","type":"RC"},{"code":"81001","type":"HCPCS"}],"standard_charges":[{"gross_charge":105.0,"discounted_cash":57.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Urinalysis Microscopic Only","code_information":[{"code":"60075220","type":"CDM"},{"code":"307","type":"RC"},{"code":"81015","type":"HCPCS"}],"standard_charges":[{"gross_charge":47.0,"discounted_cash":25.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Hcg Urine Qualitative","code_information":[{"code":"60075290","type":"CDM"},{"code":"307","type":"RC"},{"code":"81025","type":"HCPCS"}],"standard_charges":[{"gross_charge":106.0,"discounted_cash":58.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Urinalysis Dipstick Auto","code_information":[{"code":"60075320","type":"CDM"},{"code":"307","type":"RC"},{"code":"81003","type":"HCPCS"}],"standard_charges":[{"gross_charge":45.0,"discounted_cash":24.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Noncdm Charge Record","code_information":[{"code":"60075400","type":"CDM"},{"code":"301","type":"RC"},{"code":"83986","type":"HCPCS"}],"standard_charges":[{"gross_charge":52.0,"discounted_cash":28.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Lchg Crystal Identification","code_information":[{"code":"60075430","type":"CDM"},{"code":"309","type":"RC"},{"code":"89060","type":"HCPCS"}],"standard_charges":[{"gross_charge":121.0,"discounted_cash":66.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Occult Blood Gastric","code_information":[{"code":"60075450","type":"CDM"},{"code":"301","type":"RC"},{"code":"82271","type":"HCPCS"}],"standard_charges":[{"gross_charge":52.0,"discounted_cash":28.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Hemosiderin Urine","code_information":[{"code":"60075470","type":"CDM"},{"code":"301","type":"RC"},{"code":"83070","type":"HCPCS"}],"standard_charges":[{"gross_charge":15.0,"discounted_cash":8.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Drug Screen Meconium Iv","code_information":[{"code":"60075863","type":"CDM"},{"code":"301","type":"RC"},{"code":"80307","type":"HCPCS"}],"standard_charges":[{"gross_charge":368.0,"discounted_cash":202.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Occult Blood Feces (Non Cancer Scrn)","code_information":[{"code":"60075880","type":"CDM"},{"code":"301","type":"RC"},{"code":"82272","type":"HCPCS"}],"standard_charges":[{"gross_charge":34.0,"discounted_cash":18.7,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Cannabinoids Blood Confirm I","code_information":[{"code":"60076001","type":"CDM"},{"code":"301","type":"RC"},{"code":"80349","type":"HCPCS"}],"standard_charges":[{"gross_charge":343.0,"discounted_cash":188.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Vascular Endothelial Growth Factor","code_information":[{"code":"60076720","type":"CDM"},{"code":"301","type":"RC"},{"code":"83520","type":"HCPCS"}],"standard_charges":[{"gross_charge":165.0,"discounted_cash":90.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Barbiturate Urine Qualitative Ii","code_information":[{"code":"60077032","type":"CDM"},{"code":"301","type":"RC"},{"code":"80307","type":"HCPCS"}],"standard_charges":[{"gross_charge":193.0,"discounted_cash":106.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Benzodiazepine Blood Confirm Ii","code_information":[{"code":"60077244","type":"CDM"},{"code":"301","type":"RC"},{"code":"80346","type":"HCPCS"}],"standard_charges":[{"gross_charge":288.0,"discounted_cash":158.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Cannabinoids Meconium Confirm Ii","code_information":[{"code":"60077253","type":"CDM"},{"code":"301","type":"RC"},{"code":"80349","type":"HCPCS"}],"standard_charges":[{"gross_charge":261.0,"discounted_cash":143.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Phencyclidine Urine Conf I","code_information":[{"code":"60077332","type":"CDM"},{"code":"301","type":"RC"},{"code":"83992","type":"HCPCS"}],"standard_charges":[{"gross_charge":288.0,"discounted_cash":158.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Methadone Urine Screen Ii","code_information":[{"code":"60077372","type":"CDM"},{"code":"301","type":"RC"},{"code":"80307","type":"HCPCS"}],"standard_charges":[{"gross_charge":193.0,"discounted_cash":106.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Oxycodone Urine Confirmation Iii","code_information":[{"code":"60077923","type":"CDM"},{"code":"301","type":"RC"},{"code":"80365","type":"HCPCS"}],"standard_charges":[{"gross_charge":213.0,"discounted_cash":117.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Fentanyls Urine I","code_information":[{"code":"60078761","type":"CDM"},{"code":"301","type":"RC"},{"code":"80354","type":"HCPCS"}],"standard_charges":[{"gross_charge":187.0,"discounted_cash":102.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Glucose Poct (Ip)","code_information":[{"code":"60079120","type":"CDM"},{"code":"301","type":"RC"},{"code":"82962","type":"HCPCS"}],"standard_charges":[{"gross_charge":46.0,"discounted_cash":25.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Istat Act","code_information":[{"code":"60079150","type":"CDM"},{"code":"305","type":"RC"},{"code":"85347","type":"HCPCS"}],"standard_charges":[{"gross_charge":29.0,"discounted_cash":15.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Heparin Assay Hms","code_information":[{"code":"60079490","type":"CDM"},{"code":"305","type":"RC"},{"code":"85520","type":"HCPCS"}],"standard_charges":[{"gross_charge":137.0,"discounted_cash":75.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Heparin Dose Response Poct","code_information":[{"code":"60079500","type":"CDM"},{"code":"305","type":"RC"},{"code":"85347","type":"HCPCS"}],"standard_charges":[{"gross_charge":67.0,"discounted_cash":36.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Hms Act","code_information":[{"code":"60079830","type":"CDM"},{"code":"305","type":"RC"},{"code":"85347","type":"HCPCS"}],"standard_charges":[{"gross_charge":29.0,"discounted_cash":15.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Glucose Poct","code_information":[{"code":"60079860","type":"CDM"},{"code":"301","type":"RC"},{"code":"82947","type":"HCPCS"}],"standard_charges":[{"gross_charge":53.0,"discounted_cash":29.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Mag Ab","code_information":[{"code":"60080030","type":"CDM"},{"code":"301","type":"RC"},{"code":"83516","type":"HCPCS"}],"standard_charges":[{"gross_charge":199.0,"discounted_cash":109.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Inhibin B","code_information":[{"code":"60080100","type":"CDM"},{"code":"301","type":"RC"},{"code":"83520","type":"HCPCS"}],"standard_charges":[{"gross_charge":165.0,"discounted_cash":90.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Pneumocystis By Dfa Smear","code_information":[{"code":"60080230","type":"CDM"},{"code":"306","type":"RC"},{"code":"87281","type":"HCPCS"}],"standard_charges":[{"gross_charge":48.0,"discounted_cash":26.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Noncdm Charge Record","code_information":[{"code":"60080270","type":"CDM"},{"code":"302","type":"RC"},{"code":"86331","type":"HCPCS"}],"standard_charges":[{"gross_charge":23.4,"discounted_cash":12.87,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Lchg Culture Ureaplasma","code_information":[{"code":"60080470","type":"CDM"},{"code":"306","type":"RC"},{"code":"87109","type":"HCPCS"}],"standard_charges":[{"gross_charge":196.0,"discounted_cash":107.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Giardia Lamblia Antigen","code_information":[{"code":"60080480","type":"CDM"},{"code":"306","type":"RC"},{"code":"87329","type":"HCPCS"}],"standard_charges":[{"gross_charge":243.0,"discounted_cash":133.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Alprazolam Level I","code_information":[{"code":"60080641","type":"CDM"},{"code":"301","type":"RC"},{"code":"80346","type":"HCPCS"}],"standard_charges":[{"gross_charge":288.0,"discounted_cash":158.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Noncdm Charge Record","code_information":[{"code":"60080654","type":"CDM"},{"code":"301","type":"RC"},{"code":"80307","type":"HCPCS"}],"standard_charges":[{"gross_charge":117.0,"discounted_cash":64.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Lchg Cmv Pcr","code_information":[{"code":"60080720","type":"CDM"},{"code":"306","type":"RC"},{"code":"87496","type":"HCPCS"}],"standard_charges":[{"gross_charge":205.0,"discounted_cash":112.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Lyme Disease Pcr Blood","code_information":[{"code":"60080730","type":"CDM"},{"code":"306","type":"RC"},{"code":"87476","type":"HCPCS"}],"standard_charges":[{"gross_charge":690.0,"discounted_cash":379.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Lyme Disease Ab Index","code_information":[{"code":"60080760","type":"CDM"},{"code":"302","type":"RC"},{"code":"86618","type":"HCPCS"}],"standard_charges":[{"gross_charge":137.0,"discounted_cash":75.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Mycobacterium Pcr","code_information":[{"code":"60080770","type":"CDM"},{"code":"306","type":"RC"},{"code":"87556","type":"HCPCS"}],"standard_charges":[{"gross_charge":169.0,"discounted_cash":92.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Lyme Disease Antibody Screen Blood","code_information":[{"code":"60080810","type":"CDM"},{"code":"302","type":"RC"},{"code":"86618","type":"HCPCS"}],"standard_charges":[{"gross_charge":137.0,"discounted_cash":75.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Cardiolipin Antibody Igg","code_information":[{"code":"60080890","type":"CDM"},{"code":"302","type":"RC"},{"code":"86147","type":"HCPCS"}],"standard_charges":[{"gross_charge":65.0,"discounted_cash":35.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Cardiolipin Antibody Igg I","code_information":[{"code":"60080891","type":"CDM"},{"code":"302","type":"RC"},{"code":"86147","type":"HCPCS"}],"standard_charges":[{"gross_charge":65.0,"discounted_cash":35.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Cardiolipin Antibody Igm","code_information":[{"code":"60080900","type":"CDM"},{"code":"302","type":"RC"},{"code":"86147","type":"HCPCS"}],"standard_charges":[{"gross_charge":65.0,"discounted_cash":35.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Cardiolipin Antibody Igm I","code_information":[{"code":"60080901","type":"CDM"},{"code":"302","type":"RC"},{"code":"86147","type":"HCPCS"}],"standard_charges":[{"gross_charge":65.0,"discounted_cash":35.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Cardiolipin Antibody Iga","code_information":[{"code":"60080910","type":"CDM"},{"code":"302","type":"RC"},{"code":"86147","type":"HCPCS"}],"standard_charges":[{"gross_charge":65.0,"discounted_cash":35.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Lyme Disease Western Blot Igg","code_information":[{"code":"60080960","type":"CDM"},{"code":"302","type":"RC"},{"code":"86617","type":"HCPCS"}],"standard_charges":[{"gross_charge":110.0,"discounted_cash":60.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Lyme Disease Western Blot Igm","code_information":[{"code":"60080990","type":"CDM"},{"code":"302","type":"RC"},{"code":"86617","type":"HCPCS"}],"standard_charges":[{"gross_charge":110.0,"discounted_cash":60.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Lorazepam Level I","code_information":[{"code":"60081041","type":"CDM"},{"code":"301","type":"RC"},{"code":"80346","type":"HCPCS"}],"standard_charges":[{"gross_charge":288.0,"discounted_cash":158.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Risperidone Level Ii","code_information":[{"code":"60081052","type":"CDM"},{"code":"301","type":"RC"},{"code":"80342","type":"HCPCS"}],"standard_charges":[{"gross_charge":279.0,"discounted_cash":153.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Insulin Antibody Human","code_information":[{"code":"60081120","type":"CDM"},{"code":"302","type":"RC"},{"code":"86337","type":"HCPCS"}],"standard_charges":[{"gross_charge":66.0,"discounted_cash":36.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Insulin Antibody Human I","code_information":[{"code":"60081121","type":"CDM"},{"code":"302","type":"RC"},{"code":"86337","type":"HCPCS"}],"standard_charges":[{"gross_charge":66.0,"discounted_cash":36.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Lipoprotein A","code_information":[{"code":"60081440","type":"CDM"},{"code":"301","type":"RC"},{"code":"83695","type":"HCPCS"}],"standard_charges":[{"gross_charge":207.0,"discounted_cash":113.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Chylomicrons Fluid","code_information":[{"code":"60081470","type":"CDM"},{"code":"301","type":"RC"},{"code":"82664","type":"HCPCS"}],"standard_charges":[{"gross_charge":202.0,"discounted_cash":111.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Catecholamines Urine Random","code_information":[{"code":"60081730","type":"CDM"},{"code":"301","type":"RC"},{"code":"82384","type":"HCPCS"}],"standard_charges":[{"gross_charge":262.0,"discounted_cash":144.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Herpes Simplex 1+2 Antibody Igg","code_information":[{"code":"60081860","type":"CDM"},{"code":"302","type":"RC"},{"code":"86694","type":"HCPCS"}],"standard_charges":[{"gross_charge":218.0,"discounted_cash":119.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Mycoplasma Pneumo Antibody Igg","code_information":[{"code":"60081880","type":"CDM"},{"code":"302","type":"RC"},{"code":"86738","type":"HCPCS"}],"standard_charges":[{"gross_charge":144.0,"discounted_cash":79.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Mycoplasma Pneumo Antibody Igm","code_information":[{"code":"60081890","type":"CDM"},{"code":"302","type":"RC"},{"code":"86738","type":"HCPCS"}],"standard_charges":[{"gross_charge":143.0,"discounted_cash":78.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Varicella Zoster Pcr","code_information":[{"code":"60081970","type":"CDM"},{"code":"306","type":"RC"},{"code":"87798","type":"HCPCS"}],"standard_charges":[{"gross_charge":689.0,"discounted_cash":378.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Varicella Zoster Pcr I","code_information":[{"code":"60081971","type":"CDM"},{"code":"306","type":"RC"},{"code":"87798","type":"HCPCS"}],"standard_charges":[{"gross_charge":518.0,"discounted_cash":284.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Varicella Zoster Amplified Probe Iii","code_information":[{"code":"60081973","type":"CDM"},{"code":"306","type":"RC"},{"code":"87798","type":"HCPCS"}],"standard_charges":[{"gross_charge":424.0,"discounted_cash":233.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Ehrlichia Chaffeensis Pcr","code_information":[{"code":"60081980","type":"CDM"},{"code":"306","type":"RC"},{"code":"87798","type":"HCPCS"}],"standard_charges":[{"gross_charge":494.0,"discounted_cash":271.7,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Islet Cell Antibody","code_information":[{"code":"60082260","type":"CDM"},{"code":"302","type":"RC"},{"code":"86341","type":"HCPCS"}],"standard_charges":[{"gross_charge":133.0,"discounted_cash":73.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Islet Cell Antibody I","code_information":[{"code":"60082261","type":"CDM"},{"code":"302","type":"RC"},{"code":"86341","type":"HCPCS"}],"standard_charges":[{"gross_charge":133.0,"discounted_cash":73.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Noncdm Charge Record","code_information":[{"code":"60082540","type":"CDM"},{"code":"302","type":"RC"},{"code":"86317","type":"HCPCS"}],"standard_charges":[{"gross_charge":11.89,"discounted_cash":6.54,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Lchg Thyroglobulin","code_information":[{"code":"60082600","type":"CDM"},{"code":"301","type":"RC"},{"code":"84432","type":"HCPCS"}],"standard_charges":[{"gross_charge":141.0,"discounted_cash":77.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Thyroglobulin I","code_information":[{"code":"60082601","type":"CDM"},{"code":"301","type":"RC"},{"code":"84432","type":"HCPCS"}],"standard_charges":[{"gross_charge":141.0,"discounted_cash":77.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Thyroglobulin (Tumor Mrk)","code_information":[{"code":"60082602","type":"CDM"},{"code":"301","type":"RC"},{"code":"84432","type":"HCPCS"}],"standard_charges":[{"gross_charge":141.0,"discounted_cash":77.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Thyroglobulin Ii","code_information":[{"code":"60082603","type":"CDM"},{"code":"301","type":"RC"},{"code":"84432","type":"HCPCS"}],"standard_charges":[{"gross_charge":141.0,"discounted_cash":77.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Acetylcholine Receptor Bind Ab","code_information":[{"code":"60082640","type":"CDM"},{"code":"301","type":"RC"},{"code":"83519","type":"HCPCS"}],"standard_charges":[{"gross_charge":213.0,"discounted_cash":117.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Acetylcholine Receptor Bind Ab Ii","code_information":[{"code":"60082641","type":"CDM"},{"code":"301","type":"RC"},{"code":"83519","type":"HCPCS"}],"standard_charges":[{"gross_charge":209.0,"discounted_cash":114.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Acetylcholine Receptor Block Ab I","code_information":[{"code":"60082651","type":"CDM"},{"code":"301","type":"RC"},{"code":"83516","type":"HCPCS"}],"standard_charges":[{"gross_charge":174.0,"discounted_cash":95.7,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Acetylcholine Receptor Modul Ab Ii","code_information":[{"code":"60082662","type":"CDM"},{"code":"301","type":"RC"},{"code":"83516","type":"HCPCS"}],"standard_charges":[{"gross_charge":159.0,"discounted_cash":87.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Acetylcholine Receptor Modul Ab Iii","code_information":[{"code":"60082663","type":"CDM"},{"code":"301","type":"RC"},{"code":"83519","type":"HCPCS"}],"standard_charges":[{"gross_charge":135.0,"discounted_cash":74.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Troponin I","code_information":[{"code":"60082750","type":"CDM"},{"code":"301","type":"RC"},{"code":"84484","type":"HCPCS"}],"standard_charges":[{"gross_charge":159.0,"discounted_cash":87.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Creatinine Blood I","code_information":[{"code":"60082880","type":"CDM"},{"code":"301","type":"RC"},{"code":"82565","type":"HCPCS"}],"standard_charges":[{"gross_charge":51.0,"discounted_cash":28.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Ca 27.29","code_information":[{"code":"60082940","type":"CDM"},{"code":"302","type":"RC"},{"code":"86300","type":"HCPCS"}],"standard_charges":[{"gross_charge":287.0,"discounted_cash":157.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Protein C Activated Resistance","code_information":[{"code":"60083060","type":"CDM"},{"code":"305","type":"RC"},{"code":"85307","type":"HCPCS"}],"standard_charges":[{"gross_charge":171.0,"discounted_cash":94.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Tacrolimus Level","code_information":[{"code":"60083120","type":"CDM"},{"code":"301","type":"RC"},{"code":"80197","type":"HCPCS"}],"standard_charges":[{"gross_charge":223.0,"discounted_cash":122.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Hepatitis C Rna Pcr Quant","code_information":[{"code":"60083150","type":"CDM"},{"code":"306","type":"RC"},{"code":"87522","type":"HCPCS"}],"standard_charges":[{"gross_charge":850.0,"discounted_cash":467.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Psa Free","code_information":[{"code":"60083290","type":"CDM"},{"code":"301","type":"RC"},{"code":"84154","type":"HCPCS"}],"standard_charges":[{"gross_charge":182.0,"discounted_cash":100.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Alkaline Phosphatase Bone Specific Iso","code_information":[{"code":"60083341","type":"CDM"},{"code":"301","type":"RC"},{"code":"84080","type":"HCPCS"}],"standard_charges":[{"gross_charge":140.0,"discounted_cash":77.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Ehrlichia Antibody Igg","code_information":[{"code":"60083420","type":"CDM"},{"code":"302","type":"RC"},{"code":"86666","type":"HCPCS"}],"standard_charges":[{"gross_charge":201.0,"discounted_cash":110.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Ehrlichia Antibody Igm","code_information":[{"code":"60083430","type":"CDM"},{"code":"302","type":"RC"},{"code":"86666","type":"HCPCS"}],"standard_charges":[{"gross_charge":202.0,"discounted_cash":111.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Hepatitis B Surface Antibody Quant I","code_information":[{"code":"60083441","type":"CDM"},{"code":"302","type":"RC"},{"code":"86317","type":"HCPCS"}],"standard_charges":[{"gross_charge":46.0,"discounted_cash":25.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Reptilase Time","code_information":[{"code":"60083710","type":"CDM"},{"code":"305","type":"RC"},{"code":"85635","type":"HCPCS"}],"standard_charges":[{"gross_charge":77.0,"discounted_cash":42.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Reptilase Time I","code_information":[{"code":"60083711","type":"CDM"},{"code":"305","type":"RC"},{"code":"85635","type":"HCPCS"}],"standard_charges":[{"gross_charge":33.0,"discounted_cash":18.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Helicobacter Pylori Breath","code_information":[{"code":"60083750","type":"CDM"},{"code":"301","type":"RC"},{"code":"83013","type":"HCPCS"}],"standard_charges":[{"gross_charge":233.0,"discounted_cash":128.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Bartonella Ab Igg","code_information":[{"code":"60083830","type":"CDM"},{"code":"302","type":"RC"},{"code":"86611","type":"HCPCS"}],"standard_charges":[{"gross_charge":35.0,"discounted_cash":19.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Bartonella Ab Igm","code_information":[{"code":"60083840","type":"CDM"},{"code":"302","type":"RC"},{"code":"86611","type":"HCPCS"}],"standard_charges":[{"gross_charge":35.0,"discounted_cash":19.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Hydrocodone I","code_information":[{"code":"60083852","type":"CDM"},{"code":"301","type":"RC"},{"code":"80361","type":"HCPCS"}],"standard_charges":[{"gross_charge":190.0,"discounted_cash":104.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Interleukin-6","code_information":[{"code":"60083860","type":"CDM"},{"code":"301","type":"RC"},{"code":"83520","type":"HCPCS"}],"standard_charges":[{"gross_charge":204.0,"discounted_cash":112.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Htlv I Ii Antibody","code_information":[{"code":"60083890","type":"CDM"},{"code":"302","type":"RC"},{"code":"86790","type":"HCPCS"}],"standard_charges":[{"gross_charge":98.0,"discounted_cash":53.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Sulfonylurea Hypoglycemics Iv","code_information":[{"code":"60083906","type":"CDM"},{"code":"301","type":"RC"},{"code":"80307","type":"HCPCS"}],"standard_charges":[{"gross_charge":251.0,"discounted_cash":138.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Hemoglobin Serum","code_information":[{"code":"60083930","type":"CDM"},{"code":"301","type":"RC"},{"code":"84311","type":"HCPCS"}],"standard_charges":[{"gross_charge":116.0,"discounted_cash":63.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Strongyloides Antibody Igg","code_information":[{"code":"60084000","type":"CDM"},{"code":"302","type":"RC"},{"code":"86682","type":"HCPCS"}],"standard_charges":[{"gross_charge":39.0,"discounted_cash":21.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Hiv-1 Rna Pcr Quant","code_information":[{"code":"60084010","type":"CDM"},{"code":"306","type":"RC"},{"code":"87536","type":"HCPCS"}],"standard_charges":[{"gross_charge":345.0,"discounted_cash":189.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Tropheryma Whipplei Dna","code_information":[{"code":"60084040","type":"CDM"},{"code":"306","type":"RC"},{"code":"87798","type":"HCPCS"}],"standard_charges":[{"gross_charge":518.0,"discounted_cash":284.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Gliadin Antibody Igg","code_information":[{"code":"60084200","type":"CDM"},{"code":"301","type":"RC"},{"code":"83516","type":"HCPCS"}],"standard_charges":[{"gross_charge":138.0,"discounted_cash":75.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Gliadin Antibody Iga","code_information":[{"code":"60084210","type":"CDM"},{"code":"301","type":"RC"},{"code":"83516","type":"HCPCS"}],"standard_charges":[{"gross_charge":142.0,"discounted_cash":78.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Tsh Neonatal","code_information":[{"code":"60084260","type":"CDM"},{"code":"301","type":"RC"},{"code":"84443","type":"HCPCS"}],"standard_charges":[{"gross_charge":252.0,"discounted_cash":138.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Heparin Anti-Xa Lmwh","code_information":[{"code":"60084290","type":"CDM"},{"code":"305","type":"RC"},{"code":"85520","type":"HCPCS"}],"standard_charges":[{"gross_charge":105.0,"discounted_cash":57.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Nmr Lipoprofile","code_information":[{"code":"60084300","type":"CDM"},{"code":"301","type":"RC"},{"code":"83704","type":"HCPCS"}],"standard_charges":[{"gross_charge":487.0,"discounted_cash":267.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Hiv Genotype/Drug Resistant","code_information":[{"code":"60084400","type":"CDM"},{"code":"306","type":"RC"},{"code":"87901","type":"HCPCS"}],"standard_charges":[{"gross_charge":1950.0,"discounted_cash":1072.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Alkaline Phosphatase I","code_information":[{"code":"60084500","type":"CDM"},{"code":"301","type":"RC"},{"code":"84075","type":"HCPCS"}],"standard_charges":[{"gross_charge":83.0,"discounted_cash":45.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Hepatitis C Genotype","code_information":[{"code":"60084550","type":"CDM"},{"code":"306","type":"RC"},{"code":"87902","type":"HCPCS"}],"standard_charges":[{"gross_charge":5199.0,"discounted_cash":2859.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Culture Hsv W/Typing I","code_information":[{"code":"60084581","type":"CDM"},{"code":"306","type":"RC"},{"code":"87255","type":"HCPCS"}],"standard_charges":[{"gross_charge":138.0,"discounted_cash":75.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Zinc Protoporphyrin","code_information":[{"code":"60084710","type":"CDM"},{"code":"301","type":"RC"},{"code":"84202","type":"HCPCS"}],"standard_charges":[{"gross_charge":129.0,"discounted_cash":70.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Gammahydroxybutyrate Blood Ii","code_information":[{"code":"60084772","type":"CDM"},{"code":"301","type":"RC"},{"code":"80307","type":"HCPCS"}],"standard_charges":[{"gross_charge":151.0,"discounted_cash":83.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Venlafaxine Level I","code_information":[{"code":"60084791","type":"CDM"},{"code":"301","type":"RC"},{"code":"80338","type":"HCPCS"}],"standard_charges":[{"gross_charge":2.0,"discounted_cash":1.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Hydroxyindolacetic Acid","code_information":[{"code":"60084810","type":"CDM"},{"code":"301","type":"RC"},{"code":"83497","type":"HCPCS"}],"standard_charges":[{"gross_charge":205.0,"discounted_cash":112.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Helicobacter Pylori Antigen Stool","code_information":[{"code":"60084920","type":"CDM"},{"code":"306","type":"RC"},{"code":"87338","type":"HCPCS"}],"standard_charges":[{"gross_charge":219.0,"discounted_cash":120.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Flunitrazepam Urine Quant Ii","code_information":[{"code":"60084933","type":"CDM"},{"code":"301","type":"RC"},{"code":"80346","type":"HCPCS"}],"standard_charges":[{"gross_charge":288.0,"discounted_cash":158.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Olanzapine Level (Zyprexa) Ii","code_information":[{"code":"60084942","type":"CDM"},{"code":"301","type":"RC"},{"code":"80342","type":"HCPCS"}],"standard_charges":[{"gross_charge":136.0,"discounted_cash":74.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Beta-2 Glycoprotein","code_information":[{"code":"60085070","type":"CDM"},{"code":"302","type":"RC"},{"code":"86146","type":"HCPCS"}],"standard_charges":[{"gross_charge":61.0,"discounted_cash":33.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Tumor Necrosis","code_information":[{"code":"60085100","type":"CDM"},{"code":"301","type":"RC"},{"code":"83520","type":"HCPCS"}],"standard_charges":[{"gross_charge":165.0,"discounted_cash":90.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg N-Telopeptide Crossl Urine","code_information":[{"code":"60085170","type":"CDM"},{"code":"301","type":"RC"},{"code":"82523","type":"HCPCS"}],"standard_charges":[{"gross_charge":165.0,"discounted_cash":90.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Adenosine Deaminase","code_information":[{"code":"60085220","type":"CDM"},{"code":"301","type":"RC"},{"code":"84311","type":"HCPCS"}],"standard_charges":[{"gross_charge":116.0,"discounted_cash":63.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Oxcarbazepine Ii","code_information":[{"code":"60085232","type":"CDM"},{"code":"301","type":"RC"},{"code":"80183","type":"HCPCS"}],"standard_charges":[{"gross_charge":263.0,"discounted_cash":144.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Pancreatic Polypeptide","code_information":[{"code":"60085310","type":"CDM"},{"code":"301","type":"RC"},{"code":"83519","type":"HCPCS"}],"standard_charges":[{"gross_charge":180.0,"discounted_cash":99.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Chromogranin A","code_information":[{"code":"60085320","type":"CDM"},{"code":"302","type":"RC"},{"code":"86316","type":"HCPCS"}],"standard_charges":[{"gross_charge":318.0,"discounted_cash":174.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Fentanyls Blood I","code_information":[{"code":"60085341","type":"CDM"},{"code":"301","type":"RC"},{"code":"80354","type":"HCPCS"}],"standard_charges":[{"gross_charge":186.0,"discounted_cash":102.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Niacin","code_information":[{"code":"60085630","type":"CDM"},{"code":"301","type":"RC"},{"code":"84591","type":"HCPCS"}],"standard_charges":[{"gross_charge":56.0,"discounted_cash":30.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Allergen Milk Ige","code_information":[{"code":"60085850","type":"CDM"},{"code":"302","type":"RC"},{"code":"86003","type":"HCPCS"}],"standard_charges":[{"gross_charge":48.0,"discounted_cash":26.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Herpes Simplex 1+2 Antibody Igm","code_information":[{"code":"60085940","type":"CDM"},{"code":"302","type":"RC"},{"code":"86694","type":"HCPCS"}],"standard_charges":[{"gross_charge":213.0,"discounted_cash":117.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Angiotensin Convert Enzyme Csf","code_information":[{"code":"60086090","type":"CDM"},{"code":"301","type":"RC"},{"code":"82164","type":"HCPCS"}],"standard_charges":[{"gross_charge":231.0,"discounted_cash":127.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Lead Capillary","code_information":[{"code":"60086110","type":"CDM"},{"code":"301","type":"RC"},{"code":"83655","type":"HCPCS"}],"standard_charges":[{"gross_charge":128.0,"discounted_cash":70.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg T4 Free Direct Dialysis","code_information":[{"code":"60086170","type":"CDM"},{"code":"301","type":"RC"},{"code":"84439","type":"HCPCS"}],"standard_charges":[{"gross_charge":148.0,"discounted_cash":81.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Gammahydroxybutyrate Urine Iii","code_information":[{"code":"60086274","type":"CDM"},{"code":"301","type":"RC"},{"code":"80307","type":"HCPCS"}],"standard_charges":[{"gross_charge":151.0,"discounted_cash":83.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Zonisamide Level I","code_information":[{"code":"60086301","type":"CDM"},{"code":"301","type":"RC"},{"code":"80203","type":"HCPCS"}],"standard_charges":[{"gross_charge":274.0,"discounted_cash":150.7,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Babesia Ab Igg","code_information":[{"code":"60086330","type":"CDM"},{"code":"302","type":"RC"},{"code":"86753","type":"HCPCS"}],"standard_charges":[{"gross_charge":37.0,"discounted_cash":20.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Babesia Ab Igm","code_information":[{"code":"60086340","type":"CDM"},{"code":"302","type":"RC"},{"code":"86753","type":"HCPCS"}],"standard_charges":[{"gross_charge":37.0,"discounted_cash":20.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Noncdm Charge Record","code_information":[{"code":"60086410","type":"CDM"},{"code":"301","type":"RC"},{"code":"83516","type":"HCPCS"}],"standard_charges":[{"gross_charge":35.0,"discounted_cash":19.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Lchg Chlamydia Dna Probe I","code_information":[{"code":"60086440","type":"CDM"},{"code":"306","type":"RC"},{"code":"87491","type":"HCPCS"}],"standard_charges":[{"gross_charge":142.0,"discounted_cash":78.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Legionella By Pcr","code_information":[{"code":"60086590","type":"CDM"},{"code":"306","type":"RC"},{"code":"87541","type":"HCPCS"}],"standard_charges":[{"gross_charge":374.0,"discounted_cash":205.7,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Inhibin A","code_information":[{"code":"60086640","type":"CDM"},{"code":"302","type":"RC"},{"code":"86336","type":"HCPCS"}],"standard_charges":[{"gross_charge":165.0,"discounted_cash":90.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Tissue Transglutaminase Ab Iga","code_information":[{"code":"60086650","type":"CDM"},{"code":"301","type":"RC"},{"code":"83516","type":"HCPCS"}],"standard_charges":[{"gross_charge":189.0,"discounted_cash":103.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Smooth Muscle Antibody Titer","code_information":[{"code":"60086700","type":"CDM"},{"code":"302","type":"RC"},{"code":"86256","type":"HCPCS"}],"standard_charges":[{"gross_charge":110.0,"discounted_cash":60.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Striated Muscle Antibody Titer I","code_information":[{"code":"60086711","type":"CDM"},{"code":"302","type":"RC"},{"code":"86256","type":"HCPCS"}],"standard_charges":[{"gross_charge":110.0,"discounted_cash":60.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Endomysial Antibody Iga","code_information":[{"code":"60086730","type":"CDM"},{"code":"302","type":"RC"},{"code":"86256","type":"HCPCS"}],"standard_charges":[{"gross_charge":184.0,"discounted_cash":101.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Neuronal Nuclear Antibody Titer I","code_information":[{"code":"60086761","type":"CDM"},{"code":"302","type":"RC"},{"code":"86256","type":"HCPCS"}],"standard_charges":[{"gross_charge":110.0,"discounted_cash":60.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Neuronal Nuclear Antibody Titer Csf","code_information":[{"code":"60086762","type":"CDM"},{"code":"302","type":"RC"},{"code":"86256","type":"HCPCS"}],"standard_charges":[{"gross_charge":110.0,"discounted_cash":60.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Echinococcus Antibody","code_information":[{"code":"60086880","type":"CDM"},{"code":"302","type":"RC"},{"code":"86682","type":"HCPCS"}],"standard_charges":[{"gross_charge":117.0,"discounted_cash":64.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Tissue Transglutaminase Ab Igg","code_information":[{"code":"60087000","type":"CDM"},{"code":"301","type":"RC"},{"code":"83516","type":"HCPCS"}],"standard_charges":[{"gross_charge":138.0,"discounted_cash":75.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg West Nile Virus Antibody Igg","code_information":[{"code":"60087020","type":"CDM"},{"code":"302","type":"RC"},{"code":"86789","type":"HCPCS"}],"standard_charges":[{"gross_charge":136.0,"discounted_cash":74.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg West Nile Virus Antibody Igm","code_information":[{"code":"60087030","type":"CDM"},{"code":"302","type":"RC"},{"code":"86788","type":"HCPCS"}],"standard_charges":[{"gross_charge":87.0,"discounted_cash":47.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Vitamin B12 Binding Capacity","code_information":[{"code":"60087050","type":"CDM"},{"code":"301","type":"RC"},{"code":"82608","type":"HCPCS"}],"standard_charges":[{"gross_charge":48.0,"discounted_cash":26.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg West Nile Virus Antibody Igg Csf","code_information":[{"code":"60087350","type":"CDM"},{"code":"302","type":"RC"},{"code":"86789","type":"HCPCS"}],"standard_charges":[{"gross_charge":136.0,"discounted_cash":74.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg West Nile Virus Antibody Igm Csf","code_information":[{"code":"60087360","type":"CDM"},{"code":"302","type":"RC"},{"code":"86788","type":"HCPCS"}],"standard_charges":[{"gross_charge":87.0,"discounted_cash":47.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Adenosine Deaminase Fluid","code_information":[{"code":"60087390","type":"CDM"},{"code":"301","type":"RC"},{"code":"84311","type":"HCPCS"}],"standard_charges":[{"gross_charge":116.0,"discounted_cash":63.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Metanephrines Plasma","code_information":[{"code":"60087440","type":"CDM"},{"code":"301","type":"RC"},{"code":"83835","type":"HCPCS"}],"standard_charges":[{"gross_charge":253.0,"discounted_cash":139.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Progesterone I","code_information":[{"code":"60087460","type":"CDM"},{"code":"301","type":"RC"},{"code":"84144","type":"HCPCS"}],"standard_charges":[{"gross_charge":300.0,"discounted_cash":165.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Lyme Disease Pcr Csf","code_information":[{"code":"60087550","type":"CDM"},{"code":"306","type":"RC"},{"code":"87476","type":"HCPCS"}],"standard_charges":[{"gross_charge":690.0,"discounted_cash":379.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Porphyrins Fractionated Ii","code_information":[{"code":"60087572","type":"CDM"},{"code":"301","type":"RC"},{"code":"82542","type":"HCPCS"}],"standard_charges":[{"gross_charge":288.0,"discounted_cash":158.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Estrone","code_information":[{"code":"60087580","type":"CDM"},{"code":"301","type":"RC"},{"code":"82679","type":"HCPCS"}],"standard_charges":[{"gross_charge":84.0,"discounted_cash":46.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Nmp22 Urine","code_information":[{"code":"60087610","type":"CDM"},{"code":"302","type":"RC"},{"code":"86316","type":"HCPCS"}],"standard_charges":[{"gross_charge":314.0,"discounted_cash":172.7,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Oxycodone Urine Screen Ii","code_information":[{"code":"60087633","type":"CDM"},{"code":"301","type":"RC"},{"code":"80307","type":"HCPCS"}],"standard_charges":[{"gross_charge":146.0,"discounted_cash":80.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Gad-65 Antibody Iii","code_information":[{"code":"60087713","type":"CDM"},{"code":"302","type":"RC"},{"code":"86341","type":"HCPCS"}],"standard_charges":[{"gross_charge":191.0,"discounted_cash":105.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Cmv Dna Real-Time Pcr Qual","code_information":[{"code":"60087730","type":"CDM"},{"code":"306","type":"RC"},{"code":"87496","type":"HCPCS"}],"standard_charges":[{"gross_charge":142.0,"discounted_cash":78.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Cmv Dna Real-Time Pcr Quant","code_information":[{"code":"60087740","type":"CDM"},{"code":"306","type":"RC"},{"code":"87497","type":"HCPCS"}],"standard_charges":[{"gross_charge":180.0,"discounted_cash":99.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Complement C1 Esteras Inhib Func","code_information":[{"code":"60087951","type":"CDM"},{"code":"302","type":"RC"},{"code":"86161","type":"HCPCS"}],"standard_charges":[{"gross_charge":159.0,"discounted_cash":87.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Htlv I/Ii Antibody Western Blot","code_information":[{"code":"60087980","type":"CDM"},{"code":"302","type":"RC"},{"code":"86689","type":"HCPCS"}],"standard_charges":[{"gross_charge":179.0,"discounted_cash":98.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Biopsy Muscle H+E Tc","code_information":[{"code":"60088010","type":"CDM"},{"code":"310","type":"RC"},{"code":"88305","type":"HCPCS"}],"standard_charges":[{"gross_charge":479.0,"discounted_cash":263.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Biopsy Muscle H+E Pc","code_information":[{"code":"60088020","type":"CDM"},{"code":"310","type":"RC"},{"code":"88305","type":"HCPCS"}],"standard_charges":[{"gross_charge":494.0,"discounted_cash":271.7,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Mrs Histochemistry Tc","code_information":[{"code":"60088150","type":"CDM"},{"code":"312","type":"RC"},{"code":"88319","type":"HCPCS"}],"standard_charges":[{"gross_charge":384.0,"discounted_cash":211.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Immunoassay Analyte Quantitative","code_information":[{"code":"60088180","type":"CDM"},{"code":"301","type":"RC"},{"code":"83520","type":"HCPCS"}],"standard_charges":[{"gross_charge":47.0,"discounted_cash":25.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Noncdm Charge Record","code_information":[{"code":"60088189","type":"CDM"},{"code":"301","type":"RC"},{"code":"83520","type":"HCPCS"}],"standard_charges":[{"gross_charge":35.67,"discounted_cash":19.62,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Lchg Pth Hormone","code_information":[{"code":"60088260","type":"CDM"},{"code":"301","type":"RC"},{"code":"83970","type":"HCPCS"}],"standard_charges":[{"gross_charge":260.0,"discounted_cash":143.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Aspergillus I","code_information":[{"code":"60088320","type":"CDM"},{"code":"302","type":"RC"},{"code":"86606","type":"HCPCS"}],"standard_charges":[{"gross_charge":87.0,"discounted_cash":47.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Coccidioides Antibody I","code_information":[{"code":"60088340","type":"CDM"},{"code":"302","type":"RC"},{"code":"86635","type":"HCPCS"}],"standard_charges":[{"gross_charge":38.0,"discounted_cash":20.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Histoplasma I","code_information":[{"code":"60088350","type":"CDM"},{"code":"302","type":"RC"},{"code":"86698","type":"HCPCS"}],"standard_charges":[{"gross_charge":78.0,"discounted_cash":42.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Bordetella Pcr Each","code_information":[{"code":"60088460","type":"CDM"},{"code":"306","type":"RC"},{"code":"87798","type":"HCPCS"}],"standard_charges":[{"gross_charge":499.0,"discounted_cash":274.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Sirolimus","code_information":[{"code":"60088480","type":"CDM"},{"code":"301","type":"RC"},{"code":"80195","type":"HCPCS"}],"standard_charges":[{"gross_charge":47.0,"discounted_cash":25.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Culture Salmonella+Shigella","code_information":[{"code":"60088520","type":"CDM"},{"code":"306","type":"RC"},{"code":"87045","type":"HCPCS"}],"standard_charges":[{"gross_charge":214.0,"discounted_cash":117.7,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Culture Stool Each Organism","code_information":[{"code":"60088530","type":"CDM"},{"code":"306","type":"RC"},{"code":"87046","type":"HCPCS"}],"standard_charges":[{"gross_charge":156.0,"discounted_cash":85.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Organism Id Aerobe","code_information":[{"code":"60088550","type":"CDM"},{"code":"306","type":"RC"},{"code":"87077","type":"HCPCS"}],"standard_charges":[{"gross_charge":50.0,"discounted_cash":27.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Organism Id Aerobe Each Refer","code_information":[{"code":"60088551","type":"CDM"},{"code":"306","type":"RC"},{"code":"87077","type":"HCPCS"}],"standard_charges":[{"gross_charge":47.0,"discounted_cash":25.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Organism Id Arthropod","code_information":[{"code":"60088570","type":"CDM"},{"code":"306","type":"RC"},{"code":"87168","type":"HCPCS"}],"standard_charges":[{"gross_charge":18.0,"discounted_cash":9.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Drvvt 50/50","code_information":[{"code":"60088830","type":"CDM"},{"code":"305","type":"RC"},{"code":"85613","type":"HCPCS"}],"standard_charges":[{"gross_charge":91.0,"discounted_cash":50.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Drvvt 50/50 I","code_information":[{"code":"60088831","type":"CDM"},{"code":"305","type":"RC"},{"code":"85613","type":"HCPCS"}],"standard_charges":[{"gross_charge":145.0,"discounted_cash":79.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Culture Typing Immuno","code_information":[{"code":"60088920","type":"CDM"},{"code":"306","type":"RC"},{"code":"87140","type":"HCPCS"}],"standard_charges":[{"gross_charge":66.0,"discounted_cash":36.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Fluorescent Antibody Screen","code_information":[{"code":"60089220","type":"CDM"},{"code":"302","type":"RC"},{"code":"86255","type":"HCPCS"}],"standard_charges":[{"gross_charge":124.0,"discounted_cash":68.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Rheumatoid Factor Ii","code_information":[{"code":"60089230","type":"CDM"},{"code":"302","type":"RC"},{"code":"86431","type":"HCPCS"}],"standard_charges":[{"gross_charge":91.0,"discounted_cash":50.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Cd4/Cd8 + Ratio I","code_information":[{"code":"60089410","type":"CDM"},{"code":"302","type":"RC"},{"code":"86360","type":"HCPCS"}],"standard_charges":[{"gross_charge":708.0,"discounted_cash":389.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg T Cell Total","code_information":[{"code":"60089420","type":"CDM"},{"code":"302","type":"RC"},{"code":"86359","type":"HCPCS"}],"standard_charges":[{"gross_charge":569.0,"discounted_cash":312.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Ptt Ii","code_information":[{"code":"60089550","type":"CDM"},{"code":"305","type":"RC"},{"code":"85730","type":"HCPCS"}],"standard_charges":[{"gross_charge":36.0,"discounted_cash":19.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Drvvt Screen","code_information":[{"code":"60089570","type":"CDM"},{"code":"305","type":"RC"},{"code":"85613","type":"HCPCS"}],"standard_charges":[{"gross_charge":145.0,"discounted_cash":79.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Thrombin Time I","code_information":[{"code":"60089600","type":"CDM"},{"code":"305","type":"RC"},{"code":"85670","type":"HCPCS"}],"standard_charges":[{"gross_charge":90.0,"discounted_cash":49.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Albumin Index","code_information":[{"code":"60089650","type":"CDM"},{"code":"301","type":"RC"},{"code":"82040","type":"HCPCS"}],"standard_charges":[{"gross_charge":75.0,"discounted_cash":41.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Igg Index","code_information":[{"code":"60089660","type":"CDM"},{"code":"301","type":"RC"},{"code":"82784","type":"HCPCS"}],"standard_charges":[{"gross_charge":106.0,"discounted_cash":58.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Iga Blood I","code_information":[{"code":"60089850","type":"CDM"},{"code":"301","type":"RC"},{"code":"82784","type":"HCPCS"}],"standard_charges":[{"gross_charge":152.0,"discounted_cash":83.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Chemiluminescent Assay","code_information":[{"code":"60089880","type":"CDM"},{"code":"301","type":"RC"},{"code":"82397","type":"HCPCS"}],"standard_charges":[{"gross_charge":226.0,"discounted_cash":124.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Cytopath Othr Sourc Prep Scrn Intrp Nl","code_information":[{"code":"60089900","type":"CDM"},{"code":"310","type":"RC"},{"code":"88161","type":"HCPCS"}],"standard_charges":[{"gross_charge":103.0,"discounted_cash":56.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Ena Ii","code_information":[{"code":"60089920","type":"CDM"},{"code":"302","type":"RC"},{"code":"86235","type":"HCPCS"}],"standard_charges":[{"gross_charge":269.0,"discounted_cash":147.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Hepatitis C Quantitative","code_information":[{"code":"60089980","type":"CDM"},{"code":"306","type":"RC"},{"code":"87522","type":"HCPCS"}],"standard_charges":[{"gross_charge":860.0,"discounted_cash":473.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Mopath Procedure Level 2 Apoe","code_information":[{"code":"60100080","type":"CDM"},{"code":"310","type":"RC"},{"code":"81401","type":"HCPCS"}],"standard_charges":[{"gross_charge":1376.0,"discounted_cash":756.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Pmp22 Gene Full Sequence","code_information":[{"code":"60100120","type":"CDM"},{"code":"310","type":"RC"},{"code":"81325","type":"HCPCS"}],"standard_charges":[{"gross_charge":3724.0,"discounted_cash":2048.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Receptor Antibody If Titer Nmda","code_information":[{"code":"60101230","type":"CDM"},{"code":"302","type":"RC"},{"code":"86256","type":"HCPCS"}],"standard_charges":[{"gross_charge":110.0,"discounted_cash":60.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Receptor Antibody Ampa","code_information":[{"code":"60101240","type":"CDM"},{"code":"302","type":"RC"},{"code":"86255","type":"HCPCS"}],"standard_charges":[{"gross_charge":124.0,"discounted_cash":68.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Receptor Antibody If Titer Ampa","code_information":[{"code":"60101250","type":"CDM"},{"code":"302","type":"RC"},{"code":"86256","type":"HCPCS"}],"standard_charges":[{"gross_charge":110.0,"discounted_cash":60.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Receptor Antibody Gaba-B","code_information":[{"code":"60101260","type":"CDM"},{"code":"302","type":"RC"},{"code":"86255","type":"HCPCS"}],"standard_charges":[{"gross_charge":124.0,"discounted_cash":68.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Receptor Antibody If Titer Gaba-B","code_information":[{"code":"60101270","type":"CDM"},{"code":"302","type":"RC"},{"code":"86256","type":"HCPCS"}],"standard_charges":[{"gross_charge":110.0,"discounted_cash":60.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Digoxin Level Free","code_information":[{"code":"60101280","type":"CDM"},{"code":"301","type":"RC"},{"code":"80163","type":"HCPCS"}],"standard_charges":[{"gross_charge":38.0,"discounted_cash":20.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Drug Screen Multi Class A Non-Tlc Iv","code_information":[{"code":"60101304","type":"CDM"},{"code":"301","type":"RC"},{"code":"80306","type":"HCPCS"}],"standard_charges":[{"gross_charge":305.0,"discounted_cash":167.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Drug Screen Sglcls A Vi","code_information":[{"code":"60101326","type":"CDM"},{"code":"301","type":"RC"},{"code":"80307","type":"HCPCS"}],"standard_charges":[{"gross_charge":151.0,"discounted_cash":83.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Drug Screen Sglcls A Vii","code_information":[{"code":"60101327","type":"CDM"},{"code":"301","type":"RC"},{"code":"80307","type":"HCPCS"}],"standard_charges":[{"gross_charge":305.0,"discounted_cash":167.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Drug Screen Presump Anycls Ea Othr Iv","code_information":[{"code":"60101354","type":"CDM"},{"code":"301","type":"RC"},{"code":"80307","type":"HCPCS"}],"standard_charges":[{"gross_charge":549.0,"discounted_cash":301.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Opiates Urine Confirmation Iii","code_information":[{"code":"60101363","type":"CDM"},{"code":"301","type":"RC"},{"code":"80364","type":"HCPCS"}],"standard_charges":[{"gross_charge":343.0,"discounted_cash":188.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Opiates Blood Confirmation Ii","code_information":[{"code":"60101365","type":"CDM"},{"code":"301","type":"RC"},{"code":"80361","type":"HCPCS"}],"standard_charges":[{"gross_charge":190.0,"discounted_cash":104.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Opiates Urine Confirmation Iv","code_information":[{"code":"60101366","type":"CDM"},{"code":"301","type":"RC"},{"code":"80361","type":"HCPCS"}],"standard_charges":[{"gross_charge":196.0,"discounted_cash":107.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Cocaine Blood Confirm I","code_information":[{"code":"60101370","type":"CDM"},{"code":"301","type":"RC"},{"code":"80353","type":"HCPCS"}],"standard_charges":[{"gross_charge":353.0,"discounted_cash":194.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Cocaine Meconium Confirm I","code_information":[{"code":"60101371","type":"CDM"},{"code":"301","type":"RC"},{"code":"80353","type":"HCPCS"}],"standard_charges":[{"gross_charge":337.0,"discounted_cash":185.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Barbiturate Blood Confirmation I","code_information":[{"code":"60101380","type":"CDM"},{"code":"301","type":"RC"},{"code":"80345","type":"HCPCS"}],"standard_charges":[{"gross_charge":375.0,"discounted_cash":206.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Barbiturate Urine Confirmation Iii","code_information":[{"code":"60101383","type":"CDM"},{"code":"301","type":"RC"},{"code":"80345","type":"HCPCS"}],"standard_charges":[{"gross_charge":375.0,"discounted_cash":206.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Benzodiazepine Urine Confirm Iii","code_information":[{"code":"60101393","type":"CDM"},{"code":"301","type":"RC"},{"code":"80347","type":"HCPCS"}],"standard_charges":[{"gross_charge":343.0,"discounted_cash":188.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Benzodiazepine Urine Confirm Iv","code_information":[{"code":"60101394","type":"CDM"},{"code":"301","type":"RC"},{"code":"80346","type":"HCPCS"}],"standard_charges":[{"gross_charge":136.0,"discounted_cash":74.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Amphetamine Urine Confirm Iii","code_information":[{"code":"60101403","type":"CDM"},{"code":"301","type":"RC"},{"code":"80326","type":"HCPCS"}],"standard_charges":[{"gross_charge":343.0,"discounted_cash":188.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Amphetamine Blood Confirm Ii","code_information":[{"code":"60101404","type":"CDM"},{"code":"301","type":"RC"},{"code":"80324","type":"HCPCS"}],"standard_charges":[{"gross_charge":343.0,"discounted_cash":188.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Methadone Urine Confirmation Iii","code_information":[{"code":"60101411","type":"CDM"},{"code":"301","type":"RC"},{"code":"80358","type":"HCPCS"}],"standard_charges":[{"gross_charge":224.0,"discounted_cash":123.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Cutaneous Immunofluorescence Ab","code_information":[{"code":"60101430","type":"CDM"},{"code":"302","type":"RC"},{"code":"86255","type":"HCPCS"}],"standard_charges":[{"gross_charge":124.0,"discounted_cash":68.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Drug Screen Umbilical 80307","code_information":[{"code":"60101461","type":"CDM"},{"code":"301","type":"RC"},{"code":"80307","type":"HCPCS"}],"standard_charges":[{"gross_charge":364.0,"discounted_cash":200.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Alcohol Biomarkers 1-2","code_information":[{"code":"60101530","type":"CDM"},{"code":"301","type":"RC"},{"code":"80321","type":"HCPCS"}],"standard_charges":[{"gross_charge":353.0,"discounted_cash":194.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Amphetamines 3-4","code_information":[{"code":"60101570","type":"CDM"},{"code":"301","type":"RC"},{"code":"80325","type":"HCPCS"}],"standard_charges":[{"gross_charge":150.0,"discounted_cash":82.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Amphetamines  5 Or More","code_information":[{"code":"60101580","type":"CDM"},{"code":"301","type":"RC"},{"code":"80326","type":"HCPCS"}],"standard_charges":[{"gross_charge":343.0,"discounted_cash":188.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Antidepressants Not Specified","code_information":[{"code":"60101700","type":"CDM"},{"code":"301","type":"RC"},{"code":"80338","type":"HCPCS"}],"standard_charges":[{"gross_charge":264.0,"discounted_cash":145.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Benzodiazepines 13 Or More","code_information":[{"code":"60101780","type":"CDM"},{"code":"301","type":"RC"},{"code":"80347","type":"HCPCS"}],"standard_charges":[{"gross_charge":343.0,"discounted_cash":188.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Opiates + Opiate Analogs 5 Or More I","code_information":[{"code":"60101851","type":"CDM"},{"code":"301","type":"RC"},{"code":"80364","type":"HCPCS"}],"standard_charges":[{"gross_charge":150.0,"discounted_cash":82.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Skeletal Muscle Relaxants 1-2","code_information":[{"code":"60101870","type":"CDM"},{"code":"301","type":"RC"},{"code":"80369","type":"HCPCS"}],"standard_charges":[{"gross_charge":186.0,"discounted_cash":102.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Ihc Adtl Stn Each Pc","code_information":[{"code":"60101930","type":"CDM"},{"code":"971","type":"RC"},{"code":"88341","type":"HCPCS"}],"standard_charges":[{"gross_charge":300.0,"discounted_cash":165.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Ihc Adtl Stn Each Ref Tc","code_information":[{"code":"60101950","type":"CDM"},{"code":"310","type":"RC"},{"code":"88341","type":"HCPCS"}],"standard_charges":[{"gross_charge":462.0,"discounted_cash":254.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Ihc Adtl Stn Each Ref Nl","code_information":[{"code":"60101960","type":"CDM"},{"code":"310","type":"RC"},{"code":"88341","type":"HCPCS"}],"standard_charges":[{"gross_charge":472.0,"discounted_cash":259.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Ihc Adtl Stn Each Tc","code_information":[{"code":"60101970","type":"CDM"},{"code":"310","type":"RC"},{"code":"88341","type":"HCPCS"}],"standard_charges":[{"gross_charge":459.0,"discounted_cash":252.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Ihc Multiplex Antibody Stn Tc","code_information":[{"code":"60101990","type":"CDM"},{"code":"310","type":"RC"},{"code":"88344","type":"HCPCS"}],"standard_charges":[{"gross_charge":472.0,"discounted_cash":259.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Hpv High Risk Types","code_information":[{"code":"60102110","type":"CDM"},{"code":"306","type":"RC"},{"code":"87624","type":"HCPCS"}],"standard_charges":[{"gross_charge":449.0,"discounted_cash":246.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Mlh1 Promoter Methylation","code_information":[{"code":"60102180","type":"CDM"},{"code":"310","type":"RC"},{"code":"81288","type":"HCPCS"}],"standard_charges":[{"gross_charge":958.0,"discounted_cash":526.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Methylenedioxyamphetamines Confirm Blood","code_information":[{"code":"60102202","type":"CDM"},{"code":"301","type":"RC"},{"code":"80359","type":"HCPCS"}],"standard_charges":[{"gross_charge":343.0,"discounted_cash":188.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Mopath Procedure Unlisted","code_information":[{"code":"60102430","type":"CDM"},{"code":"310","type":"RC"},{"code":"81479","type":"HCPCS"}],"standard_charges":[{"gross_charge":4738.0,"discounted_cash":2605.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Mopath Procedure Unlisted I","code_information":[{"code":"60102431","type":"CDM"},{"code":"310","type":"RC"},{"code":"81479","type":"HCPCS"}],"standard_charges":[{"gross_charge":1104.0,"discounted_cash":607.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Pten Sequencing Known Variant","code_information":[{"code":"60102450","type":"CDM"},{"code":"310","type":"RC"},{"code":"81322","type":"HCPCS"}],"standard_charges":[{"gross_charge":226.0,"discounted_cash":124.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Alcohols","code_information":[{"code":"60102460","type":"CDM"},{"code":"301","type":"RC"},{"code":"80320","type":"HCPCS"}],"standard_charges":[{"gross_charge":354.0,"discounted_cash":194.7,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Alcohol Urine Screen I","code_information":[{"code":"60102551","type":"CDM"},{"code":"301","type":"RC"},{"code":"80307","type":"HCPCS"}],"standard_charges":[{"gross_charge":200.0,"discounted_cash":110.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Jc Virus Pcr Quantitative","code_information":[{"code":"60102680","type":"CDM"},{"code":"306","type":"RC"},{"code":"87799","type":"HCPCS"}],"standard_charges":[{"gross_charge":479.0,"discounted_cash":263.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Alk Gene Rearrangement By Fish","code_information":[{"code":"60102760","type":"CDM"},{"code":"310","type":"RC"},{"code":"88366","type":"HCPCS"}],"standard_charges":[{"gross_charge":1219.0,"discounted_cash":670.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Treponema Pallidum Antibody","code_information":[{"code":"60102850","type":"CDM"},{"code":"302","type":"RC"},{"code":"86780","type":"HCPCS"}],"standard_charges":[{"gross_charge":41.0,"discounted_cash":22.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Treponema Pallidum Antibody I","code_information":[{"code":"60102851","type":"CDM"},{"code":"302","type":"RC"},{"code":"86780","type":"HCPCS"}],"standard_charges":[{"gross_charge":385.0,"discounted_cash":211.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Glucose Urine Random","code_information":[{"code":"60103420","type":"CDM"},{"code":"301","type":"RC"},{"code":"82945","type":"HCPCS"}],"standard_charges":[{"gross_charge":41.0,"discounted_cash":22.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Glucose Urine Timed","code_information":[{"code":"60103430","type":"CDM"},{"code":"301","type":"RC"},{"code":"82945","type":"HCPCS"}],"standard_charges":[{"gross_charge":69.0,"discounted_cash":37.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Chikungunya Antibody Igg","code_information":[{"code":"60103650","type":"CDM"},{"code":"302","type":"RC"},{"code":"86790","type":"HCPCS"}],"standard_charges":[{"gross_charge":98.0,"discounted_cash":53.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Des-Gamma-Carboxy Prothrombin","code_information":[{"code":"60103760","type":"CDM"},{"code":"301","type":"RC"},{"code":"83951","type":"HCPCS"}],"standard_charges":[{"gross_charge":186.0,"discounted_cash":102.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Dna Antibody Double Strand W/Rflx","code_information":[{"code":"60103770","type":"CDM"},{"code":"302","type":"RC"},{"code":"86225","type":"HCPCS"}],"standard_charges":[{"gross_charge":203.0,"discounted_cash":111.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Dna Antibody Ds Crithidia Ifa","code_information":[{"code":"60103780","type":"CDM"},{"code":"302","type":"RC"},{"code":"86225","type":"HCPCS"}],"standard_charges":[{"gross_charge":203.0,"discounted_cash":111.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Noncdm Charge Record","code_information":[{"code":"60103870","type":"CDM"},{"code":"306","type":"RC"},{"code":"87185","type":"HCPCS"}],"standard_charges":[{"gross_charge":58.5,"discounted_cash":32.18,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Lchg Morphometric Tumor Ihc Manual Tc","code_information":[{"code":"60104020","type":"CDM"},{"code":"310","type":"RC"},{"code":"88360","type":"HCPCS"}],"standard_charges":[{"gross_charge":619.0,"discounted_cash":340.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Drug Screen Comprehensive 80307","code_information":[{"code":"60104041","type":"CDM"},{"code":"301","type":"RC"},{"code":"80307","type":"HCPCS"}],"standard_charges":[{"gross_charge":151.0,"discounted_cash":83.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Methylenedioxyamphetamines Ur Comp","code_information":[{"code":"60104070","type":"CDM"},{"code":"301","type":"RC"},{"code":"80359","type":"HCPCS"}],"standard_charges":[{"gross_charge":343.0,"discounted_cash":188.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Myeloid Malignancy Gene Seq","code_information":[{"code":"60104210","type":"CDM"},{"code":"310","type":"RC"},{"code":"81455","type":"HCPCS"}],"standard_charges":[{"gross_charge":12613.0,"discounted_cash":6937.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Chikungunya Antibody Igm","code_information":[{"code":"60104220","type":"CDM"},{"code":"302","type":"RC"},{"code":"86790","type":"HCPCS"}],"standard_charges":[{"gross_charge":98.0,"discounted_cash":53.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Tissue In Situ Hybrid Multiplex Tc","code_information":[{"code":"60104250","type":"CDM"},{"code":"310","type":"RC"},{"code":"88366","type":"HCPCS"}],"standard_charges":[{"gross_charge":2039.0,"discounted_cash":1121.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Thyroxine Binding Capacity","code_information":[{"code":"60104310","type":"CDM"},{"code":"301","type":"RC"},{"code":"84479","type":"HCPCS"}],"standard_charges":[{"gross_charge":102.0,"discounted_cash":56.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Alpha Defensins Antibody","code_information":[{"code":"60104500","type":"CDM"},{"code":"301","type":"RC"},{"code":"83516","type":"HCPCS"}],"standard_charges":[{"gross_charge":174.0,"discounted_cash":95.7,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Bacterial Id Nonenteric Php","code_information":[{"code":"60104580","type":"CDM"},{"code":"306","type":"RC"},{"code":"87077","type":"HCPCS"}],"standard_charges":[{"gross_charge":48.0,"discounted_cash":26.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Enteric Bacterial Id","code_information":[{"code":"60104590","type":"CDM"},{"code":"306","type":"RC"},{"code":"87077","type":"HCPCS"}],"standard_charges":[{"gross_charge":34.0,"discounted_cash":18.7,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Flt3 Tkd Variants","code_information":[{"code":"60105240","type":"CDM"},{"code":"310","type":"RC"},{"code":"81246","type":"HCPCS"}],"standard_charges":[{"gross_charge":402.0,"discounted_cash":221.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Clobazam Quant Blood I","code_information":[{"code":"60105321","type":"CDM"},{"code":"301","type":"RC"},{"code":"80339","type":"HCPCS"}],"standard_charges":[{"gross_charge":284.0,"discounted_cash":156.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Paraneoplastic Abs Rflx Screen Csf","code_information":[{"code":"60105590","type":"CDM"},{"code":"302","type":"RC"},{"code":"86255","type":"HCPCS"}],"standard_charges":[{"gross_charge":184.0,"discounted_cash":101.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Adamts13 Activity Inhibitor","code_information":[{"code":"60106340","type":"CDM"},{"code":"305","type":"RC"},{"code":"85335","type":"HCPCS"}],"standard_charges":[{"gross_charge":240.0,"discounted_cash":132.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Calr Gene Anaylsis","code_information":[{"code":"60106460","type":"CDM"},{"code":"310","type":"RC"},{"code":"81219","type":"HCPCS"}],"standard_charges":[{"gross_charge":607.0,"discounted_cash":333.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Immunofluorescent Study Adtl Stn Tc","code_information":[{"code":"60106470","type":"CDM"},{"code":"310","type":"RC"},{"code":"88350","type":"HCPCS"}],"standard_charges":[{"gross_charge":150.0,"discounted_cash":82.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Immunofluorescent Study Adtl Stn Pc","code_information":[{"code":"60106490","type":"CDM"},{"code":"971","type":"RC"},{"code":"88350","type":"HCPCS"}],"standard_charges":[{"gross_charge":95.0,"discounted_cash":52.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Oxycodone Blood Confirmation","code_information":[{"code":"60106500","type":"CDM"},{"code":"301","type":"RC"},{"code":"80365","type":"HCPCS"}],"standard_charges":[{"gross_charge":213.0,"discounted_cash":117.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Kit Targeted Seq Gene Analysis","code_information":[{"code":"60106520","type":"CDM"},{"code":"310","type":"RC"},{"code":"81272","type":"HCPCS"}],"standard_charges":[{"gross_charge":1424.0,"discounted_cash":783.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Pdgfra Gene Analysis","code_information":[{"code":"60106530","type":"CDM"},{"code":"310","type":"RC"},{"code":"81314","type":"HCPCS"}],"standard_charges":[{"gross_charge":1424.0,"discounted_cash":783.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Kit D816 Gene Analysis","code_information":[{"code":"60106540","type":"CDM"},{"code":"310","type":"RC"},{"code":"81273","type":"HCPCS"}],"standard_charges":[{"gross_charge":1250.0,"discounted_cash":687.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Kras Gene Analysis Adtl Variants","code_information":[{"code":"60106550","type":"CDM"},{"code":"310","type":"RC"},{"code":"81276","type":"HCPCS"}],"standard_charges":[{"gross_charge":1555.0,"discounted_cash":855.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Nras Gene Analysis","code_information":[{"code":"60106600","type":"CDM"},{"code":"310","type":"RC"},{"code":"81311","type":"HCPCS"}],"standard_charges":[{"gross_charge":1430.0,"discounted_cash":786.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Methyl Thioquanine-6 Quant","code_information":[{"code":"60106680","type":"CDM"},{"code":"301","type":"RC"},{"code":"82542","type":"HCPCS"}],"standard_charges":[{"gross_charge":288.0,"discounted_cash":158.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Psa Ultrasensitive","code_information":[{"code":"60106980","type":"CDM"},{"code":"301","type":"RC"},{"code":"84153","type":"HCPCS"}],"standard_charges":[{"gross_charge":267.0,"discounted_cash":146.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Mopath Procedure Level 5 Egfr2","code_information":[{"code":"60107220","type":"CDM"},{"code":"310","type":"RC"},{"code":"81404","type":"HCPCS"}],"standard_charges":[{"gross_charge":1331.0,"discounted_cash":732.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Flow Cell Cd20 1St Marker","code_information":[{"code":"60108150","type":"CDM"},{"code":"311","type":"RC"},{"code":"88184","type":"HCPCS"}],"standard_charges":[{"gross_charge":185.0,"discounted_cash":101.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Flow Cell Cd20 Add Each Marker","code_information":[{"code":"60108160","type":"CDM"},{"code":"311","type":"RC"},{"code":"88185","type":"HCPCS"}],"standard_charges":[{"gross_charge":179.0,"discounted_cash":98.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Oncology Breast Mrna","code_information":[{"code":"60108660","type":"CDM"},{"code":"310","type":"RC"},{"code":"81519","type":"HCPCS"}],"standard_charges":[{"gross_charge":13246.0,"discounted_cash":7285.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Buprenorphine Blood Confirm","code_information":[{"code":"60108790","type":"CDM"},{"code":"301","type":"RC"},{"code":"80348","type":"HCPCS"}],"standard_charges":[{"gross_charge":138.0,"discounted_cash":75.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Tranforming Growth Factor Beta","code_information":[{"code":"60108890","type":"CDM"},{"code":"301","type":"RC"},{"code":"83520","type":"HCPCS"}],"standard_charges":[{"gross_charge":152.0,"discounted_cash":83.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Neuromyelitis Optica Ab Titer","code_information":[{"code":"60108950","type":"CDM"},{"code":"302","type":"RC"},{"code":"86256","type":"HCPCS"}],"standard_charges":[{"gross_charge":110.0,"discounted_cash":60.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Factor Ix Inhibitor","code_information":[{"code":"60109090","type":"CDM"},{"code":"305","type":"RC"},{"code":"85335","type":"HCPCS"}],"standard_charges":[{"gross_charge":240.0,"discounted_cash":132.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Microdissection Manual Nras","code_information":[{"code":"60109510","type":"CDM"},{"code":"310","type":"RC"},{"code":"88381","type":"HCPCS"}],"standard_charges":[{"gross_charge":217.0,"discounted_cash":119.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Noncdm Charge Record","code_information":[{"code":"60109520","type":"CDM"},{"code":"310","type":"RC"},{"code":"81479","type":"HCPCS"}],"standard_charges":[{"gross_charge":489.0,"discounted_cash":268.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Lchg Testosterone Bioavailable","code_information":[{"code":"60109580","type":"CDM"},{"code":"301","type":"RC"},{"code":"84410","type":"HCPCS"}],"standard_charges":[{"gross_charge":168.0,"discounted_cash":92.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Gastrointestinal Pathogen","code_information":[{"code":"60110020","type":"CDM"},{"code":"306","type":"RC"},{"code":"87506","type":"HCPCS"}],"standard_charges":[{"gross_charge":2081.0,"discounted_cash":1144.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Cns Dna Amp Probe Type 12-25","code_information":[{"code":"60110040","type":"CDM"},{"code":"306","type":"RC"},{"code":"87483","type":"HCPCS"}],"standard_charges":[{"gross_charge":1691.0,"discounted_cash":930.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Dna Extraction Gene","code_information":[{"code":"60110080","type":"CDM"},{"code":"310","type":"RC"},{"code":"81479","type":"HCPCS"}],"standard_charges":[{"gross_charge":187.0,"discounted_cash":102.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Mumps Virus Pcr","code_information":[{"code":"60110090","type":"CDM"},{"code":"306","type":"RC"},{"code":"87798","type":"HCPCS"}],"standard_charges":[{"gross_charge":518.0,"discounted_cash":284.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Enterovirus Antibody","code_information":[{"code":"60110110","type":"CDM"},{"code":"302","type":"RC"},{"code":"86658","type":"HCPCS"}],"standard_charges":[{"gross_charge":40.0,"discounted_cash":22.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Historical Neg Antigen","code_information":[{"code":"60110120","type":"CDM"},{"code":"302","type":"RC"},{"code":"86999","type":"HCPCS"}],"standard_charges":[{"gross_charge":124.0,"discounted_cash":68.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Carnitine Urine Free + Total","code_information":[{"code":"60110320","type":"CDM"},{"code":"301","type":"RC"},{"code":"82379","type":"HCPCS"}],"standard_charges":[{"gross_charge":231.0,"discounted_cash":127.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Pd-L1 28-8 By Ihc","code_information":[{"code":"60110480","type":"CDM"},{"code":"310","type":"RC"},{"code":"88341","type":"HCPCS"}],"standard_charges":[{"gross_charge":472.0,"discounted_cash":259.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Fluorescent Noninfect Ab Screen Ii","code_information":[{"code":"60111070","type":"CDM"},{"code":"302","type":"RC"},{"code":"86255","type":"HCPCS"}],"standard_charges":[{"gross_charge":124.0,"discounted_cash":68.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Noncdm Charge Record","code_information":[{"code":"60111120","type":"CDM"},{"code":"310","type":"RC"},{"code":"G0416","type":"HCPCS"}],"standard_charges":[{"gross_charge":728.0,"discounted_cash":400.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Lchg Antigen Id Rare","code_information":[{"code":"60111140","type":"CDM"},{"code":"302","type":"RC"},{"code":"86902","type":"HCPCS"}],"standard_charges":[{"gross_charge":832.0,"discounted_cash":457.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Sed Rate Auto","code_information":[{"code":"60111160","type":"CDM"},{"code":"305","type":"RC"},{"code":"85652","type":"HCPCS"}],"standard_charges":[{"gross_charge":53.0,"discounted_cash":29.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Lyme Disease Pcr","code_information":[{"code":"60111260","type":"CDM"},{"code":"306","type":"RC"},{"code":"87798","type":"HCPCS"}],"standard_charges":[{"gross_charge":508.0,"discounted_cash":279.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Dna Probe Fish","code_information":[{"code":"60111360","type":"CDM"},{"code":"310","type":"RC"},{"code":"88271","type":"HCPCS"}],"standard_charges":[{"gross_charge":138.0,"discounted_cash":75.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Lgi1 Igg","code_information":[{"code":"60111410","type":"CDM"},{"code":"302","type":"RC"},{"code":"86255","type":"HCPCS"}],"standard_charges":[{"gross_charge":124.0,"discounted_cash":68.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Caspr2 Igg","code_information":[{"code":"60111420","type":"CDM"},{"code":"302","type":"RC"},{"code":"86255","type":"HCPCS"}],"standard_charges":[{"gross_charge":124.0,"discounted_cash":68.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Organism Id Pbp2A","code_information":[{"code":"60114050","type":"CDM"},{"code":"306","type":"RC"},{"code":"87147","type":"HCPCS"}],"standard_charges":[{"gross_charge":66.0,"discounted_cash":36.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Infectious Agent Amplified Probe","code_information":[{"code":"60114170","type":"CDM"},{"code":"306","type":"RC"},{"code":"87801","type":"HCPCS"}],"standard_charges":[{"gross_charge":285.0,"discounted_cash":156.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Thiopurine Level","code_information":[{"code":"60114230","type":"CDM"},{"code":"301","type":"RC"},{"code":"80299","type":"HCPCS"}],"standard_charges":[{"gross_charge":298.0,"discounted_cash":163.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Yeast Identification","code_information":[{"code":"60114310","type":"CDM"},{"code":"306","type":"RC"},{"code":"87106","type":"HCPCS"}],"standard_charges":[{"gross_charge":204.0,"discounted_cash":112.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Hiv-1 Genotype By Nucleic Acid","code_information":[{"code":"60114690","type":"CDM"},{"code":"306","type":"RC"},{"code":"87906","type":"HCPCS"}],"standard_charges":[{"gross_charge":906.0,"discounted_cash":498.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Tpmt Gene Analysis Common Variants","code_information":[{"code":"60115310","type":"CDM"},{"code":"310","type":"RC"},{"code":"81335","type":"HCPCS"}],"standard_charges":[{"gross_charge":845.0,"discounted_cash":464.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Allergen Spec Ige Qnt Or Semi Qnt Each","code_information":[{"code":"60115320","type":"CDM"},{"code":"302","type":"RC"},{"code":"86008","type":"HCPCS"}],"standard_charges":[{"gross_charge":54.0,"discounted_cash":29.7,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Dpyd Gene Analysis Common Variant(S)","code_information":[{"code":"60115340","type":"CDM"},{"code":"310","type":"RC"},{"code":"81232","type":"HCPCS"}],"standard_charges":[{"gross_charge":845.0,"discounted_cash":464.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Lactic Acid Whole Blood","code_information":[{"code":"60115410","type":"CDM"},{"code":"301","type":"RC"},{"code":"83605","type":"HCPCS"}],"standard_charges":[{"gross_charge":175.0,"discounted_cash":96.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Immunoassay Analyte Semiquant","code_information":[{"code":"60115810","type":"CDM"},{"code":"301","type":"RC"},{"code":"83516","type":"HCPCS"}],"standard_charges":[{"gross_charge":174.0,"discounted_cash":95.7,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Flow Cyto Cel First Mrkr","code_information":[{"code":"60115940","type":"CDM"},{"code":"311","type":"RC"},{"code":"88184","type":"HCPCS"}],"standard_charges":[{"gross_charge":185.0,"discounted_cash":101.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Flow Ea Add Marker","code_information":[{"code":"60115950","type":"CDM"},{"code":"311","type":"RC"},{"code":"88185","type":"HCPCS"}],"standard_charges":[{"gross_charge":179.0,"discounted_cash":98.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Idh1 Common Variants","code_information":[{"code":"60116720","type":"CDM"},{"code":"310","type":"RC"},{"code":"81120","type":"HCPCS"}],"standard_charges":[{"gross_charge":902.0,"discounted_cash":496.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Idh2 Common Variants","code_information":[{"code":"60116730","type":"CDM"},{"code":"310","type":"RC"},{"code":"81121","type":"HCPCS"}],"standard_charges":[{"gross_charge":1430.0,"discounted_cash":786.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Cannabinoid Umbilical","code_information":[{"code":"60116740","type":"CDM"},{"code":"301","type":"RC"},{"code":"80349","type":"HCPCS"}],"standard_charges":[{"gross_charge":364.0,"discounted_cash":200.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Ihc Adtl Stn Ab Cmv","code_information":[{"code":"60116810","type":"CDM"},{"code":"310","type":"RC"},{"code":"88341","type":"HCPCS"}],"standard_charges":[{"gross_charge":472.0,"discounted_cash":259.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Hla Type Lo Res Kir","code_information":[{"code":"60117760","type":"CDM"},{"code":"310","type":"RC"},{"code":"81403","type":"HCPCS"}],"standard_charges":[{"gross_charge":895.0,"discounted_cash":492.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Rbc Ag Typing Dna 35 Ag 11 Bld Grps Wb","code_information":[{"code":"60117790","type":"CDM"},{"code":"302","type":"RC"},{"code":"0001U","type":"HCPCS"}],"standard_charges":[{"gross_charge":2462.0,"discounted_cash":1354.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Tumor Immunohistochem Pd-L1","code_information":[{"code":"60117900","type":"CDM"},{"code":"310","type":"RC"},{"code":"88360","type":"HCPCS"}],"standard_charges":[{"gross_charge":494.0,"discounted_cash":271.7,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Albumin Urine Random Quant","code_information":[{"code":"60117930","type":"CDM"},{"code":"301","type":"RC"},{"code":"82043","type":"HCPCS"}],"standard_charges":[{"gross_charge":84.0,"discounted_cash":46.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Histochemical Stain Add-On Nl","code_information":[{"code":"60117940","type":"CDM"},{"code":"310","type":"RC"},{"code":"88314","type":"HCPCS"}],"standard_charges":[{"gross_charge":172.0,"discounted_cash":94.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Targeted Genomic Seq Analysis Lung","code_information":[{"code":"60118330","type":"CDM"},{"code":"310","type":"RC"},{"code":"81445","type":"HCPCS"}],"standard_charges":[{"gross_charge":1886.0,"discounted_cash":1037.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Microdissection Manual Lung","code_information":[{"code":"60118340","type":"CDM"},{"code":"310","type":"RC"},{"code":"88381","type":"HCPCS"}],"standard_charges":[{"gross_charge":217.0,"discounted_cash":119.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Noncdm Charge Record","code_information":[{"code":"60119620","type":"CDM"},{"code":"302","type":"RC"},{"code":"86828","type":"HCPCS"}],"standard_charges":[{"gross_charge":330.0,"discounted_cash":181.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Lchg Exam Archive Tissue Molec Anal Nl","code_information":[{"code":"60119970","type":"CDM"},{"code":"310","type":"RC"},{"code":"88363","type":"HCPCS"}],"standard_charges":[{"gross_charge":103.0,"discounted_cash":56.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Immunofluorescent Study Adtl Stn Nl","code_information":[{"code":"60120000","type":"CDM"},{"code":"310","type":"RC"},{"code":"88350","type":"HCPCS"}],"standard_charges":[{"gross_charge":150.0,"discounted_cash":82.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Fine Needle Aspir W Interp Tc Nl Ii","code_information":[{"code":"60120010","type":"CDM"},{"code":"310","type":"RC"},{"code":"88173","type":"HCPCS"}],"standard_charges":[{"gross_charge":478.0,"discounted_cash":262.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Sp G+M Level Iv Tc Nl Ii","code_information":[{"code":"60120020","type":"CDM"},{"code":"310","type":"RC"},{"code":"88305","type":"HCPCS"}],"standard_charges":[{"gross_charge":494.0,"discounted_cash":271.7,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Sp Stain Grp Ii Tc Nl Ii","code_information":[{"code":"60120030","type":"CDM"},{"code":"310","type":"RC"},{"code":"88313","type":"HCPCS"}],"standard_charges":[{"gross_charge":228.0,"discounted_cash":125.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Ihc Adtl Stn Each Tc Ii","code_information":[{"code":"60120040","type":"CDM"},{"code":"310","type":"RC"},{"code":"88341","type":"HCPCS"}],"standard_charges":[{"gross_charge":472.0,"discounted_cash":259.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Rsv Dna/Rna Amp Probe","code_information":[{"code":"60120530","type":"CDM"},{"code":"306","type":"RC"},{"code":"87634","type":"HCPCS"}],"standard_charges":[{"gross_charge":285.0,"discounted_cash":156.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Phospholipase A2 Receptor Ab","code_information":[{"code":"60120900","type":"CDM"},{"code":"302","type":"RC"},{"code":"86255","type":"HCPCS"}],"standard_charges":[{"gross_charge":236.0,"discounted_cash":129.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Phospholipase A2 Receptor Ab Titer","code_information":[{"code":"60120910","type":"CDM"},{"code":"302","type":"RC"},{"code":"86256","type":"HCPCS"}],"standard_charges":[{"gross_charge":110.0,"discounted_cash":60.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Drug Test Def 1-7 Classes","code_information":[{"code":"60121230","type":"CDM"},{"code":"301","type":"RC"},{"code":"G0480","type":"HCPCS"}],"standard_charges":[{"gross_charge":343.0,"discounted_cash":188.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Hiv-1 Naat Quant","code_information":[{"code":"60121400","type":"CDM"},{"code":"306","type":"RC"},{"code":"87536","type":"HCPCS"}],"standard_charges":[{"gross_charge":287.0,"discounted_cash":157.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Cannabinoid Synthetic 7/More Ii","code_information":[{"code":"60121420","type":"CDM"},{"code":"301","type":"RC"},{"code":"80352","type":"HCPCS"}],"standard_charges":[{"gross_charge":353.0,"discounted_cash":194.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Sp Stain Group I Tc Nl Ii","code_information":[{"code":"60121520","type":"CDM"},{"code":"310","type":"RC"},{"code":"88312","type":"HCPCS"}],"standard_charges":[{"gross_charge":232.0,"discounted_cash":127.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Infectious Disease Chrnc Hcv 6 Assays","code_information":[{"code":"60121730","type":"CDM"},{"code":"310","type":"RC"},{"code":"81596","type":"HCPCS"}],"standard_charges":[{"gross_charge":256.0,"discounted_cash":140.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Mdm2 Gene Amplification Fish","code_information":[{"code":"60122110","type":"CDM"},{"code":"310","type":"RC"},{"code":"88377","type":"HCPCS"}],"standard_charges":[{"gross_charge":1146.0,"discounted_cash":630.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Fish Deletion 1019Q","code_information":[{"code":"60122120","type":"CDM"},{"code":"310","type":"RC"},{"code":"88377","type":"HCPCS"}],"standard_charges":[{"gross_charge":682.0,"discounted_cash":375.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Immunofluorescent Study Adtl Stn Tc Nl Ii","code_information":[{"code":"60122130","type":"CDM"},{"code":"310","type":"RC"},{"code":"88350","type":"HCPCS"}],"standard_charges":[{"gross_charge":150.0,"discounted_cash":82.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Cmv Qual Amplified Probe","code_information":[{"code":"60122150","type":"CDM"},{"code":"306","type":"RC"},{"code":"87496","type":"HCPCS"}],"standard_charges":[{"gross_charge":205.0,"discounted_cash":112.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Her2 Rai1 Reflex Fish Bill Only","code_information":[{"code":"60122480","type":"CDM"},{"code":"310","type":"RC"},{"code":"88377","type":"HCPCS"}],"standard_charges":[{"gross_charge":956.0,"discounted_cash":525.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Immunohistochem Her-2/Neu I","code_information":[{"code":"60122500","type":"CDM"},{"code":"310","type":"RC"},{"code":"88360","type":"HCPCS"}],"standard_charges":[{"gross_charge":650.0,"discounted_cash":357.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Gad65 Ab Bld","code_information":[{"code":"60122640","type":"CDM"},{"code":"300","type":"RC"},{"code":"86341","type":"HCPCS"}],"standard_charges":[{"gross_charge":133.0,"discounted_cash":73.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Fluorescent Noninfect Ab Each I","code_information":[{"code":"60122650","type":"CDM"},{"code":"300","type":"RC"},{"code":"86255","type":"HCPCS"}],"standard_charges":[{"gross_charge":134.0,"discounted_cash":73.7,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Rpr Titer Ii","code_information":[{"code":"60122730","type":"CDM"},{"code":"302","type":"RC"},{"code":"86593","type":"HCPCS"}],"standard_charges":[{"gross_charge":64.0,"discounted_cash":35.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Hcv Dna Genotype Blood","code_information":[{"code":"60122870","type":"CDM"},{"code":"306","type":"RC"},{"code":"87902","type":"HCPCS"}],"standard_charges":[{"gross_charge":939.0,"discounted_cash":516.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Tumor Immunohistochem Pd-L1 Ii","code_information":[{"code":"60122960","type":"CDM"},{"code":"310","type":"RC"},{"code":"88360","type":"HCPCS"}],"standard_charges":[{"gross_charge":620.0,"discounted_cash":341.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Nudt15 Gene Common Variants","code_information":[{"code":"60122970","type":"CDM"},{"code":"310","type":"RC"},{"code":"81306","type":"HCPCS"}],"standard_charges":[{"gross_charge":1410.0,"discounted_cash":775.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Fibrin Split Products Ii","code_information":[{"code":"60123050","type":"CDM"},{"code":"305","type":"RC"},{"code":"85362","type":"HCPCS"}],"standard_charges":[{"gross_charge":23.0,"discounted_cash":12.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Infectious Agent Dna/Rna Multi Org","code_information":[{"code":"60124280","type":"CDM"},{"code":"306","type":"RC"},{"code":"87800","type":"HCPCS"}],"standard_charges":[{"gross_charge":575.0,"discounted_cash":316.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Rotavirus Pcr","code_information":[{"code":"60124290","type":"CDM"},{"code":"306","type":"RC"},{"code":"87798","type":"HCPCS"}],"standard_charges":[{"gross_charge":508.0,"discounted_cash":279.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Granulocytes","code_information":[{"code":"60124340","type":"CDM"},{"code":"390","type":"RC"},{"code":"P9050","type":"HCPCS"}],"standard_charges":[{"gross_charge":3863.0,"discounted_cash":2124.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Lyme Disease Ab Igg I","code_information":[{"code":"60125760","type":"CDM"},{"code":"301","type":"RC"},{"code":"86618","type":"HCPCS"}],"standard_charges":[{"gross_charge":247.0,"discounted_cash":135.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Troponin T I","code_information":[{"code":"60125800","type":"CDM"},{"code":"301","type":"RC"},{"code":"84484","type":"HCPCS"}],"standard_charges":[{"gross_charge":159.0,"discounted_cash":87.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Ca 19-9 I","code_information":[{"code":"60125840","type":"CDM"},{"code":"302","type":"RC"},{"code":"86301","type":"HCPCS"}],"standard_charges":[{"gross_charge":306.0,"discounted_cash":168.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Fibrinolysins Ii","code_information":[{"code":"60125880","type":"CDM"},{"code":"305","type":"RC"},{"code":"85390","type":"HCPCS"}],"standard_charges":[{"gross_charge":117.0,"discounted_cash":64.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Von Willebrand Factor Activity Iii","code_information":[{"code":"60125890","type":"CDM"},{"code":"305","type":"RC"},{"code":"85397","type":"HCPCS"}],"standard_charges":[{"gross_charge":197.0,"discounted_cash":108.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Factor Viii Ristocetin Cofactor Ii","code_information":[{"code":"60125900","type":"CDM"},{"code":"305","type":"RC"},{"code":"85245","type":"HCPCS"}],"standard_charges":[{"gross_charge":396.0,"discounted_cash":217.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Factor Xi Inhibitor","code_information":[{"code":"60125910","type":"CDM"},{"code":"305","type":"RC"},{"code":"85335","type":"HCPCS"}],"standard_charges":[{"gross_charge":240.0,"discounted_cash":132.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Russells Viper Venom Time","code_information":[{"code":"60125960","type":"CDM"},{"code":"305","type":"RC"},{"code":"85613","type":"HCPCS"}],"standard_charges":[{"gross_charge":253.0,"discounted_cash":139.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Von Willebrand Factor Multimer","code_information":[{"code":"60125970","type":"CDM"},{"code":"305","type":"RC"},{"code":"85247","type":"HCPCS"}],"standard_charges":[{"gross_charge":364.0,"discounted_cash":200.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Factor V Inhibitor","code_information":[{"code":"60126030","type":"CDM"},{"code":"305","type":"RC"},{"code":"85335","type":"HCPCS"}],"standard_charges":[{"gross_charge":240.0,"discounted_cash":132.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Noncdm Charge Record","code_information":[{"code":"60126050","type":"CDM"},{"code":"301","type":"RC"},{"code":"84210","type":"HCPCS"}],"standard_charges":[{"gross_charge":86.0,"discounted_cash":47.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."},{"gross_charge":51.0,"discounted_cash":28.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Lchg Eval C/V Amniotic Fluid Proteins","code_information":[{"code":"60126140","type":"CDM"},{"code":"309","type":"RC"},{"code":"84112","type":"HCPCS"}],"standard_charges":[{"gross_charge":405.0,"discounted_cash":222.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Sperm Screen Post Vas","code_information":[{"code":"60126160","type":"CDM"},{"code":"309","type":"RC"},{"code":"89321","type":"HCPCS"}],"standard_charges":[{"gross_charge":172.0,"discounted_cash":94.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Cotinine Blood","code_information":[{"code":"60126530","type":"CDM"},{"code":"301","type":"RC"},{"code":"80307","type":"HCPCS"}],"standard_charges":[{"gross_charge":151.0,"discounted_cash":83.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Tzanck Smear","code_information":[{"code":"60126540","type":"CDM"},{"code":"306","type":"RC"},{"code":"87207","type":"HCPCS"}],"standard_charges":[{"gross_charge":133.0,"discounted_cash":73.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Bcr-Abl1 Gene Major Quant 1","code_information":[{"code":"60126690","type":"CDM"},{"code":"310","type":"RC"},{"code":"81206","type":"HCPCS"}],"standard_charges":[{"gross_charge":984.0,"discounted_cash":541.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Susceptibility Mic Refer","code_information":[{"code":"60127060","type":"CDM"},{"code":"306","type":"RC"},{"code":"87186","type":"HCPCS"}],"standard_charges":[{"gross_charge":174.0,"discounted_cash":95.7,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Malaria Pcr","code_information":[{"code":"60127070","type":"CDM"},{"code":"306","type":"RC"},{"code":"87798","type":"HCPCS"}],"standard_charges":[{"gross_charge":508.0,"discounted_cash":279.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Hemoglobin Poct","code_information":[{"code":"60127580","type":"CDM"},{"code":"305","type":"RC"},{"code":"85018","type":"HCPCS"}],"standard_charges":[{"gross_charge":38.0,"discounted_cash":20.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Tumor Immunohistochem Erbb2","code_information":[{"code":"60128450","type":"CDM"},{"code":"310","type":"RC"},{"code":"88360","type":"HCPCS"}],"standard_charges":[{"gross_charge":687.0,"discounted_cash":377.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Insitu Hybrid Morph Manual Erbb2","code_information":[{"code":"60128460","type":"CDM"},{"code":"310","type":"RC"},{"code":"88377","type":"HCPCS"}],"standard_charges":[{"gross_charge":687.0,"discounted_cash":377.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Insitu Hybrid Morph Manual Her2Rai1","code_information":[{"code":"60128480","type":"CDM"},{"code":"310","type":"RC"},{"code":"88377","type":"HCPCS"}],"standard_charges":[{"gross_charge":819.0,"discounted_cash":450.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Ihc 1St Stn Ab Mismatch Repair","code_information":[{"code":"60128610","type":"CDM"},{"code":"310","type":"RC"},{"code":"88342","type":"HCPCS"}],"standard_charges":[{"gross_charge":479.0,"discounted_cash":263.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Ihc Adtl Stn Ab Mismatch Repair","code_information":[{"code":"60128620","type":"CDM"},{"code":"310","type":"RC"},{"code":"88341","type":"HCPCS"}],"standard_charges":[{"gross_charge":472.0,"discounted_cash":259.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Buprenorphine Urine Qualitative","code_information":[{"code":"60128880","type":"CDM"},{"code":"301","type":"RC"},{"code":"80307","type":"HCPCS"}],"standard_charges":[{"gross_charge":205.0,"discounted_cash":112.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Adenosine Deaminase Csf I","code_information":[{"code":"60128900","type":"CDM"},{"code":"301","type":"RC"},{"code":"84311","type":"HCPCS"}],"standard_charges":[{"gross_charge":116.0,"discounted_cash":63.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Albumin Urine Ii","code_information":[{"code":"60128910","type":"CDM"},{"code":"301","type":"RC"},{"code":"82043","type":"HCPCS"}],"standard_charges":[{"gross_charge":80.0,"discounted_cash":44.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Creatinine Urine Ii","code_information":[{"code":"60128920","type":"CDM"},{"code":"301","type":"RC"},{"code":"82570","type":"HCPCS"}],"standard_charges":[{"gross_charge":76.0,"discounted_cash":41.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Mopath Procedure Level 3","code_information":[{"code":"60128930","type":"CDM"},{"code":"310","type":"RC"},{"code":"81402","type":"HCPCS"}],"standard_charges":[{"gross_charge":750.0,"discounted_cash":412.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Antithrombin Iii Activity Iii","code_information":[{"code":"60129330","type":"CDM"},{"code":"305","type":"RC"},{"code":"85300","type":"HCPCS"}],"standard_charges":[{"gross_charge":187.0,"discounted_cash":102.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Antithrombin Iii Antigen Ii","code_information":[{"code":"60129340","type":"CDM"},{"code":"305","type":"RC"},{"code":"85301","type":"HCPCS"}],"standard_charges":[{"gross_charge":177.0,"discounted_cash":97.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Bartonella Species Pcr Blood","code_information":[{"code":"60129360","type":"CDM"},{"code":"306","type":"RC"},{"code":"87471","type":"HCPCS"}],"standard_charges":[{"gross_charge":147.0,"discounted_cash":80.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Lyme Disease Ab Igg Csf I","code_information":[{"code":"60129380","type":"CDM"},{"code":"302","type":"RC"},{"code":"86617","type":"HCPCS"}],"standard_charges":[{"gross_charge":110.0,"discounted_cash":60.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Lyme Disease Ab Igm Csf I","code_information":[{"code":"60129390","type":"CDM"},{"code":"302","type":"RC"},{"code":"86617","type":"HCPCS"}],"standard_charges":[{"gross_charge":110.0,"discounted_cash":60.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Bullous Pemphigoid Ag 180/230 Igg","code_information":[{"code":"60129400","type":"CDM"},{"code":"301","type":"RC"},{"code":"83516","type":"HCPCS"}],"standard_charges":[{"gross_charge":174.0,"discounted_cash":95.7,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Chlamydia Dna Probe Ii","code_information":[{"code":"60129450","type":"CDM"},{"code":"306","type":"RC"},{"code":"87491","type":"HCPCS"}],"standard_charges":[{"gross_charge":251.0,"discounted_cash":138.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Gc Amplified Probe Ii","code_information":[{"code":"60129460","type":"CDM"},{"code":"306","type":"RC"},{"code":"87591","type":"HCPCS"}],"standard_charges":[{"gross_charge":697.0,"discounted_cash":383.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Chr Cytogen Interp/Report Ii","code_information":[{"code":"60129470","type":"CDM"},{"code":"311","type":"RC"},{"code":"88291","type":"HCPCS"}],"standard_charges":[{"gross_charge":144.0,"discounted_cash":79.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Chr (15-20Ct/2K/Bd) Gene Ii","code_information":[{"code":"60129480","type":"CDM"},{"code":"311","type":"RC"},{"code":"88262","type":"HCPCS"}],"standard_charges":[{"gross_charge":1400.0,"discounted_cash":770.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Chr (15-20Ct/2K/Bd) Gene Iii","code_information":[{"code":"60129490","type":"CDM"},{"code":"311","type":"RC"},{"code":"88262","type":"HCPCS"}],"standard_charges":[{"gross_charge":1400.0,"discounted_cash":770.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Chr Tissue Culture Skin Tissue Ii","code_information":[{"code":"60129500","type":"CDM"},{"code":"311","type":"RC"},{"code":"88233","type":"HCPCS"}],"standard_charges":[{"gross_charge":74.0,"discounted_cash":40.7,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Chr Cytogen Interp/Report Iii","code_information":[{"code":"60129510","type":"CDM"},{"code":"311","type":"RC"},{"code":"88291","type":"HCPCS"}],"standard_charges":[{"gross_charge":144.0,"discounted_cash":79.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Citalopram I","code_information":[{"code":"60129520","type":"CDM"},{"code":"301","type":"RC"},{"code":"80299","type":"HCPCS"}],"standard_charges":[{"gross_charge":303.0,"discounted_cash":166.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Ckmb I","code_information":[{"code":"60129530","type":"CDM"},{"code":"301","type":"RC"},{"code":"82553","type":"HCPCS"}],"standard_charges":[{"gross_charge":39.0,"discounted_cash":21.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Coccidioides Titer","code_information":[{"code":"60129540","type":"CDM"},{"code":"302","type":"RC"},{"code":"86635","type":"HCPCS"}],"standard_charges":[{"gross_charge":38.0,"discounted_cash":20.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Coccidioides Ab Igg","code_information":[{"code":"60129550","type":"CDM"},{"code":"302","type":"RC"},{"code":"86635","type":"HCPCS"}],"standard_charges":[{"gross_charge":38.0,"discounted_cash":20.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Coccidioides Ab Igm","code_information":[{"code":"60129560","type":"CDM"},{"code":"302","type":"RC"},{"code":"86635","type":"HCPCS"}],"standard_charges":[{"gross_charge":38.0,"discounted_cash":20.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Cold Agglutinins Titer I","code_information":[{"code":"60129580","type":"CDM"},{"code":"302","type":"RC"},{"code":"86157","type":"HCPCS"}],"standard_charges":[{"gross_charge":84.0,"discounted_cash":46.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Culture Helicobacter Pylori I","code_information":[{"code":"60129610","type":"CDM"},{"code":"306","type":"RC"},{"code":"87070","type":"HCPCS"}],"standard_charges":[{"gross_charge":183.0,"discounted_cash":100.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Homogenization Tissue I","code_information":[{"code":"60129620","type":"CDM"},{"code":"306","type":"RC"},{"code":"87176","type":"HCPCS"}],"standard_charges":[{"gross_charge":25.0,"discounted_cash":13.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Culture Legionella I","code_information":[{"code":"60129630","type":"CDM"},{"code":"306","type":"RC"},{"code":"87081","type":"HCPCS"}],"standard_charges":[{"gross_charge":194.0,"discounted_cash":106.7,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Chr (15-20Ct/2K/Bd) Gene Iv","code_information":[{"code":"60129700","type":"CDM"},{"code":"311","type":"RC"},{"code":"88262","type":"HCPCS"}],"standard_charges":[{"gross_charge":1358.0,"discounted_cash":746.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Chr Culture Tissue Skin/Other Solid Ii","code_information":[{"code":"60129710","type":"CDM"},{"code":"311","type":"RC"},{"code":"88233","type":"HCPCS"}],"standard_charges":[{"gross_charge":74.0,"discounted_cash":40.7,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Chr Cytogen Interp/Report V","code_information":[{"code":"60129720","type":"CDM"},{"code":"311","type":"RC"},{"code":"88291","type":"HCPCS"}],"standard_charges":[{"gross_charge":144.0,"discounted_cash":79.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Rbc Ab Scrn Each Tech I","code_information":[{"code":"60129770","type":"CDM"},{"code":"300","type":"RC"},{"code":"86850","type":"HCPCS"}],"standard_charges":[{"gross_charge":129.0,"discounted_cash":70.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Enterovirus Pcr Csf I","code_information":[{"code":"60129790","type":"CDM"},{"code":"306","type":"RC"},{"code":"87498","type":"HCPCS"}],"standard_charges":[{"gross_charge":147.0,"discounted_cash":80.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Sp Stain Group Ii Other","code_information":[{"code":"60129800","type":"CDM"},{"code":"310","type":"RC"},{"code":"88313","type":"HCPCS"}],"standard_charges":[{"gross_charge":759.0,"discounted_cash":417.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Path Consult Comp Review Of His","code_information":[{"code":"60129830","type":"CDM"},{"code":"310","type":"RC"},{"code":"88325","type":"HCPCS"}],"standard_charges":[{"gross_charge":473.0,"discounted_cash":260.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Electron Microscopy I","code_information":[{"code":"60129840","type":"CDM"},{"code":"310","type":"RC"},{"code":"88348","type":"HCPCS"}],"standard_charges":[{"gross_charge":1271.0,"discounted_cash":699.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Sp G+M Rb I","code_information":[{"code":"60129860","type":"CDM"},{"code":"310","type":"RC"},{"code":"88305","type":"HCPCS"}],"standard_charges":[{"gross_charge":494.0,"discounted_cash":271.7,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Ihc 1St Stain Initial","code_information":[{"code":"60129880","type":"CDM"},{"code":"310","type":"RC"},{"code":"88342","type":"HCPCS"}],"standard_charges":[{"gross_charge":494.0,"discounted_cash":271.7,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Epstein-Barr Virus Pcr Qual","code_information":[{"code":"60129890","type":"CDM"},{"code":"301","type":"RC"},{"code":"87798","type":"HCPCS"}],"standard_charges":[{"gross_charge":518.0,"discounted_cash":284.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Ethyl Glucuronide Umbilical I","code_information":[{"code":"60129900","type":"CDM"},{"code":"301","type":"RC"},{"code":"80321","type":"HCPCS"}],"standard_charges":[{"gross_charge":353.0,"discounted_cash":194.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Factor V Gene Leiden G1691A","code_information":[{"code":"60129910","type":"CDM"},{"code":"310","type":"RC"},{"code":"81241","type":"HCPCS"}],"standard_charges":[{"gross_charge":790.0,"discounted_cash":434.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Factor Ii Assay Ii","code_information":[{"code":"60129920","type":"CDM"},{"code":"305","type":"RC"},{"code":"85210","type":"HCPCS"}],"standard_charges":[{"gross_charge":96.0,"discounted_cash":52.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Factor Ii Inhibitor Ii","code_information":[{"code":"60129930","type":"CDM"},{"code":"305","type":"RC"},{"code":"85335","type":"HCPCS"}],"standard_charges":[{"gross_charge":240.0,"discounted_cash":132.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Factor Ix Assay Iii","code_information":[{"code":"60129940","type":"CDM"},{"code":"305","type":"RC"},{"code":"85250","type":"HCPCS"}],"standard_charges":[{"gross_charge":304.0,"discounted_cash":167.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Factor Ix Inhibitor I","code_information":[{"code":"60129950","type":"CDM"},{"code":"305","type":"RC"},{"code":"85335","type":"HCPCS"}],"standard_charges":[{"gross_charge":240.0,"discounted_cash":132.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Factor V Assay Iii","code_information":[{"code":"60129960","type":"CDM"},{"code":"305","type":"RC"},{"code":"85220","type":"HCPCS"}],"standard_charges":[{"gross_charge":269.0,"discounted_cash":147.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Factor V Inhibitor I","code_information":[{"code":"60129970","type":"CDM"},{"code":"305","type":"RC"},{"code":"85335","type":"HCPCS"}],"standard_charges":[{"gross_charge":240.0,"discounted_cash":132.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Factor Vii Assay Iii","code_information":[{"code":"60129990","type":"CDM"},{"code":"305","type":"RC"},{"code":"85230","type":"HCPCS"}],"standard_charges":[{"gross_charge":285.0,"discounted_cash":156.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Factor Vii Inhibitor Ii","code_information":[{"code":"60130000","type":"CDM"},{"code":"305","type":"RC"},{"code":"85335","type":"HCPCS"}],"standard_charges":[{"gross_charge":240.0,"discounted_cash":132.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Factor Viii Assay W/Rflx Inhib","code_information":[{"code":"60130010","type":"CDM"},{"code":"305","type":"RC"},{"code":"85240","type":"HCPCS"}],"standard_charges":[{"gross_charge":36.0,"discounted_cash":19.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Bethesda Qt Factor 8","code_information":[{"code":"60130020","type":"CDM"},{"code":"305","type":"RC"},{"code":"85335","type":"HCPCS"}],"standard_charges":[{"gross_charge":240.0,"discounted_cash":132.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Factor Viii Assay Iii","code_information":[{"code":"60130030","type":"CDM"},{"code":"305","type":"RC"},{"code":"85240","type":"HCPCS"}],"standard_charges":[{"gross_charge":107.0,"discounted_cash":58.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Factor Xi Assay Ii","code_information":[{"code":"60130050","type":"CDM"},{"code":"305","type":"RC"},{"code":"85270","type":"HCPCS"}],"standard_charges":[{"gross_charge":285.0,"discounted_cash":156.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Factor Xi Inhibitor Ii","code_information":[{"code":"60130060","type":"CDM"},{"code":"305","type":"RC"},{"code":"85335","type":"HCPCS"}],"standard_charges":[{"gross_charge":240.0,"discounted_cash":132.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Factor Xii Assay Ii","code_information":[{"code":"60130070","type":"CDM"},{"code":"305","type":"RC"},{"code":"85280","type":"HCPCS"}],"standard_charges":[{"gross_charge":308.0,"discounted_cash":169.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Factor Xii Inhibitor I","code_information":[{"code":"60130080","type":"CDM"},{"code":"305","type":"RC"},{"code":"85335","type":"HCPCS"}],"standard_charges":[{"gross_charge":240.0,"discounted_cash":132.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Fentanyl Urine Scn I","code_information":[{"code":"60130110","type":"CDM"},{"code":"301","type":"RC"},{"code":"80307","type":"HCPCS"}],"standard_charges":[{"gross_charge":186.0,"discounted_cash":102.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Dna Probe Fish All I","code_information":[{"code":"60130130","type":"CDM"},{"code":"311","type":"RC"},{"code":"88271","type":"HCPCS"}],"standard_charges":[{"gross_charge":142.0,"discounted_cash":78.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Interphase Hybrid 100-300 All","code_information":[{"code":"60130140","type":"CDM"},{"code":"311","type":"RC"},{"code":"88275","type":"HCPCS"}],"standard_charges":[{"gross_charge":469.0,"discounted_cash":257.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Dna Probe Fish All-Aml-Bcr-Abl","code_information":[{"code":"60130150","type":"CDM"},{"code":"311","type":"RC"},{"code":"88271","type":"HCPCS"}],"standard_charges":[{"gross_charge":142.0,"discounted_cash":78.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Interphase Hybrid 100-300 All-Aml-Bcr","code_information":[{"code":"60130160","type":"CDM"},{"code":"311","type":"RC"},{"code":"88275","type":"HCPCS"}],"standard_charges":[{"gross_charge":469.0,"discounted_cash":257.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Dna Probe Fish Aml I","code_information":[{"code":"60130170","type":"CDM"},{"code":"311","type":"RC"},{"code":"88271","type":"HCPCS"}],"standard_charges":[{"gross_charge":142.0,"discounted_cash":78.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Interphase Hybrid 100-300 Aml I","code_information":[{"code":"60130180","type":"CDM"},{"code":"311","type":"RC"},{"code":"88275","type":"HCPCS"}],"standard_charges":[{"gross_charge":469.0,"discounted_cash":257.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Dna Probe Fish Bcl2","code_information":[{"code":"60130190","type":"CDM"},{"code":"311","type":"RC"},{"code":"88271","type":"HCPCS"}],"standard_charges":[{"gross_charge":142.0,"discounted_cash":78.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Interphase Hybrid 10-300 Bcl2 I","code_information":[{"code":"60130200","type":"CDM"},{"code":"311","type":"RC"},{"code":"88275","type":"HCPCS"}],"standard_charges":[{"gross_charge":469.0,"discounted_cash":257.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Dna Probe Fish Cll Igh 14Q32","code_information":[{"code":"60130210","type":"CDM"},{"code":"311","type":"RC"},{"code":"88271","type":"HCPCS"}],"standard_charges":[{"gross_charge":142.0,"discounted_cash":78.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Interphase Hybrid 100-300 Cll Igh I","code_information":[{"code":"60130220","type":"CDM"},{"code":"311","type":"RC"},{"code":"88275","type":"HCPCS"}],"standard_charges":[{"gross_charge":469.0,"discounted_cash":257.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Chr Cytogen Interp/Report Fish Cll","code_information":[{"code":"60130230","type":"CDM"},{"code":"311","type":"RC"},{"code":"88291","type":"HCPCS"}],"standard_charges":[{"gross_charge":144.0,"discounted_cash":79.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Tissue Culture Lymphocyte Blood I","code_information":[{"code":"60130240","type":"CDM"},{"code":"311","type":"RC"},{"code":"88230","type":"HCPCS"}],"standard_charges":[{"gross_charge":469.0,"discounted_cash":257.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Fish Chromosome Dna Probe 1P36","code_information":[{"code":"60130250","type":"CDM"},{"code":"311","type":"RC"},{"code":"88271","type":"HCPCS"}],"standard_charges":[{"gross_charge":142.0,"discounted_cash":78.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Fish Chromosome Dna Probe Iii","code_information":[{"code":"60130270","type":"CDM"},{"code":"311","type":"RC"},{"code":"88271","type":"HCPCS"}],"standard_charges":[{"gross_charge":142.0,"discounted_cash":78.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Interphase Hybrid 100-300 T11;18 I","code_information":[{"code":"60130280","type":"CDM"},{"code":"311","type":"RC"},{"code":"88275","type":"HCPCS"}],"standard_charges":[{"gross_charge":469.0,"discounted_cash":257.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Fish Chromosome Dna Probe Iiii","code_information":[{"code":"60130290","type":"CDM"},{"code":"311","type":"RC"},{"code":"88271","type":"HCPCS"}],"standard_charges":[{"gross_charge":142.0,"discounted_cash":78.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Interphase Hybrid 100-300 T2;5 I","code_information":[{"code":"60130300","type":"CDM"},{"code":"311","type":"RC"},{"code":"88275","type":"HCPCS"}],"standard_charges":[{"gross_charge":469.0,"discounted_cash":257.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Fish Chromosome Dna Probe Burkitts","code_information":[{"code":"60130310","type":"CDM"},{"code":"311","type":"RC"},{"code":"88271","type":"HCPCS"}],"standard_charges":[{"gross_charge":142.0,"discounted_cash":78.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Interphase Hybrid 100-300 8Q24 I","code_information":[{"code":"60130320","type":"CDM"},{"code":"311","type":"RC"},{"code":"88275","type":"HCPCS"}],"standard_charges":[{"gross_charge":469.0,"discounted_cash":257.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Fish Chromosome Dna Probe Mds 5Q33","code_information":[{"code":"60130330","type":"CDM"},{"code":"311","type":"RC"},{"code":"88271","type":"HCPCS"}],"standard_charges":[{"gross_charge":142.0,"discounted_cash":78.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Interphase Hybrid 100-300 5Q33 I","code_information":[{"code":"60130340","type":"CDM"},{"code":"311","type":"RC"},{"code":"88275","type":"HCPCS"}],"standard_charges":[{"gross_charge":469.0,"discounted_cash":257.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Fish Chromosome Dna Probe Mds 7Q31 I","code_information":[{"code":"60130350","type":"CDM"},{"code":"311","type":"RC"},{"code":"88271","type":"HCPCS"}],"standard_charges":[{"gross_charge":142.0,"discounted_cash":78.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Interphase Hybrid 100-300 7Q31 I","code_information":[{"code":"60130360","type":"CDM"},{"code":"311","type":"RC"},{"code":"88275","type":"HCPCS"}],"standard_charges":[{"gross_charge":469.0,"discounted_cash":257.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Fish Chromosome Dna Mds Pnl I","code_information":[{"code":"60130370","type":"CDM"},{"code":"311","type":"RC"},{"code":"88271","type":"HCPCS"}],"standard_charges":[{"gross_charge":142.0,"discounted_cash":78.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Interphase Hybrid 100-300 Mds Pnl I","code_information":[{"code":"60130380","type":"CDM"},{"code":"311","type":"RC"},{"code":"88275","type":"HCPCS"}],"standard_charges":[{"gross_charge":469.0,"discounted_cash":257.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Dna Probe Fish Gene Iii","code_information":[{"code":"60130390","type":"CDM"},{"code":"311","type":"RC"},{"code":"88271","type":"HCPCS"}],"standard_charges":[{"gross_charge":142.0,"discounted_cash":78.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Interphase Hybrid 100-300 Gene Iii","code_information":[{"code":"60130400","type":"CDM"},{"code":"311","type":"RC"},{"code":"88275","type":"HCPCS"}],"standard_charges":[{"gross_charge":469.0,"discounted_cash":257.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Chr Cytogen Interp/Report Iiii","code_information":[{"code":"60130410","type":"CDM"},{"code":"311","type":"RC"},{"code":"88291","type":"HCPCS"}],"standard_charges":[{"gross_charge":144.0,"discounted_cash":79.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Nephelometry Ea Hcv Fibro","code_information":[{"code":"60130490","type":"CDM"},{"code":"301","type":"RC"},{"code":"83883","type":"HCPCS"}],"standard_charges":[{"gross_charge":212.0,"discounted_cash":116.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Ast Blood Ii","code_information":[{"code":"60130500","type":"CDM"},{"code":"301","type":"RC"},{"code":"84550","type":"HCPCS"}],"standard_charges":[{"gross_charge":39.0,"discounted_cash":21.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Alt Blood I","code_information":[{"code":"60130510","type":"CDM"},{"code":"301","type":"RC"},{"code":"84460","type":"HCPCS"}],"standard_charges":[{"gross_charge":91.0,"discounted_cash":50.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Bun Ii","code_information":[{"code":"60130520","type":"CDM"},{"code":"301","type":"RC"},{"code":"84520","type":"HCPCS"}],"standard_charges":[{"gross_charge":87.0,"discounted_cash":47.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Ggt Ii","code_information":[{"code":"60130530","type":"CDM"},{"code":"301","type":"RC"},{"code":"82977","type":"HCPCS"}],"standard_charges":[{"gross_charge":117.0,"discounted_cash":64.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Platelet Ab Igg","code_information":[{"code":"60130570","type":"CDM"},{"code":"302","type":"RC"},{"code":"86022","type":"HCPCS"}],"standard_charges":[{"gross_charge":244.0,"discounted_cash":134.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Platelet Ab Iga/Igm","code_information":[{"code":"60130590","type":"CDM"},{"code":"302","type":"RC"},{"code":"86022","type":"HCPCS"}],"standard_charges":[{"gross_charge":151.0,"discounted_cash":83.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Platelet Ab Sra I","code_information":[{"code":"60130610","type":"CDM"},{"code":"302","type":"RC"},{"code":"86022","type":"HCPCS"}],"standard_charges":[{"gross_charge":151.0,"discounted_cash":83.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Platelet Ab Induced I","code_information":[{"code":"60130620","type":"CDM"},{"code":"302","type":"RC"},{"code":"86022","type":"HCPCS"}],"standard_charges":[{"gross_charge":151.0,"discounted_cash":83.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Platelet Ab Hit Pf4","code_information":[{"code":"60130630","type":"CDM"},{"code":"302","type":"RC"},{"code":"86022","type":"HCPCS"}],"standard_charges":[{"gross_charge":151.0,"discounted_cash":83.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Hepatitis C Ab Ii","code_information":[{"code":"60130640","type":"CDM"},{"code":"302","type":"RC"},{"code":"86803","type":"HCPCS"}],"standard_charges":[{"gross_charge":227.0,"discounted_cash":124.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Hcv Rna Genotype Ns3/4A I","code_information":[{"code":"60130660","type":"CDM"},{"code":"306","type":"RC"},{"code":"87902","type":"HCPCS"}],"standard_charges":[{"gross_charge":939.0,"discounted_cash":516.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Hmgcr Antibody Igg","code_information":[{"code":"60130770","type":"CDM"},{"code":"301","type":"RC"},{"code":"83516","type":"HCPCS"}],"standard_charges":[{"gross_charge":185.0,"discounted_cash":101.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Ihc Adtl Stn Ref Ii","code_information":[{"code":"60130800","type":"CDM"},{"code":"310","type":"RC"},{"code":"88342","type":"HCPCS"}],"standard_charges":[{"gross_charge":494.0,"discounted_cash":271.7,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Herpes Simplex 1+2 Ab Igg/Igm Csf","code_information":[{"code":"60130810","type":"CDM"},{"code":"302","type":"RC"},{"code":"86694","type":"HCPCS"}],"standard_charges":[{"gross_charge":218.0,"discounted_cash":119.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Herpes Simplex 2 Ab Igg Csf I","code_information":[{"code":"60130820","type":"CDM"},{"code":"302","type":"RC"},{"code":"86696","type":"HCPCS"}],"standard_charges":[{"gross_charge":117.0,"discounted_cash":64.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Herpes Simplex 1 Ab Igg Csf","code_information":[{"code":"60130830","type":"CDM"},{"code":"302","type":"RC"},{"code":"86695","type":"HCPCS"}],"standard_charges":[{"gross_charge":203.0,"discounted_cash":111.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Humoral Immunity Pnl","code_information":[{"code":"60130840","type":"CDM"},{"code":"302","type":"RC"},{"code":"86317","type":"HCPCS"}],"standard_charges":[{"gross_charge":218.0,"discounted_cash":119.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Igg Subclasses I","code_information":[{"code":"60130850","type":"CDM"},{"code":"301","type":"RC"},{"code":"82787","type":"HCPCS"}],"standard_charges":[{"gross_charge":67.0,"discounted_cash":36.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Immunoglobulin Ii","code_information":[{"code":"60130860","type":"CDM"},{"code":"301","type":"RC"},{"code":"82784","type":"HCPCS"}],"standard_charges":[{"gross_charge":106.0,"discounted_cash":58.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Influenza Pcr Dna Probe I","code_information":[{"code":"60130880","type":"CDM"},{"code":"306","type":"RC"},{"code":"87502","type":"HCPCS"}],"standard_charges":[{"gross_charge":438.0,"discounted_cash":240.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Uric Acid Urind Timed Ii","code_information":[{"code":"60130940","type":"CDM"},{"code":"301","type":"RC"},{"code":"84560","type":"HCPCS"}],"standard_charges":[{"gross_charge":85.0,"discounted_cash":46.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Magnesium Urine Timed Ii","code_information":[{"code":"60130950","type":"CDM"},{"code":"301","type":"RC"},{"code":"83735","type":"HCPCS"}],"standard_charges":[{"gross_charge":115.0,"discounted_cash":63.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Phosphorus Urine Timed Ii","code_information":[{"code":"60130970","type":"CDM"},{"code":"301","type":"RC"},{"code":"84105","type":"HCPCS"}],"standard_charges":[{"gross_charge":85.0,"discounted_cash":46.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Potassium Urine Timed Ii","code_information":[{"code":"60130980","type":"CDM"},{"code":"301","type":"RC"},{"code":"84133","type":"HCPCS"}],"standard_charges":[{"gross_charge":69.0,"discounted_cash":37.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Sodium Urine Timed Ii","code_information":[{"code":"60130990","type":"CDM"},{"code":"301","type":"RC"},{"code":"84300","type":"HCPCS"}],"standard_charges":[{"gross_charge":79.0,"discounted_cash":43.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Ph Urine Timed Ii","code_information":[{"code":"60131010","type":"CDM"},{"code":"301","type":"RC"},{"code":"83986","type":"HCPCS"}],"standard_charges":[{"gross_charge":91.0,"discounted_cash":50.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Encephalitis Lacrosse","code_information":[{"code":"60131020","type":"CDM"},{"code":"302","type":"RC"},{"code":"86651","type":"HCPCS"}],"standard_charges":[{"gross_charge":89.0,"discounted_cash":48.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Lamotrigine Level Iii","code_information":[{"code":"60131030","type":"CDM"},{"code":"301","type":"RC"},{"code":"80175","type":"HCPCS"}],"standard_charges":[{"gross_charge":276.0,"discounted_cash":151.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Histochemical Stain Add-On Congo Red Stain I","code_information":[{"code":"60131040","type":"CDM"},{"code":"312","type":"RC"},{"code":"88314","type":"HCPCS"}],"standard_charges":[{"gross_charge":178.0,"discounted_cash":97.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Leptin Ab I","code_information":[{"code":"60131050","type":"CDM"},{"code":"301","type":"RC"},{"code":"83520","type":"HCPCS"}],"standard_charges":[{"gross_charge":151.0,"discounted_cash":83.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Levetiracetam Level Iii","code_information":[{"code":"60131060","type":"CDM"},{"code":"301","type":"RC"},{"code":"80177","type":"HCPCS"}],"standard_charges":[{"gross_charge":276.0,"discounted_cash":151.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Lyme Disease Ab Total I","code_information":[{"code":"60131090","type":"CDM"},{"code":"302","type":"RC"},{"code":"86618","type":"HCPCS"}],"standard_charges":[{"gross_charge":133.0,"discounted_cash":73.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Lyme Disease Ab Screen Blood Ii","code_information":[{"code":"60131100","type":"CDM"},{"code":"302","type":"RC"},{"code":"86618","type":"HCPCS"}],"standard_charges":[{"gross_charge":141.0,"discounted_cash":77.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg T Cells Absolute Cd4 Cnt","code_information":[{"code":"60131110","type":"CDM"},{"code":"302","type":"RC"},{"code":"86361","type":"HCPCS"}],"standard_charges":[{"gross_charge":411.0,"discounted_cash":226.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg T Cell Total Count I","code_information":[{"code":"60131120","type":"CDM"},{"code":"302","type":"RC"},{"code":"86359","type":"HCPCS"}],"standard_charges":[{"gross_charge":117.0,"discounted_cash":64.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg T Cells Abs Cd4/Cd8 Ratio","code_information":[{"code":"60131130","type":"CDM"},{"code":"302","type":"RC"},{"code":"86360","type":"HCPCS"}],"standard_charges":[{"gross_charge":708.0,"discounted_cash":389.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Macroamylase Bld Ii","code_information":[{"code":"60131160","type":"CDM"},{"code":"301","type":"RC"},{"code":"84999","type":"HCPCS"}],"standard_charges":[{"gross_charge":241.0,"discounted_cash":132.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Mump Antibody Igg/Igm","code_information":[{"code":"60131180","type":"CDM"},{"code":"302","type":"RC"},{"code":"86735","type":"HCPCS"}],"standard_charges":[{"gross_charge":144.0,"discounted_cash":79.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Mycobacterium Avium Complex Ampl Probe","code_information":[{"code":"60131190","type":"CDM"},{"code":"306","type":"RC"},{"code":"87561","type":"HCPCS"}],"standard_charges":[{"gross_charge":147.0,"discounted_cash":80.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Mycobacteria Id I","code_information":[{"code":"60131200","type":"CDM"},{"code":"306","type":"RC"},{"code":"87118","type":"HCPCS"}],"standard_charges":[{"gross_charge":290.0,"discounted_cash":159.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Susceptibility Mycobacteria Rapid","code_information":[{"code":"60131210","type":"CDM"},{"code":"306","type":"RC"},{"code":"87186","type":"HCPCS"}],"standard_charges":[{"gross_charge":174.0,"discounted_cash":95.7,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Mycobacterium Tb Pcr Ii","code_information":[{"code":"60131220","type":"CDM"},{"code":"306","type":"RC"},{"code":"87556","type":"HCPCS"}],"standard_charges":[{"gross_charge":115.0,"discounted_cash":63.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Susceptibility Mycobacteria Tb","code_information":[{"code":"60131230","type":"CDM"},{"code":"306","type":"RC"},{"code":"87188","type":"HCPCS"}],"standard_charges":[{"gross_charge":383.0,"discounted_cash":210.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Nmo Apq4 Igg","code_information":[{"code":"60131240","type":"CDM"},{"code":"302","type":"RC"},{"code":"86255","type":"HCPCS"}],"standard_charges":[{"gross_charge":124.0,"discounted_cash":68.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Nmo Apq4 Igg Titer","code_information":[{"code":"60131250","type":"CDM"},{"code":"302","type":"RC"},{"code":"86256","type":"HCPCS"}],"standard_charges":[{"gross_charge":110.0,"discounted_cash":60.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Nmo Apq4 Igg Csf","code_information":[{"code":"60131260","type":"CDM"},{"code":"302","type":"RC"},{"code":"86255","type":"HCPCS"}],"standard_charges":[{"gross_charge":124.0,"discounted_cash":68.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Nmo Apq4 Igg Titer Csf","code_information":[{"code":"60131270","type":"CDM"},{"code":"302","type":"RC"},{"code":"86256","type":"HCPCS"}],"standard_charges":[{"gross_charge":110.0,"discounted_cash":60.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Neutrophil Ab Screen I","code_information":[{"code":"60131290","type":"CDM"},{"code":"302","type":"RC"},{"code":"86021","type":"HCPCS"}],"standard_charges":[{"gross_charge":45.0,"discounted_cash":24.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Receptor Ab Nmda Igg","code_information":[{"code":"60131320","type":"CDM"},{"code":"302","type":"RC"},{"code":"86255","type":"HCPCS"}],"standard_charges":[{"gross_charge":38.0,"discounted_cash":20.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Nmda Receptor Ab Titer I","code_information":[{"code":"60131330","type":"CDM"},{"code":"302","type":"RC"},{"code":"86256","type":"HCPCS"}],"standard_charges":[{"gross_charge":110.0,"discounted_cash":60.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Opiates Urine Screen I","code_information":[{"code":"60131350","type":"CDM"},{"code":"301","type":"RC"},{"code":"80307","type":"HCPCS"}],"standard_charges":[{"gross_charge":321.0,"discounted_cash":176.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg O+P Exam Fld/Urine","code_information":[{"code":"60131360","type":"CDM"},{"code":"306","type":"RC"},{"code":"87177","type":"HCPCS"}],"standard_charges":[{"gross_charge":38.0,"discounted_cash":20.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Smear Complex Stn O+P","code_information":[{"code":"60131370","type":"CDM"},{"code":"306","type":"RC"},{"code":"87209","type":"HCPCS"}],"standard_charges":[{"gross_charge":292.0,"discounted_cash":160.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Platelet Ab Id I","code_information":[{"code":"60131470","type":"CDM"},{"code":"302","type":"RC"},{"code":"86022","type":"HCPCS"}],"standard_charges":[{"gross_charge":151.0,"discounted_cash":83.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Platelet Id Immuno","code_information":[{"code":"60131480","type":"CDM"},{"code":"302","type":"RC"},{"code":"86023","type":"HCPCS"}],"standard_charges":[{"gross_charge":71.0,"discounted_cash":39.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Protein C Activity Ii","code_information":[{"code":"60131510","type":"CDM"},{"code":"305","type":"RC"},{"code":"85303","type":"HCPCS"}],"standard_charges":[{"gross_charge":47.0,"discounted_cash":25.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Iga Blood Iii","code_information":[{"code":"60131520","type":"CDM"},{"code":"301","type":"RC"},{"code":"82784","type":"HCPCS"}],"standard_charges":[{"gross_charge":178.0,"discounted_cash":97.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Igg Blood Iii","code_information":[{"code":"60131530","type":"CDM"},{"code":"301","type":"RC"},{"code":"82784","type":"HCPCS"}],"standard_charges":[{"gross_charge":178.0,"discounted_cash":97.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Igm Blood Iii","code_information":[{"code":"60131540","type":"CDM"},{"code":"301","type":"RC"},{"code":"82784","type":"HCPCS"}],"standard_charges":[{"gross_charge":178.0,"discounted_cash":97.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Protein S Total Ii","code_information":[{"code":"60131550","type":"CDM"},{"code":"305","type":"RC"},{"code":"85305","type":"HCPCS"}],"standard_charges":[{"gross_charge":184.0,"discounted_cash":101.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Protein S Free Ii","code_information":[{"code":"60131560","type":"CDM"},{"code":"305","type":"RC"},{"code":"85306","type":"HCPCS"}],"standard_charges":[{"gross_charge":170.0,"discounted_cash":93.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Calcium Blood Ii","code_information":[{"code":"60131570","type":"CDM"},{"code":"301","type":"RC"},{"code":"82310","type":"HCPCS"}],"standard_charges":[{"gross_charge":79.0,"discounted_cash":43.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Q Fever Ab Titer Igg Phase I","code_information":[{"code":"60131580","type":"CDM"},{"code":"302","type":"RC"},{"code":"86638","type":"HCPCS"}],"standard_charges":[{"gross_charge":37.0,"discounted_cash":20.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Q Fever Ab Titer Igg Phase Ii","code_information":[{"code":"60131590","type":"CDM"},{"code":"302","type":"RC"},{"code":"86638","type":"HCPCS"}],"standard_charges":[{"gross_charge":37.0,"discounted_cash":20.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Influenza A By Dfa I","code_information":[{"code":"60131600","type":"CDM"},{"code":"306","type":"RC"},{"code":"87276","type":"HCPCS"}],"standard_charges":[{"gross_charge":65.0,"discounted_cash":35.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Influenza B By Dfa I","code_information":[{"code":"60131610","type":"CDM"},{"code":"306","type":"RC"},{"code":"87275","type":"HCPCS"}],"standard_charges":[{"gross_charge":50.0,"discounted_cash":27.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Parainfluenza By Dfa Ii","code_information":[{"code":"60131620","type":"CDM"},{"code":"306","type":"RC"},{"code":"87279","type":"HCPCS"}],"standard_charges":[{"gross_charge":66.0,"discounted_cash":36.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Rsv Antigen By Dfa I","code_information":[{"code":"60131630","type":"CDM"},{"code":"306","type":"RC"},{"code":"87280","type":"HCPCS"}],"standard_charges":[{"gross_charge":54.0,"discounted_cash":29.7,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Adenovirus Antigen Y Dfa I","code_information":[{"code":"60131640","type":"CDM"},{"code":"306","type":"RC"},{"code":"87260","type":"HCPCS"}],"standard_charges":[{"gross_charge":59.0,"discounted_cash":32.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Metapneumovirus By Dfa I","code_information":[{"code":"60131650","type":"CDM"},{"code":"306","type":"RC"},{"code":"87299","type":"HCPCS"}],"standard_charges":[{"gross_charge":65.0,"discounted_cash":35.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Bun Post","code_information":[{"code":"60131960","type":"CDM"},{"code":"301","type":"RC"},{"code":"84520","type":"HCPCS"}],"standard_charges":[{"gross_charge":87.0,"discounted_cash":47.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Bun Peripheral","code_information":[{"code":"60131970","type":"CDM"},{"code":"301","type":"RC"},{"code":"84520","type":"HCPCS"}],"standard_charges":[{"gross_charge":87.0,"discounted_cash":47.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Bun Arterial","code_information":[{"code":"60131980","type":"CDM"},{"code":"301","type":"RC"},{"code":"84520","type":"HCPCS"}],"standard_charges":[{"gross_charge":87.0,"discounted_cash":47.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Bun Venous","code_information":[{"code":"60131990","type":"CDM"},{"code":"301","type":"RC"},{"code":"84520","type":"HCPCS"}],"standard_charges":[{"gross_charge":87.0,"discounted_cash":47.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Vancomycin Peak 1Hr","code_information":[{"code":"60132000","type":"CDM"},{"code":"301","type":"RC"},{"code":"80202","type":"HCPCS"}],"standard_charges":[{"gross_charge":42.0,"discounted_cash":23.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Vancomycin Peak 2Hr","code_information":[{"code":"60132010","type":"CDM"},{"code":"301","type":"RC"},{"code":"80202","type":"HCPCS"}],"standard_charges":[{"gross_charge":42.0,"discounted_cash":23.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Drug Assay Adalimumab","code_information":[{"code":"60132050","type":"CDM"},{"code":"301","type":"RC"},{"code":"80145","type":"HCPCS"}],"standard_charges":[{"gross_charge":116.0,"discounted_cash":63.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Drug Assay Infliximab","code_information":[{"code":"60132060","type":"CDM"},{"code":"301","type":"RC"},{"code":"80230","type":"HCPCS"}],"standard_charges":[{"gross_charge":119.0,"discounted_cash":65.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Drug Assay Lacosamide","code_information":[{"code":"60132070","type":"CDM"},{"code":"301","type":"RC"},{"code":"80235","type":"HCPCS"}],"standard_charges":[{"gross_charge":81.0,"discounted_cash":44.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Drug Assay Voriconazole","code_information":[{"code":"60132090","type":"CDM"},{"code":"301","type":"RC"},{"code":"80285","type":"HCPCS"}],"standard_charges":[{"gross_charge":81.0,"discounted_cash":44.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Hcg Beta Chain Free","code_information":[{"code":"60132110","type":"CDM"},{"code":"301","type":"RC"},{"code":"84704","type":"HCPCS"}],"standard_charges":[{"gross_charge":51.0,"discounted_cash":28.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Iadna Mycoplasma Genitalium Amp Probe","code_information":[{"code":"60132150","type":"CDM"},{"code":"306","type":"RC"},{"code":"87563","type":"HCPCS"}],"standard_charges":[{"gross_charge":118.0,"discounted_cash":64.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Noncdm Charge Record","code_information":[{"code":"60132410","type":"CDM"},{"code":"311","type":"RC"},{"code":"88271","type":"HCPCS"}],"standard_charges":[{"gross_charge":150.0,"discounted_cash":82.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Noncdm Charge Record","code_information":[{"code":"60132420","type":"CDM"},{"code":"311","type":"RC"},{"code":"88275","type":"HCPCS"}],"standard_charges":[{"gross_charge":494.0,"discounted_cash":271.7,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Lchg Dna Probe Fish Mm","code_information":[{"code":"60132440","type":"CDM"},{"code":"311","type":"RC"},{"code":"88271","type":"HCPCS"}],"standard_charges":[{"gross_charge":142.0,"discounted_cash":78.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Interphase Hybrid 100-300 Mm","code_information":[{"code":"60132450","type":"CDM"},{"code":"311","type":"RC"},{"code":"88275","type":"HCPCS"}],"standard_charges":[{"gross_charge":469.0,"discounted_cash":257.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Dna Probe Fish Mds","code_information":[{"code":"60132460","type":"CDM"},{"code":"311","type":"RC"},{"code":"88271","type":"HCPCS"}],"standard_charges":[{"gross_charge":219.0,"discounted_cash":120.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Interphase Hybrid 100-300 Mds","code_information":[{"code":"60132470","type":"CDM"},{"code":"311","type":"RC"},{"code":"88275","type":"HCPCS"}],"standard_charges":[{"gross_charge":468.0,"discounted_cash":257.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Dna Probe Fish Eos","code_information":[{"code":"60132550","type":"CDM"},{"code":"311","type":"RC"},{"code":"88271","type":"HCPCS"}],"standard_charges":[{"gross_charge":182.0,"discounted_cash":100.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Interphase Hybrid 100-300 Eos","code_information":[{"code":"60132560","type":"CDM"},{"code":"311","type":"RC"},{"code":"88275","type":"HCPCS"}],"standard_charges":[{"gross_charge":389.0,"discounted_cash":213.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Noncdm Charge Record","code_information":[{"code":"60132570","type":"CDM"},{"code":"311","type":"RC"},{"code":"88271","type":"HCPCS"}],"standard_charges":[{"gross_charge":235.0,"discounted_cash":129.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Lchg Interphase Hybrid 100-300 Lymph","code_information":[{"code":"60132580","type":"CDM"},{"code":"311","type":"RC"},{"code":"88275","type":"HCPCS"}],"standard_charges":[{"gross_charge":469.0,"discounted_cash":257.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Rubella Ab Igm I","code_information":[{"code":"60132970","type":"CDM"},{"code":"302","type":"RC"},{"code":"86762","type":"HCPCS"}],"standard_charges":[{"gross_charge":600.0,"discounted_cash":330.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Topiramate Level Ii","code_information":[{"code":"60132990","type":"CDM"},{"code":"301","type":"RC"},{"code":"80201","type":"HCPCS"}],"standard_charges":[{"gross_charge":212.0,"discounted_cash":116.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Valproic Acid Total I","code_information":[{"code":"60133000","type":"CDM"},{"code":"301","type":"RC"},{"code":"80164","type":"HCPCS"}],"standard_charges":[{"gross_charge":218.0,"discounted_cash":119.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Valproic Acid Free I","code_information":[{"code":"60133010","type":"CDM"},{"code":"301","type":"RC"},{"code":"80165","type":"HCPCS"}],"standard_charges":[{"gross_charge":48.0,"discounted_cash":26.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Varicella Zoster Antibody Igg I","code_information":[{"code":"60133020","type":"CDM"},{"code":"302","type":"RC"},{"code":"86787","type":"HCPCS"}],"standard_charges":[{"gross_charge":137.0,"discounted_cash":75.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Varicella Zoster Ab Igg Csf","code_information":[{"code":"60133030","type":"CDM"},{"code":"302","type":"RC"},{"code":"86787","type":"HCPCS"}],"standard_charges":[{"gross_charge":87.0,"discounted_cash":47.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Varicella Zoster Ab Igm Csf","code_information":[{"code":"60133040","type":"CDM"},{"code":"302","type":"RC"},{"code":"86787","type":"HCPCS"}],"standard_charges":[{"gross_charge":87.0,"discounted_cash":47.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Vdrl Titer Ii","code_information":[{"code":"60133050","type":"CDM"},{"code":"302","type":"RC"},{"code":"86593","type":"HCPCS"}],"standard_charges":[{"gross_charge":53.0,"discounted_cash":29.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Viral Culture Addl Stdy Each I","code_information":[{"code":"60133060","type":"CDM"},{"code":"306","type":"RC"},{"code":"87254","type":"HCPCS"}],"standard_charges":[{"gross_charge":108.0,"discounted_cash":59.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Drug Screen Quant Alcohols I","code_information":[{"code":"60133070","type":"CDM"},{"code":"301","type":"RC"},{"code":"80320","type":"HCPCS"}],"standard_charges":[{"gross_charge":354.0,"discounted_cash":194.7,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Ethylene Glycol Iii","code_information":[{"code":"60133080","type":"CDM"},{"code":"301","type":"RC"},{"code":"82693","type":"HCPCS"}],"standard_charges":[{"gross_charge":230.0,"discounted_cash":126.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Legionella Dfa Ii","code_information":[{"code":"60133130","type":"CDM"},{"code":"306","type":"RC"},{"code":"87278","type":"HCPCS"}],"standard_charges":[{"gross_charge":108.0,"discounted_cash":59.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Clw A1 Antigen Testing","code_information":[{"code":"60133430","type":"CDM"},{"code":"302","type":"RC"},{"code":"86905","type":"HCPCS"}],"standard_charges":[{"gross_charge":555.0,"discounted_cash":305.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Clw Antigen Type Pt","code_information":[{"code":"60133440","type":"CDM"},{"code":"302","type":"RC"},{"code":"86905","type":"HCPCS"}],"standard_charges":[{"gross_charge":113.0,"discounted_cash":62.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Clw Antigen Type Unit","code_information":[{"code":"60133450","type":"CDM"},{"code":"302","type":"RC"},{"code":"86902","type":"HCPCS"}],"standard_charges":[{"gross_charge":81.0,"discounted_cash":44.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Clw Immune Abo Cord","code_information":[{"code":"60133460","type":"CDM"},{"code":"302","type":"RC"},{"code":"86870","type":"HCPCS"}],"standard_charges":[{"gross_charge":259.0,"discounted_cash":142.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Clw Reference Elat Test","code_information":[{"code":"60133480","type":"CDM"},{"code":"300","type":"RC"},{"code":"83518","type":"HCPCS"}],"standard_charges":[{"gross_charge":53.0,"discounted_cash":29.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Clw Reference Lab Alloadsorption","code_information":[{"code":"60133490","type":"CDM"},{"code":"302","type":"RC"},{"code":"86978","type":"HCPCS"}],"standard_charges":[{"gross_charge":248.0,"discounted_cash":136.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Clw Reference Lab Panel Iat","code_information":[{"code":"60133500","type":"CDM"},{"code":"302","type":"RC"},{"code":"86870","type":"HCPCS"}],"standard_charges":[{"gross_charge":259.0,"discounted_cash":142.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Clw Reference Lab Panel Rt","code_information":[{"code":"60133510","type":"CDM"},{"code":"302","type":"RC"},{"code":"86940","type":"HCPCS"}],"standard_charges":[{"gross_charge":43.0,"discounted_cash":23.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Clw Reference Lab Preselect Unit","code_information":[{"code":"60133520","type":"CDM"},{"code":"302","type":"RC"},{"code":"86904","type":"HCPCS"}],"standard_charges":[{"gross_charge":163.0,"discounted_cash":89.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Clw Reference Lab Rare Ag Type","code_information":[{"code":"60133530","type":"CDM"},{"code":"302","type":"RC"},{"code":"86905","type":"HCPCS"}],"standard_charges":[{"gross_charge":555.0,"discounted_cash":305.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Clw Reference Lab Rare Cell Panel","code_information":[{"code":"60133540","type":"CDM"},{"code":"302","type":"RC"},{"code":"86870","type":"HCPCS"}],"standard_charges":[{"gross_charge":812.0,"discounted_cash":446.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Clw Reference Lab Rare Search","code_information":[{"code":"60133550","type":"CDM"},{"code":"302","type":"RC"},{"code":"86870","type":"HCPCS"}],"standard_charges":[{"gross_charge":812.0,"discounted_cash":446.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Clw Reference Lab Screened Unit Hgbs","code_information":[{"code":"60133560","type":"CDM"},{"code":"302","type":"RC"},{"code":"86999","type":"HCPCS"}],"standard_charges":[{"gross_charge":112.0,"discounted_cash":61.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Clw Reference Lab Selected Cell Panel","code_information":[{"code":"60133570","type":"CDM"},{"code":"302","type":"RC"},{"code":"86870","type":"HCPCS"}],"standard_charges":[{"gross_charge":112.0,"discounted_cash":61.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Clw Reference Lab Selected Cell Screen","code_information":[{"code":"60133580","type":"CDM"},{"code":"302","type":"RC"},{"code":"86850","type":"HCPCS"}],"standard_charges":[{"gross_charge":106.0,"discounted_cash":58.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Clw Ref Lab Adsorbed Serum Crossmatch","code_information":[{"code":"60133590","type":"CDM"},{"code":"302","type":"RC"},{"code":"86922","type":"HCPCS"}],"standard_charges":[{"gross_charge":289.0,"discounted_cash":158.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Clw Ref Lab Rare Antigen Typing","code_information":[{"code":"60133600","type":"CDM"},{"code":"302","type":"RC"},{"code":"86905","type":"HCPCS"}],"standard_charges":[{"gross_charge":555.0,"discounted_cash":305.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Kappa Lite Chain Free I","code_information":[{"code":"60133711","type":"CDM"},{"code":"301","type":"RC"},{"code":"83520","type":"HCPCS"}],"standard_charges":[{"gross_charge":151.0,"discounted_cash":83.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Lambda Lite Chain Free I","code_information":[{"code":"60133721","type":"CDM"},{"code":"301","type":"RC"},{"code":"83520","type":"HCPCS"}],"standard_charges":[{"gross_charge":151.0,"discounted_cash":83.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Hydroxylase 21 Autoantibody","code_information":[{"code":"60133730","type":"CDM"},{"code":"301","type":"RC"},{"code":"83516","type":"HCPCS"}],"standard_charges":[{"gross_charge":40.0,"discounted_cash":22.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Myd88 Gene Pleu265 Pro Vrnt","code_information":[{"code":"60133950","type":"CDM"},{"code":"310","type":"RC"},{"code":"81305","type":"HCPCS"}],"standard_charges":[{"gross_charge":757.0,"discounted_cash":416.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Gc Amplified Probe  Iii","code_information":[{"code":"60133970","type":"CDM"},{"code":"306","type":"RC"},{"code":"87591","type":"HCPCS"}],"standard_charges":[{"gross_charge":482.0,"discounted_cash":265.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Urine Total Protein Monoclonal","code_information":[{"code":"60133980","type":"CDM"},{"code":"301","type":"RC"},{"code":"84156","type":"HCPCS"}],"standard_charges":[{"gross_charge":87.0,"discounted_cash":47.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Immunoassay Quant Nos Monoclonal","code_information":[{"code":"60133990","type":"CDM"},{"code":"301","type":"RC"},{"code":"83520","type":"HCPCS"}],"standard_charges":[{"gross_charge":166.0,"discounted_cash":91.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Salivary Cortisol","code_information":[{"code":"60134440","type":"CDM"},{"code":"301","type":"RC"},{"code":"82533","type":"HCPCS"}],"standard_charges":[{"gross_charge":260.0,"discounted_cash":143.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Blastomyces Antigen Urine","code_information":[{"code":"60134450","type":"CDM"},{"code":"306","type":"RC"},{"code":"87449","type":"HCPCS"}],"standard_charges":[{"gross_charge":50.0,"discounted_cash":27.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Nj 10 Drug Mic Suscep Stdy Agar Dilut","code_information":[{"code":"60134540","type":"CDM"},{"code":"306","type":"RC"},{"code":"87181","type":"HCPCS"}],"standard_charges":[{"gross_charge":56.0,"discounted_cash":30.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Nj10 Drug Mic Susceptibility","code_information":[{"code":"60134550","type":"CDM"},{"code":"306","type":"RC"},{"code":"87186","type":"HCPCS"}],"standard_charges":[{"gross_charge":174.0,"discounted_cash":95.7,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Nj 15 Drug Mic Susceptibility","code_information":[{"code":"60134560","type":"CDM"},{"code":"306","type":"RC"},{"code":"87186","type":"HCPCS"}],"standard_charges":[{"gross_charge":174.0,"discounted_cash":95.7,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Nj 20 Drug Mic Susceptibility","code_information":[{"code":"60134570","type":"CDM"},{"code":"306","type":"RC"},{"code":"87186","type":"HCPCS"}],"standard_charges":[{"gross_charge":174.0,"discounted_cash":95.7,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Nj Ntm Resist Mkr; Amb Prb Ea Org","code_information":[{"code":"60134580","type":"CDM"},{"code":"306","type":"RC"},{"code":"87798","type":"HCPCS"}],"standard_charges":[{"gross_charge":170.0,"discounted_cash":93.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Microdissection Manual Idh1+2","code_information":[{"code":"60134620","type":"CDM"},{"code":"310","type":"RC"},{"code":"88381","type":"HCPCS"}],"standard_charges":[{"gross_charge":217.0,"discounted_cash":119.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Biopsy Renal Surg Path Level Iv","code_information":[{"code":"60134670","type":"CDM"},{"code":"310","type":"RC"},{"code":"88305","type":"HCPCS"}],"standard_charges":[{"gross_charge":494.0,"discounted_cash":271.7,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Biopsy Renal Electron Micro Diag","code_information":[{"code":"60134680","type":"CDM"},{"code":"310","type":"RC"},{"code":"88348","type":"HCPCS"}],"standard_charges":[{"gross_charge":1271.0,"discounted_cash":699.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Biopsy Renal Spec Stn Grp 2","code_information":[{"code":"60134690","type":"CDM"},{"code":"310","type":"RC"},{"code":"88313","type":"HCPCS"}],"standard_charges":[{"gross_charge":228.0,"discounted_cash":125.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Biopsy Renal Immunofluor Stdy Direct","code_information":[{"code":"60134700","type":"CDM"},{"code":"310","type":"RC"},{"code":"88346","type":"HCPCS"}],"standard_charges":[{"gross_charge":139.0,"discounted_cash":76.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Biopsy Renal Antb Addl Stn","code_information":[{"code":"60134710","type":"CDM"},{"code":"310","type":"RC"},{"code":"88350","type":"HCPCS"}],"standard_charges":[{"gross_charge":150.0,"discounted_cash":82.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Sars-Cov-2 (Covid-19)","code_information":[{"code":"60134800","type":"CDM"},{"code":"306","type":"RC"},{"code":"87635","type":"HCPCS"}],"standard_charges":[{"gross_charge":210.0,"discounted_cash":115.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Sars-Cov-2  (Covid-19) Iii","code_information":[{"code":"60134830","type":"CDM"},{"code":"306","type":"RC"},{"code":"87635","type":"HCPCS"}],"standard_charges":[{"gross_charge":210.0,"discounted_cash":115.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Sars-Cov-2  (Covid-19) Iiii","code_information":[{"code":"60134860","type":"CDM"},{"code":"306","type":"RC"},{"code":"87635","type":"HCPCS"}],"standard_charges":[{"gross_charge":210.0,"discounted_cash":115.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Chrom Anaylysis 15-20 Cells; Poc","code_information":[{"code":"60136130","type":"CDM"},{"code":"311","type":"RC"},{"code":"88262","type":"HCPCS"}],"standard_charges":[{"gross_charge":1400.0,"discounted_cash":770.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Tiss Cult Skin Or Solid Bx Poc","code_information":[{"code":"60136140","type":"CDM"},{"code":"311","type":"RC"},{"code":"88233","type":"HCPCS"}],"standard_charges":[{"gross_charge":74.0,"discounted_cash":40.7,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Cg Mcg; Int & Rep Poc","code_information":[{"code":"60136150","type":"CDM"},{"code":"311","type":"RC"},{"code":"88291","type":"HCPCS"}],"standard_charges":[{"gross_charge":144.0,"discounted_cash":79.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Hepatitis B Ab I","code_information":[{"code":"60136160","type":"CDM"},{"code":"302","type":"RC"},{"code":"86317","type":"HCPCS"}],"standard_charges":[{"gross_charge":46.0,"discounted_cash":25.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Hepatitis Be Hbeab","code_information":[{"code":"60136170","type":"CDM"},{"code":"302","type":"RC"},{"code":"86707","type":"HCPCS"}],"standard_charges":[{"gross_charge":36.0,"discounted_cash":19.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Hepatitis Be Antigen Ii","code_information":[{"code":"60136180","type":"CDM"},{"code":"306","type":"RC"},{"code":"87350","type":"HCPCS"}],"standard_charges":[{"gross_charge":48.0,"discounted_cash":26.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Protein Synovial Fluid","code_information":[{"code":"60136190","type":"CDM"},{"code":"301","type":"RC"},{"code":"84157","type":"HCPCS"}],"standard_charges":[{"gross_charge":13.0,"discounted_cash":7.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Glucose Synovial Fluid","code_information":[{"code":"60136200","type":"CDM"},{"code":"301","type":"RC"},{"code":"82945","type":"HCPCS"}],"standard_charges":[{"gross_charge":80.0,"discounted_cash":44.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Sars-Cov-2 (Covid-19) Antibody Igg","code_information":[{"code":"60136220","type":"CDM"},{"code":"302","type":"RC"},{"code":"86769","type":"HCPCS"}],"standard_charges":[{"gross_charge":55.0,"discounted_cash":30.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Blood Typing Rbc Antigens","code_information":[{"code":"60136750","type":"CDM"},{"code":"302","type":"RC"},{"code":"86905","type":"HCPCS"}],"standard_charges":[{"gross_charge":812.0,"discounted_cash":446.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Antibody Id Rbc Antibodies","code_information":[{"code":"60136760","type":"CDM"},{"code":"302","type":"RC"},{"code":"86870","type":"HCPCS"}],"standard_charges":[{"gross_charge":259.0,"discounted_cash":142.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Ref Lab Donath-Landsteiner Therm Ab","code_information":[{"code":"60137910","type":"CDM"},{"code":"302","type":"RC"},{"code":"86941","type":"HCPCS"}],"standard_charges":[{"gross_charge":441.0,"discounted_cash":242.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Sp Stain Grp Ii Amyloid Protein","code_information":[{"code":"60138150","type":"CDM"},{"code":"310","type":"RC"},{"code":"88313","type":"HCPCS"}],"standard_charges":[{"gross_charge":228.0,"discounted_cash":125.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Amyloid Protein Mass Spec","code_information":[{"code":"60138160","type":"CDM"},{"code":"301","type":"RC"},{"code":"82542","type":"HCPCS"}],"standard_charges":[{"gross_charge":203.0,"discounted_cash":111.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Microdissection Laser Amyloid Protein","code_information":[{"code":"60138170","type":"CDM"},{"code":"310","type":"RC"},{"code":"88380","type":"HCPCS"}],"standard_charges":[{"gross_charge":958.0,"discounted_cash":526.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Immunofixation Blood","code_information":[{"code":"60138210","type":"CDM"},{"code":"302","type":"RC"},{"code":"86334","type":"HCPCS"}],"standard_charges":[{"gross_charge":244.0,"discounted_cash":134.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg 5-Hiaa Plasma","code_information":[{"code":"60138220","type":"CDM"},{"code":"301","type":"RC"},{"code":"82542","type":"HCPCS"}],"standard_charges":[{"gross_charge":288.0,"discounted_cash":158.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Susceptibility Viridans Strep","code_information":[{"code":"60138250","type":"CDM"},{"code":"306","type":"RC"},{"code":"87186","type":"HCPCS"}],"standard_charges":[{"gross_charge":174.0,"discounted_cash":95.7,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Susceptibility Gram Positive Rod","code_information":[{"code":"60138260","type":"CDM"},{"code":"306","type":"RC"},{"code":"87186","type":"HCPCS"}],"standard_charges":[{"gross_charge":210.0,"discounted_cash":115.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Susceptibility Enterobacteriaceae","code_information":[{"code":"60138270","type":"CDM"},{"code":"306","type":"RC"},{"code":"87186","type":"HCPCS"}],"standard_charges":[{"gross_charge":35.0,"discounted_cash":19.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Microdissection Manual Poc","code_information":[{"code":"60138300","type":"CDM"},{"code":"310","type":"RC"},{"code":"88381","type":"HCPCS"}],"standard_charges":[{"gross_charge":212.0,"discounted_cash":116.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Flow Cell Hemoglobinuria","code_information":[{"code":"60138380","type":"CDM"},{"code":"311","type":"RC"},{"code":"88184","type":"HCPCS"}],"standard_charges":[{"gross_charge":165.0,"discounted_cash":90.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Flow Cell Hemoglobinuria Add Ea Marker","code_information":[{"code":"60138390","type":"CDM"},{"code":"311","type":"RC"},{"code":"88185","type":"HCPCS"}],"standard_charges":[{"gross_charge":159.0,"discounted_cash":87.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Tick Borne Blood Pcr","code_information":[{"code":"60138410","type":"CDM"},{"code":"306","type":"RC"},{"code":"87798","type":"HCPCS"}],"standard_charges":[{"gross_charge":494.0,"discounted_cash":271.7,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Hemoglobin S Ref","code_information":[{"code":"60138830","type":"CDM"},{"code":"305","type":"RC"},{"code":"85660","type":"HCPCS"}],"standard_charges":[{"gross_charge":284.0,"discounted_cash":156.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg F Tularensis Agglutinins","code_information":[{"code":"60138950","type":"CDM"},{"code":"302","type":"RC"},{"code":"86000","type":"HCPCS"}],"standard_charges":[{"gross_charge":43.0,"discounted_cash":23.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Biofire Respiratory Panel 2.1","code_information":[{"code":"60139180","type":"CDM"},{"code":"300","type":"RC"},{"code":"0202U","type":"HCPCS"}],"standard_charges":[{"gross_charge":619.0,"discounted_cash":340.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Rare Unit Sent Ref","code_information":[{"code":"60139350","type":"CDM"},{"code":"302","type":"RC"},{"code":"86022","type":"HCPCS"}],"standard_charges":[{"gross_charge":151.0,"discounted_cash":83.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Plt Crossmatch Ref","code_information":[{"code":"60139360","type":"CDM"},{"code":"302","type":"RC"},{"code":"86022","type":"HCPCS"}],"standard_charges":[{"gross_charge":151.0,"discounted_cash":83.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Hla Molecular Phenotype Ref","code_information":[{"code":"60139370","type":"CDM"},{"code":"300","type":"RC"},{"code":"81373","type":"HCPCS"}],"standard_charges":[{"gross_charge":617.0,"discounted_cash":339.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Hpa Molecular Phenotype Ref","code_information":[{"code":"60139380","type":"CDM"},{"code":"310","type":"RC"},{"code":"81400","type":"HCPCS"}],"standard_charges":[{"gross_charge":310.0,"discounted_cash":170.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Rhd Variant Assay Ref","code_information":[{"code":"60139390","type":"CDM"},{"code":"310","type":"RC"},{"code":"81403","type":"HCPCS"}],"standard_charges":[{"gross_charge":898.0,"discounted_cash":493.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Sars-Cov-2 (Covid-19) Antigen","code_information":[{"code":"60139610","type":"CDM"},{"code":"306","type":"RC"},{"code":"87426","type":"HCPCS"}],"standard_charges":[{"gross_charge":101.0,"discounted_cash":55.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Sars-Cov-2 (Covid-19) + Influ A/B + Rsv","code_information":[{"code":"60139810","type":"CDM"},{"code":"306","type":"RC"},{"code":"0241U","type":"HCPCS"}],"standard_charges":[{"gross_charge":456.0,"discounted_cash":250.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Sars-Cov-2 (Covid-19) + Influ A/B","code_information":[{"code":"60139820","type":"CDM"},{"code":"306","type":"RC"},{"code":"0240U","type":"HCPCS"}],"standard_charges":[{"gross_charge":456.0,"discounted_cash":250.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Protein Wb;Im Id For Bands","code_information":[{"code":"60139840","type":"CDM"},{"code":"301","type":"RC"},{"code":"84182","type":"HCPCS"}],"standard_charges":[{"gross_charge":99.0,"discounted_cash":54.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Arsenic Speciation Urine Random","code_information":[{"code":"60139870","type":"CDM"},{"code":"301","type":"RC"},{"code":"82175","type":"HCPCS"}],"standard_charges":[{"gross_charge":118.0,"discounted_cash":64.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Creatinine Urine Random Ii","code_information":[{"code":"60139880","type":"CDM"},{"code":"301","type":"RC"},{"code":"82570","type":"HCPCS"}],"standard_charges":[{"gross_charge":79.0,"discounted_cash":43.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Sars-Cov-2+Influenza A+B Probe","code_information":[{"code":"60139950","type":"CDM"},{"code":"306","type":"RC"},{"code":"87636","type":"HCPCS"}],"standard_charges":[{"gross_charge":583.0,"discounted_cash":320.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Sars-Cov-2+Influenza A+B+Rsv Probe","code_information":[{"code":"60139960","type":"CDM"},{"code":"306","type":"RC"},{"code":"87637","type":"HCPCS"}],"standard_charges":[{"gross_charge":579.0,"discounted_cash":318.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Amiodarone And Metabolite Assay","code_information":[{"code":"60140000","type":"CDM"},{"code":"301","type":"RC"},{"code":"80151","type":"HCPCS"}],"standard_charges":[{"gross_charge":56.0,"discounted_cash":30.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Methanol Assay","code_information":[{"code":"60140010","type":"CDM"},{"code":"301","type":"RC"},{"code":"82077","type":"HCPCS"}],"standard_charges":[{"gross_charge":57.0,"discounted_cash":31.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Carbamazepine Epoxide 10,11","code_information":[{"code":"60140020","type":"CDM"},{"code":"301","type":"RC"},{"code":"80161","type":"HCPCS"}],"standard_charges":[{"gross_charge":56.0,"discounted_cash":30.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Felbamate Assay","code_information":[{"code":"60140030","type":"CDM"},{"code":"301","type":"RC"},{"code":"80167","type":"HCPCS"}],"standard_charges":[{"gross_charge":56.0,"discounted_cash":30.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Itraconazole Assay","code_information":[{"code":"60140040","type":"CDM"},{"code":"301","type":"RC"},{"code":"80189","type":"HCPCS"}],"standard_charges":[{"gross_charge":83.0,"discounted_cash":45.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Jak2 Exon 12 Mutation","code_information":[{"code":"60140050","type":"CDM"},{"code":"310","type":"RC"},{"code":"81279","type":"HCPCS"}],"standard_charges":[{"gross_charge":898.0,"discounted_cash":493.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Noncdm Charge Record","code_information":[{"code":"60140060","type":"CDM"},{"code":"301","type":"RC"},{"code":"80210","type":"HCPCS"}],"standard_charges":[{"gross_charge":117.0,"discounted_cash":64.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Lchg Mpl Gene Analysis","code_information":[{"code":"60140070","type":"CDM"},{"code":"310","type":"RC"},{"code":"81338","type":"HCPCS"}],"standard_charges":[{"gross_charge":727.0,"discounted_cash":399.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Methotrexate Assay","code_information":[{"code":"60140120","type":"CDM"},{"code":"301","type":"RC"},{"code":"80204","type":"HCPCS"}],"standard_charges":[{"gross_charge":116.0,"discounted_cash":63.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Acetaminophen Assay","code_information":[{"code":"60140130","type":"CDM"},{"code":"301","type":"RC"},{"code":"80143","type":"HCPCS"}],"standard_charges":[{"gross_charge":56.0,"discounted_cash":30.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Salicylate Assay","code_information":[{"code":"60140140","type":"CDM"},{"code":"301","type":"RC"},{"code":"80179","type":"HCPCS"}],"standard_charges":[{"gross_charge":56.0,"discounted_cash":30.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Ethyl Alcohol Bld","code_information":[{"code":"60140150","type":"CDM"},{"code":"301","type":"RC"},{"code":"82077","type":"HCPCS"}],"standard_charges":[{"gross_charge":57.0,"discounted_cash":31.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Targeted Genomic Seq Analys Aml","code_information":[{"code":"60141250","type":"CDM"},{"code":"310","type":"RC"},{"code":"81450","type":"HCPCS"}],"standard_charges":[{"gross_charge":3674.0,"discounted_cash":2020.7,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Methylmalonic Acid Blood I","code_information":[{"code":"60141890","type":"CDM"},{"code":"301","type":"RC"},{"code":"83921","type":"HCPCS"}],"standard_charges":[{"gross_charge":225.0,"discounted_cash":123.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Organism Id","code_information":[{"code":"60142560","type":"CDM"},{"code":"306","type":"RC"},{"code":"87158","type":"HCPCS"}],"standard_charges":[{"gross_charge":32.0,"discounted_cash":17.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Carbamylated Protein Ab Igg","code_information":[{"code":"60142610","type":"CDM"},{"code":"301","type":"RC"},{"code":"83516","type":"HCPCS"}],"standard_charges":[{"gross_charge":174.0,"discounted_cash":95.7,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Actin (Smooth Muscle) Ab","code_information":[{"code":"60144210","type":"CDM"},{"code":"302","type":"RC"},{"code":"86015","type":"HCPCS"}],"standard_charges":[{"gross_charge":35.0,"discounted_cash":19.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Anca Screen","code_information":[{"code":"60144230","type":"CDM"},{"code":"302","type":"RC"},{"code":"86036","type":"HCPCS"}],"standard_charges":[{"gross_charge":36.0,"discounted_cash":19.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Anca Screen I","code_information":[{"code":"60144240","type":"CDM"},{"code":"302","type":"RC"},{"code":"86036","type":"HCPCS"}],"standard_charges":[{"gross_charge":36.0,"discounted_cash":19.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Mog Igg1 Antibody (Cba)","code_information":[{"code":"60144250","type":"CDM"},{"code":"302","type":"RC"},{"code":"86362","type":"HCPCS"}],"standard_charges":[{"gross_charge":127.0,"discounted_cash":69.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Endomysial Antibody (Ema) I","code_information":[{"code":"60144300","type":"CDM"},{"code":"302","type":"RC"},{"code":"86231","type":"HCPCS"}],"standard_charges":[{"gross_charge":36.0,"discounted_cash":19.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Light Chains (Kappa, Lambda) Free","code_information":[{"code":"60144340","type":"CDM"},{"code":"301","type":"RC"},{"code":"83521","type":"HCPCS"}],"standard_charges":[{"gross_charge":57.0,"discounted_cash":31.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Light Chains (Kappa, Lambda) Free I","code_information":[{"code":"60144350","type":"CDM"},{"code":"301","type":"RC"},{"code":"83521","type":"HCPCS"}],"standard_charges":[{"gross_charge":57.0,"discounted_cash":31.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Interleukin-6 (Il-6)","code_information":[{"code":"60144360","type":"CDM"},{"code":"301","type":"RC"},{"code":"83529","type":"HCPCS"}],"standard_charges":[{"gross_charge":226.0,"discounted_cash":124.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Mitochondrial Antibody (M2)","code_information":[{"code":"60144370","type":"CDM"},{"code":"302","type":"RC"},{"code":"86381","type":"HCPCS"}],"standard_charges":[{"gross_charge":76.0,"discounted_cash":41.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Pancreatic Elastase (El-1) Fecal Quant","code_information":[{"code":"60144390","type":"CDM"},{"code":"301","type":"RC"},{"code":"82653","type":"HCPCS"}],"standard_charges":[{"gross_charge":75.0,"discounted_cash":41.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Voltage-Gated Calcium Channel Ab","code_information":[{"code":"60144400","type":"CDM"},{"code":"302","type":"RC"},{"code":"86596","type":"HCPCS"}],"standard_charges":[{"gross_charge":55.0,"discounted_cash":30.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Neuromyelitis Optica (Nmo) Ab (Cba)","code_information":[{"code":"60144410","type":"CDM"},{"code":"302","type":"RC"},{"code":"86052","type":"HCPCS"}],"standard_charges":[{"gross_charge":1079.0,"discounted_cash":593.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Deaminated Gliadin Ab (Dgp) Iga","code_information":[{"code":"60144570","type":"CDM"},{"code":"302","type":"RC"},{"code":"86258","type":"HCPCS"}],"standard_charges":[{"gross_charge":128.0,"discounted_cash":70.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Deaminated Gliadin Ab (Dgp) Igg","code_information":[{"code":"60144580","type":"CDM"},{"code":"302","type":"RC"},{"code":"86258","type":"HCPCS"}],"standard_charges":[{"gross_charge":34.0,"discounted_cash":18.7,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Tissue Transglutaminase Igg","code_information":[{"code":"60144590","type":"CDM"},{"code":"302","type":"RC"},{"code":"86364","type":"HCPCS"}],"standard_charges":[{"gross_charge":35.0,"discounted_cash":19.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg P/Q Type Calcium Channel Ab","code_information":[{"code":"60144600","type":"CDM"},{"code":"302","type":"RC"},{"code":"86596","type":"HCPCS"}],"standard_charges":[{"gross_charge":55.0,"discounted_cash":30.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Tissue Transglutaminase Iga","code_information":[{"code":"60144610","type":"CDM"},{"code":"302","type":"RC"},{"code":"86364","type":"HCPCS"}],"standard_charges":[{"gross_charge":35.0,"discounted_cash":19.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Nmo Aqp4 Facs Ea","code_information":[{"code":"60144630","type":"CDM"},{"code":"302","type":"RC"},{"code":"86053","type":"HCPCS"}],"standard_charges":[{"gross_charge":113.0,"discounted_cash":62.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Nmo Aqp4 Facs Titer Ea","code_information":[{"code":"60144640","type":"CDM"},{"code":"302","type":"RC"},{"code":"86053","type":"HCPCS"}],"standard_charges":[{"gross_charge":113.0,"discounted_cash":62.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Tissue Transglutaminase Iga Ii","code_information":[{"code":"60144650","type":"CDM"},{"code":"302","type":"RC"},{"code":"86364","type":"HCPCS"}],"standard_charges":[{"gross_charge":35.0,"discounted_cash":19.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Tissue Transglutaminase Igg Ii","code_information":[{"code":"60144660","type":"CDM"},{"code":"302","type":"RC"},{"code":"86364","type":"HCPCS"}],"standard_charges":[{"gross_charge":35.0,"discounted_cash":19.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Culture Typing Id Bld Pathogen 6+ Targets","code_information":[{"code":"60144960","type":"CDM"},{"code":"306","type":"RC"},{"code":"87154","type":"HCPCS"}],"standard_charges":[{"gross_charge":885.0,"discounted_cash":486.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Vedolizumab Quant","code_information":[{"code":"60145020","type":"CDM"},{"code":"301","type":"RC"},{"code":"80280","type":"HCPCS"}],"standard_charges":[{"gross_charge":848.0,"discounted_cash":466.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Sulfonylurea Hypoglycemics I","code_information":[{"code":"60145160","type":"CDM"},{"code":"301","type":"RC"},{"code":"80377","type":"HCPCS"}],"standard_charges":[{"gross_charge":470.0,"discounted_cash":258.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Noncdm Charge Record","code_information":[{"code":"60146230","type":"CDM"},{"code":"305","type":"RC"},{"code":"85246","type":"HCPCS"}],"standard_charges":[{"gross_charge":181.0,"discounted_cash":99.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Lchg Ureaplasma/Mycoplasma Amp Probe","code_information":[{"code":"60146350","type":"CDM"},{"code":"306","type":"RC"},{"code":"87798","type":"HCPCS"}],"standard_charges":[{"gross_charge":432.0,"discounted_cash":237.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Noncdm Charge Record","code_information":[{"code":"60146360","type":"CDM"},{"code":"306","type":"RC"},{"code":"87563","type":"HCPCS"}],"standard_charges":[{"gross_charge":170.0,"discounted_cash":93.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Noncdm Charge Record","code_information":[{"code":"60147400","type":"CDM"},{"code":"301","type":"RC"},{"code":"83520","type":"HCPCS"}],"standard_charges":[{"gross_charge":63.67,"discounted_cash":35.02,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Noncdm Charge Record","code_information":[{"code":"60147480","type":"CDM"},{"code":"302","type":"RC"},{"code":"86900","type":"HCPCS"}],"standard_charges":[{"gross_charge":290.0,"discounted_cash":159.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Noncdm Charge Record","code_information":[{"code":"60147510","type":"CDM"},{"code":"302","type":"RC"},{"code":"86901","type":"HCPCS"}],"standard_charges":[{"gross_charge":290.0,"discounted_cash":159.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Lchg Susceptibility Fungus/Yeast","code_information":[{"code":"60147530","type":"CDM"},{"code":"306","type":"RC"},{"code":"87186","type":"HCPCS"}],"standard_charges":[{"gross_charge":98.0,"discounted_cash":53.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Orthopoxvirus By Naa Amp Probe","code_information":[{"code":"60147700","type":"CDM"},{"code":"306","type":"RC"},{"code":"87593","type":"HCPCS"}],"standard_charges":[{"gross_charge":157.0,"discounted_cash":86.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Chromogranin A Ii","code_information":[{"code":"60147810","type":"CDM"},{"code":"302","type":"RC"},{"code":"86316","type":"HCPCS"}],"standard_charges":[{"gross_charge":316.0,"discounted_cash":173.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Sars-Cov-2 (Covid-19) Antibody Igg Ii","code_information":[{"code":"60147870","type":"CDM"},{"code":"302","type":"RC"},{"code":"86769","type":"HCPCS"}],"standard_charges":[{"gross_charge":40.0,"discounted_cash":22.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Ehrlichia Chaffeensis Amplified Prb","code_information":[{"code":"60148700","type":"CDM"},{"code":"306","type":"RC"},{"code":"87484","type":"HCPCS"}],"standard_charges":[{"gross_charge":118.0,"discounted_cash":64.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Ehrlichia Chaffeensis Amplified Prb I","code_information":[{"code":"60148701","type":"CDM"},{"code":"306","type":"RC"},{"code":"87484","type":"HCPCS"}],"standard_charges":[{"gross_charge":118.0,"discounted_cash":64.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Noncdm Charge Record","code_information":[{"code":"60148710","type":"CDM"},{"code":"301","type":"RC"},{"code":"84433","type":"HCPCS"}],"standard_charges":[{"gross_charge":170.0,"discounted_cash":93.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Lchg Anaplasma Phagocytophilum Amp Prb","code_information":[{"code":"60148720","type":"CDM"},{"code":"306","type":"RC"},{"code":"87468","type":"HCPCS"}],"standard_charges":[{"gross_charge":118.0,"discounted_cash":64.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Anaplasma Phagocytophilum Amp Prb I","code_information":[{"code":"60148721","type":"CDM"},{"code":"306","type":"RC"},{"code":"87468","type":"HCPCS"}],"standard_charges":[{"gross_charge":118.0,"discounted_cash":64.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Babesia Microti Amplified Probe","code_information":[{"code":"60148730","type":"CDM"},{"code":"306","type":"RC"},{"code":"87469","type":"HCPCS"}],"standard_charges":[{"gross_charge":86.0,"discounted_cash":47.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Babesia Microti Amplified Probe I","code_information":[{"code":"60148731","type":"CDM"},{"code":"306","type":"RC"},{"code":"87469","type":"HCPCS"}],"standard_charges":[{"gross_charge":118.0,"discounted_cash":64.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Prdcts Of Concept Dna Ploidy By Flow","code_information":[{"code":"60149090","type":"CDM"},{"code":"311","type":"RC"},{"code":"88182","type":"HCPCS"}],"standard_charges":[{"gross_charge":227.0,"discounted_cash":124.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Noncdm Charge Record","code_information":[{"code":"60149100","type":"CDM"},{"code":"311","type":"RC"},{"code":"81352","type":"HCPCS"}],"standard_charges":[{"gross_charge":1967.5,"discounted_cash":1082.12,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Noncdm Charge Record","code_information":[{"code":"60149180","type":"CDM"},{"code":"306","type":"RC"},{"code":"87158","type":"HCPCS"}],"standard_charges":[{"gross_charge":53.0,"discounted_cash":29.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."},{"gross_charge":162.0,"discounted_cash":89.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Lchg Q Fever Ab Screen","code_information":[{"code":"60149390","type":"CDM"},{"code":"302","type":"RC"},{"code":"86638","type":"HCPCS"}],"standard_charges":[{"gross_charge":55.0,"discounted_cash":30.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Braf Gene Ii","code_information":[{"code":"60149400","type":"CDM"},{"code":"310","type":"RC"},{"code":"81210","type":"HCPCS"}],"standard_charges":[{"gross_charge":634.0,"discounted_cash":348.7,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Celiac Disease Cascade","code_information":[{"code":"60149480","type":"CDM"},{"code":"302","type":"RC"},{"code":"86364","type":"HCPCS"}],"standard_charges":[{"gross_charge":117.0,"discounted_cash":64.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Noncdm Charge Record","code_information":[{"code":"60149500","type":"CDM"},{"code":"306","type":"RC"},{"code":"87153","type":"HCPCS"}],"standard_charges":[{"gross_charge":1027.0,"discounted_cash":564.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Lchg Infect Dis Dna Untargeted Ngs","code_information":[{"code":"60149520","type":"CDM"},{"code":"300","type":"RC"},{"code":"0152U","type":"HCPCS"}],"standard_charges":[{"gross_charge":4939.0,"discounted_cash":2716.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Acetylcholine Receptor Binding Ab","code_information":[{"code":"60149540","type":"CDM"},{"code":"300","type":"RC"},{"code":"86041","type":"HCPCS"}],"standard_charges":[{"gross_charge":40.0,"discounted_cash":22.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Acetylcholine Receptor Blocking Ab","code_information":[{"code":"60149550","type":"CDM"},{"code":"300","type":"RC"},{"code":"86042","type":"HCPCS"}],"standard_charges":[{"gross_charge":90.0,"discounted_cash":49.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Acetylcholine Receptor Modulating Ab","code_information":[{"code":"60149560","type":"CDM"},{"code":"300","type":"RC"},{"code":"86043","type":"HCPCS"}],"standard_charges":[{"gross_charge":90.0,"discounted_cash":49.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Muscle-Specific Kinase (Musk) Ab","code_information":[{"code":"60149580","type":"CDM"},{"code":"300","type":"RC"},{"code":"86366","type":"HCPCS"}],"standard_charges":[{"gross_charge":40.0,"discounted_cash":22.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Acetylcholine Receptor Binding Ab Ii","code_information":[{"code":"60149590","type":"CDM"},{"code":"300","type":"RC"},{"code":"86041","type":"HCPCS"}],"standard_charges":[{"gross_charge":40.0,"discounted_cash":22.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Acetylcholine Receptor Blocking Ab Ii","code_information":[{"code":"60149600","type":"CDM"},{"code":"300","type":"RC"},{"code":"86042","type":"HCPCS"}],"standard_charges":[{"gross_charge":40.0,"discounted_cash":22.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Noncdm Charge Record","code_information":[{"code":"60149610","type":"CDM"},{"code":"300","type":"RC"},{"code":"81457","type":"HCPCS"}],"standard_charges":[{"gross_charge":350.0,"discounted_cash":192.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Lchg Treponema Pallidum Ab Igg","code_information":[{"code":"60149660","type":"CDM"},{"code":"302","type":"RC"},{"code":"86780","type":"HCPCS"}],"standard_charges":[{"gross_charge":28.0,"discounted_cash":15.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Dna Antibody Igg","code_information":[{"code":"60149930","type":"CDM"},{"code":"302","type":"RC"},{"code":"86225","type":"HCPCS"}],"standard_charges":[{"gross_charge":132.0,"discounted_cash":72.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Rpr Titer Iii","code_information":[{"code":"60149980","type":"CDM"},{"code":"302","type":"RC"},{"code":"86593","type":"HCPCS"}],"standard_charges":[{"gross_charge":14.0,"discounted_cash":7.7,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Congenital Syphillis","code_information":[{"code":"60150000","type":"CDM"},{"code":"302","type":"RC"},{"code":"86592","type":"HCPCS"}],"standard_charges":[{"gross_charge":14.0,"discounted_cash":7.7,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Noncdm Charge Record","code_information":[{"code":"60150090","type":"CDM"},{"code":"310","type":"RC"},{"code":"81305","type":"HCPCS"}],"standard_charges":[{"gross_charge":1400.0,"discounted_cash":770.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Lchg Creatinine Blood Referral","code_information":[{"code":"60150400","type":"CDM"},{"code":"301","type":"RC"},{"code":"82565","type":"HCPCS"}],"standard_charges":[{"gross_charge":11.0,"discounted_cash":6.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Lchg Pneumocystis Jirovecii Amp Prb","code_information":[{"code":"60150470","type":"CDM"},{"code":"306","type":"RC"},{"code":"87594","type":"HCPCS"}],"standard_charges":[{"gross_charge":440.0,"discounted_cash":242.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Noncdm Charge Record","code_information":[{"code":"60150620","type":"CDM"},{"code":"301","type":"RC"},{"code":"84393","type":"HCPCS"}],"standard_charges":[{"gross_charge":428.33,"discounted_cash":235.58,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Papaverine HCl Inj 30 MG/ML","drug_information":{"unit":1.0,"type":"ML"},"code_information":[{"code":"6030","type":"CDM"},{"code":"14789012105","type":"NDC"}],"standard_charges":[{"gross_charge":92.88,"discounted_cash":51.08,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Papaverine HCl Inj 30 MG/ML","drug_information":{"unit":1.0,"type":"ML"},"code_information":[{"code":"6030","type":"CDM"},{"code":"14789012107","type":"NDC"}],"standard_charges":[{"gross_charge":92.88,"discounted_cash":51.08,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Dextrose Inj 5%","drug_information":{"unit":250.0,"type":"ML"},"code_information":[{"code":"604160","type":"CDM"},{"code":"264751020","type":"NDC"}],"standard_charges":[{"gross_charge":21.8,"discounted_cash":11.99,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Dextrose Inj 5%","drug_information":{"unit":500.0,"type":"ML"},"code_information":[{"code":"604160","type":"CDM"},{"code":"264751010","type":"NDC"}],"standard_charges":[{"gross_charge":22.5,"discounted_cash":12.38,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Dextrose Inj 5%","drug_information":{"unit":100.0,"type":"ML"},"code_information":[{"code":"604160","type":"CDM"},{"code":"264151032","type":"NDC"}],"standard_charges":[{"gross_charge":61.35,"discounted_cash":33.74,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Dextrose Inj 5%","drug_information":{"unit":50.0,"type":"ML"},"code_information":[{"code":"604160","type":"CDM"},{"code":"264151031","type":"NDC"}],"standard_charges":[{"gross_charge":61.13,"discounted_cash":33.62,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Dextrose Inj 5%","drug_information":{"unit":1000.0,"type":"ML"},"code_information":[{"code":"604160","type":"CDM"},{"code":"65219046205","type":"NDC"}],"standard_charges":[{"gross_charge":22.5,"discounted_cash":12.38,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Penicillin G Potassium For Inj 20000000 Unit","drug_information":{"unit":0.125,"type":"EA"},"code_information":[{"code":"6085","type":"CDM"},{"code":"25021015451","type":"NDC"}],"standard_charges":[{"gross_charge":45.55,"discounted_cash":25.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Penicillin G Potassium For Inj 5000000 Unit","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"6086","type":"CDM"},{"code":"44567031110","type":"NDC"}],"standard_charges":[{"gross_charge":48.27,"discounted_cash":26.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Penicillin V Potassium For Soln 250 MG/5ML","drug_information":{"unit":100.0,"type":"ML"},"code_information":[{"code":"6091","type":"CDM"},{"code":"93412773","type":"NDC"}],"standard_charges":[{"gross_charge":66.84,"discounted_cash":36.76,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Penicillin V Potassium Tab 250 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"6092","type":"CDM"},{"code":"65862017501","type":"NDC"}],"standard_charges":[{"gross_charge":10.04,"discounted_cash":5.52,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Perphenazine Tab 2 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"6157","type":"CDM"},{"code":"64980029001","type":"NDC"}],"standard_charges":[{"gross_charge":14.72,"discounted_cash":8.10,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Phenazopyridine HCl Tab 100 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"6193","type":"CDM"},{"code":"75826011410","type":"NDC"}],"standard_charges":[{"gross_charge":9.44,"discounted_cash":5.19,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Phenazopyridine HCl Tab 100 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"6193","type":"CDM"},{"code":"65162068110","type":"NDC"}],"standard_charges":[{"gross_charge":18.4,"discounted_cash":10.12,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Phenobarbital Tab 30 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"6216","type":"CDM"},{"code":"16571067201","type":"NDC"}],"standard_charges":[{"gross_charge":9.88,"discounted_cash":5.43,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Phenobarbital Sodium Inj 65 MG/ML","drug_information":{"unit":0.461538461538462,"type":"ML"},"code_information":[{"code":"6224","type":"CDM"},{"code":"42494041501","type":"NDC"}],"standard_charges":[{"gross_charge":57.58,"discounted_cash":31.67,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Phenobarbital Sodium Inj 65 MG/ML","drug_information":{"unit":0.461538461538462,"type":"ML"},"code_information":[{"code":"6224","type":"CDM"},{"code":"42494041525","type":"NDC"}],"standard_charges":[{"gross_charge":57.59,"discounted_cash":31.67,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Phenylephrine HCl Nasal Soln 1%","drug_information":{"unit":15.0,"type":"ML"},"code_information":[{"code":"6245","type":"CDM"},{"code":"69536010015","type":"NDC"}],"standard_charges":[{"gross_charge":36.02,"discounted_cash":19.81,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Phenylephrine HCl Ophth Soln 2.5%","drug_information":{"unit":15.0,"type":"ML"},"code_information":[{"code":"6246","type":"CDM"},{"code":"70756064935","type":"NDC"}],"standard_charges":[{"gross_charge":388.25,"discounted_cash":213.54,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Phenytoin Sodium Inj 50 MG/ML","drug_information":{"unit":2.0,"type":"ML"},"code_information":[{"code":"6256","type":"CDM"},{"code":"641049321","type":"NDC"}],"standard_charges":[{"gross_charge":38.43,"discounted_cash":21.14,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Phenytoin Sodium Inj 50 MG/ML","drug_information":{"unit":2.0,"type":"ML"},"code_information":[{"code":"6256","type":"CDM"},{"code":"641049325","type":"NDC"}],"standard_charges":[{"gross_charge":38.42,"discounted_cash":21.13,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Phenytoin Sodium Extended Cap 100 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"6257","type":"CDM"},{"code":"71036924","type":"NDC"}],"standard_charges":[{"gross_charge":16.01,"discounted_cash":8.81,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Phenytoin Sodium Extended Cap 100 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"6257","type":"CDM"},{"code":"51672411101","type":"NDC"}],"standard_charges":[{"gross_charge":10.85,"discounted_cash":5.97,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Pilocarpine HCl Ophth Soln 2%","drug_information":{"unit":15.0,"type":"ML"},"code_information":[{"code":"6280","type":"CDM"},{"code":"61314020415","type":"NDC"}],"standard_charges":[{"gross_charge":349.69,"discounted_cash":192.33,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Pediatric Multiple Vitamin Drops","drug_information":{"unit":0.5,"type":"ML"},"code_information":[{"code":"6374","type":"CDM"},{"code":"87040203","type":"NDC"}],"standard_charges":[{"gross_charge":8.44,"discounted_cash":4.64,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Polymyxin B Sulfate For Inj 500000 Unit","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"6393","type":"CDM"},{"code":"63323032110","type":"NDC"}],"standard_charges":[{"gross_charge":68.59,"discounted_cash":37.72,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Potassium Acetate Inj 2 mEq/ML","drug_information":{"unit":20.0,"type":"ML"},"code_information":[{"code":"6420","type":"CDM"},{"code":"51754200104","type":"NDC"}],"standard_charges":[{"gross_charge":59.84,"discounted_cash":32.91,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Potassium Acetate Inj 2 mEq/ML","drug_information":{"unit":20.0,"type":"ML"},"code_information":[{"code":"6420","type":"CDM"},{"code":"409818311","type":"NDC"}],"standard_charges":[{"gross_charge":59.84,"discounted_cash":32.91,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Potassium Chloride Inj 2 mEq/ML","drug_information":{"unit":10.0,"type":"ML"},"code_information":[{"code":"6429","type":"CDM"},{"code":"63323096510","type":"NDC"}],"standard_charges":[{"gross_charge":43.24,"discounted_cash":23.78,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Potassium Chloride Inj 2 mEq/ML","drug_information":{"unit":5.0,"type":"ML"},"code_information":[{"code":"6429","type":"CDM"},{"code":"63323096505","type":"NDC"}],"standard_charges":[{"gross_charge":50.27,"discounted_cash":27.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Potassium Chloride Inj 2 mEq/ML","drug_information":{"unit":20.0,"type":"ML"},"code_information":[{"code":"6429","type":"CDM"},{"code":"63323096502","type":"NDC"}],"standard_charges":[{"gross_charge":44.97,"discounted_cash":24.73,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Potassium Chloride Inj 2 mEq/ML","drug_information":{"unit":250.0,"type":"ML"},"code_information":[{"code":"6429","type":"CDM"},{"code":"264194020","type":"NDC"}],"standard_charges":[{"gross_charge":141.14,"discounted_cash":77.63,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Potassium Chloride Inj 2 mEq/ML","drug_information":{"unit":20.0,"type":"ML"},"code_information":[{"code":"6429","type":"CDM"},{"code":"63323096520","type":"NDC"}],"standard_charges":[{"gross_charge":44.97,"discounted_cash":24.73,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Potassium Chloride Powder Packet 20 mEq","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"6434","type":"CDM"},{"code":"70069082301","type":"NDC"}],"standard_charges":[{"gross_charge":37.54,"discounted_cash":20.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Potassium Chloride Powder Packet 20 mEq","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"6434","type":"CDM"},{"code":"70069082330","type":"NDC"}],"standard_charges":[{"gross_charge":37.54,"discounted_cash":20.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Pralidoxime Chloride For IV Soln 1 GM","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"6462","type":"CDM"},{"code":"60977014127","type":"NDC"}],"standard_charges":[{"gross_charge":233.88,"discounted_cash":128.63,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Prazosin HCl Cap 1 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"6468","type":"CDM"},{"code":"904702061","type":"NDC"}],"standard_charges":[{"gross_charge":14.23,"discounted_cash":7.83,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Prazosin HCl Cap 5 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"6470","type":"CDM"},{"code":"76282072325","type":"NDC"}],"standard_charges":[{"gross_charge":8.53,"discounted_cash":4.69,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Prednisolone Acetate Ophth Susp 1%","drug_information":{"unit":10.0,"type":"ML"},"code_information":[{"code":"6487","type":"CDM"},{"code":"61314063710","type":"NDC"}],"standard_charges":[{"gross_charge":320.99,"discounted_cash":176.54,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Prednisone Tab 1 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"6493","type":"CDM"},{"code":"59651048401","type":"NDC"}],"standard_charges":[{"gross_charge":9.13,"discounted_cash":5.02,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Prednisone Tab 10 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"6494","type":"CDM"},{"code":"60687013411","type":"NDC"}],"standard_charges":[{"gross_charge":8.94,"discounted_cash":4.92,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Prednisone Tab 10 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"6494","type":"CDM"},{"code":"60687013401","type":"NDC"}],"standard_charges":[{"gross_charge":8.94,"discounted_cash":4.92,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Prednisone Tab 2.5 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"6495","type":"CDM"},{"code":"603533621","type":"NDC"}],"standard_charges":[{"gross_charge":8.73,"discounted_cash":4.80,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Prednisone Tab 20 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"6496","type":"CDM"},{"code":"59651048801","type":"NDC"}],"standard_charges":[{"gross_charge":9.15,"discounted_cash":5.03,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Prednisone Tab 5 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"6497","type":"CDM"},{"code":"60687012201","type":"NDC"}],"standard_charges":[{"gross_charge":8.89,"discounted_cash":4.89,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Prednisone Tab 5 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"6497","type":"CDM"},{"code":"60687012211","type":"NDC"}],"standard_charges":[{"gross_charge":8.89,"discounted_cash":4.89,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Primidone Tab 250 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"6544","type":"CDM"},{"code":"591532101","type":"NDC"}],"standard_charges":[{"gross_charge":12.43,"discounted_cash":6.84,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Procainamide HCl Inj 100 MG/ML","drug_information":{"unit":1.0,"type":"ML"},"code_information":[{"code":"6562","type":"CDM"},{"code":"76329339905","type":"NDC"}],"standard_charges":[{"gross_charge":59.05,"discounted_cash":32.48,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Prochlorperazine Maleate Tab 10 MG (Base Equivalent)","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"6582","type":"CDM"},{"code":"50268068511","type":"NDC"}],"standard_charges":[{"gross_charge":14.81,"discounted_cash":8.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Prochlorperazine Maleate Tab 10 MG (Base Equivalent)","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"6582","type":"CDM"},{"code":"50268068515","type":"NDC"}],"standard_charges":[{"gross_charge":14.83,"discounted_cash":8.16,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Prochlorperazine Maleate Tab 5 MG (Base Equivalent)","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"6583","type":"CDM"},{"code":"70954068810","type":"NDC"}],"standard_charges":[{"gross_charge":10.64,"discounted_cash":5.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Proparacaine HCl Ophth Soln 0.5%","drug_information":{"unit":15.0,"type":"ML"},"code_information":[{"code":"6644","type":"CDM"},{"code":"61314001601","type":"NDC"}],"standard_charges":[{"gross_charge":185.92,"discounted_cash":102.26,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Propranolol HCl Tab 10 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"6656","type":"CDM"},{"code":"60687058711","type":"NDC"}],"standard_charges":[{"gross_charge":9.34,"discounted_cash":5.14,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Propranolol HCl Tab 10 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"6656","type":"CDM"},{"code":"60687058701","type":"NDC"}],"standard_charges":[{"gross_charge":9.34,"discounted_cash":5.14,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Propranolol HCl Tab 40 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"6658","type":"CDM"},{"code":"60687060911","type":"NDC"}],"standard_charges":[{"gross_charge":10.98,"discounted_cash":6.04,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Protamine Sulfate Inj 10 MG/ML","drug_information":{"unit":2.5,"type":"ML"},"code_information":[{"code":"6677","type":"CDM"},{"code":"63323022905","type":"NDC"}],"standard_charges":[{"gross_charge":66.76,"discounted_cash":36.72,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Protamine Sulfate Inj 10 MG/ML","drug_information":{"unit":2.5,"type":"ML"},"code_information":[{"code":"6677","type":"CDM"},{"code":"63323022930","type":"NDC"}],"standard_charges":[{"gross_charge":55.45,"discounted_cash":30.50,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Pseudoephedrine HCl Tab 30 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"6714","type":"CDM"},{"code":"45802043262","type":"NDC"}],"standard_charges":[{"gross_charge":8.45,"discounted_cash":4.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Pyridoxine HCl Inj 100 MG/ML","drug_information":{"unit":0.1,"type":"ML"},"code_information":[{"code":"6744","type":"CDM"},{"code":"63323018001","type":"NDC"}],"standard_charges":[{"gross_charge":36.74,"discounted_cash":20.21,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Aspirin Chew Tab 81 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"680","type":"CDM"},{"code":"904679430","type":"NDC"}],"standard_charges":[{"gross_charge":3.09,"discounted_cash":1.70,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Aspirin Chew Tab 81 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"680","type":"CDM"},{"code":"77333004920","type":"NDC"}],"standard_charges":[{"gross_charge":3.14,"discounted_cash":1.73,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Aspirin Chew Tab 81 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"680","type":"CDM"},{"code":"904750930","type":"NDC"}],"standard_charges":[{"gross_charge":3.09,"discounted_cash":1.70,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Aspirin Chew Tab 81 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"680","type":"CDM"},{"code":"77333004925","type":"NDC"}],"standard_charges":[{"gross_charge":3.14,"discounted_cash":1.73,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Aspirin Tab 325 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"681","type":"CDM"},{"code":"536105429","type":"NDC"}],"standard_charges":[{"gross_charge":3.02,"discounted_cash":1.66,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Aspirin Suppos 300 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"693","type":"CDM"},{"code":"574703412","type":"NDC"}],"standard_charges":[{"gross_charge":13.61,"discounted_cash":7.49,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Dextrose Inj 10%","drug_information":{"unit":250.0,"type":"ML"},"code_information":[{"code":"700600","type":"CDM"},{"code":"338002302","type":"NDC"}],"standard_charges":[{"gross_charge":70.48,"discounted_cash":38.76,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Potassium & Sodium Phosphates Powder Pack 280-160-250 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"70284","type":"CDM"},{"code":"60258000601","type":"NDC"}],"standard_charges":[{"gross_charge":19.91,"discounted_cash":10.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Potassium & Sodium Phosphates Powder Pack 280-160-250 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"70284","type":"CDM"},{"code":"60258000615","type":"NDC"}],"standard_charges":[{"gross_charge":19.91,"discounted_cash":10.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Abatacept For IV Soln 250 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"70287","type":"CDM"},{"code":"3218713","type":"NDC"}],"standard_charges":[{"gross_charge":2422.0,"discounted_cash":1332.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Aripiprazole Tab 2 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"70306","type":"CDM"},{"code":"67877043003","type":"NDC"}],"standard_charges":[{"gross_charge":78.41,"discounted_cash":43.13,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Antihemophilic Factor/VWF (Human) For Inj 500-1200 Unit","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"70405","type":"CDM"},{"code":"63833061602","type":"NDC"}],"standard_charges":[{"gross_charge":38.62,"discounted_cash":21.24,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Ranolazine Tab ER 12HR 500 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"70434","type":"CDM"},{"code":"27241012502","type":"NDC"}],"standard_charges":[{"gross_charge":30.24,"discounted_cash":16.63,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Lubiprostone Cap 24 MCG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"70472","type":"CDM"},{"code":"254302902","type":"NDC"}],"standard_charges":[{"gross_charge":30.04,"discounted_cash":16.52,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Fluticasone Propionate Nasal Susp 50 MCG/ACT","drug_information":{"unit":16.0,"type":"GM"},"code_information":[{"code":"70536","type":"CDM"},{"code":"60505082901","type":"NDC"}],"standard_charges":[{"gross_charge":134.87,"discounted_cash":74.18,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Atenolol Tab 100 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"716","type":"CDM"},{"code":"65862017001","type":"NDC"}],"standard_charges":[{"gross_charge":12.82,"discounted_cash":7.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Atenolol Tab 25 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"717","type":"CDM"},{"code":"904718761","type":"NDC"}],"standard_charges":[{"gross_charge":9.05,"discounted_cash":4.98,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Silver Sulfadiazine Cream 1%","drug_information":{"unit":50.0,"type":"GM"},"code_information":[{"code":"7224","type":"CDM"},{"code":"67877012405","type":"NDC"}],"standard_charges":[{"gross_charge":109.34,"discounted_cash":60.14,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Silver Sulfadiazine Cream 1%","drug_information":{"unit":50.0,"type":"GM"},"code_information":[{"code":"7224","type":"CDM"},{"code":"67877012450","type":"NDC"}],"standard_charges":[{"gross_charge":109.34,"discounted_cash":60.14,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Simethicone Chew Tab 80 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"7227","type":"CDM"},{"code":"77333081210","type":"NDC"}],"standard_charges":[{"gross_charge":9.05,"discounted_cash":4.98,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Simple - Syrup","drug_information":{"unit":5.0,"type":"ML"},"code_information":[{"code":"7242","type":"CDM"},{"code":"31722093747","type":"NDC"}],"standard_charges":[{"gross_charge":8.96,"discounted_cash":4.93,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Sodium Acetate Inj 2 mEq/ML","drug_information":{"unit":50.0,"type":"ML"},"code_information":[{"code":"7301","type":"CDM"},{"code":"409329915","type":"NDC"}],"standard_charges":[{"gross_charge":95.75,"discounted_cash":52.66,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Sodium Acetate Inj 2 mEq/ML","drug_information":{"unit":100.0,"type":"ML"},"code_information":[{"code":"7301","type":"CDM"},{"code":"69784023110","type":"NDC"}],"standard_charges":[{"gross_charge":164.06,"discounted_cash":90.23,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Sodium Acetate Inj 2 mEq/ML","drug_information":{"unit":50.0,"type":"ML"},"code_information":[{"code":"7301","type":"CDM"},{"code":"409329905","type":"NDC"}],"standard_charges":[{"gross_charge":95.75,"discounted_cash":52.66,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Sodium Bicarbonate IV Soln 4.2%","drug_information":{"unit":10.0,"type":"ML"},"code_information":[{"code":"7306","type":"CDM"},{"code":"409553424","type":"NDC"}],"standard_charges":[{"gross_charge":133.18,"discounted_cash":73.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Sodium Bicarbonate IV Soln 8.4%","drug_information":{"unit":50.0,"type":"ML"},"code_information":[{"code":"7309","type":"CDM"},{"code":"76329335201","type":"NDC"}],"standard_charges":[{"gross_charge":136.24,"discounted_cash":74.93,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Sodium Bicarbonate IV Soln 8.4%","drug_information":{"unit":50.0,"type":"ML"},"code_information":[{"code":"7309","type":"CDM"},{"code":"51754501101","type":"NDC"}],"standard_charges":[{"gross_charge":243.52,"discounted_cash":133.94,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Sodium Bicarbonate IV Soln 8.4%","drug_information":{"unit":50.0,"type":"ML"},"code_information":[{"code":"7309","type":"CDM"},{"code":"81298762001","type":"NDC"}],"standard_charges":[{"gross_charge":87.07,"discounted_cash":47.89,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Sodium Bicarbonate Tab 650 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"7313","type":"CDM"},{"code":"904726161","type":"NDC"}],"standard_charges":[{"gross_charge":8.81,"discounted_cash":4.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Sodium Chloride IV Soln 0.45%","drug_information":{"unit":1000.0,"type":"ML"},"code_information":[{"code":"7318","type":"CDM"},{"code":"264780200","type":"NDC"}],"standard_charges":[{"gross_charge":66.65,"discounted_cash":36.66,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Sodium Chloride IV Soln 0.45%","drug_information":{"unit":250.0,"type":"ML"},"code_information":[{"code":"7318","type":"CDM"},{"code":"990798502","type":"NDC"}],"standard_charges":[{"gross_charge":68.56,"discounted_cash":37.71,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Sodium Chloride Preservative Free (PF) Inj 0.9%","drug_information":{"unit":2.5,"type":"ML"},"code_information":[{"code":"7319","type":"CDM"},{"code":"63323018601","type":"NDC"}],"standard_charges":[{"gross_charge":32.55,"discounted_cash":17.90,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Sodium Chloride Preservative Free (PF) Inj 0.9%","drug_information":{"unit":2.5,"type":"ML"},"code_information":[{"code":"7319","type":"CDM"},{"code":"409488806","type":"NDC"}],"standard_charges":[{"gross_charge":31.95,"discounted_cash":17.57,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Sodium Chloride Inj 0.9%,Sodium chloride flush IV,Sodium Chloride Preservative Free (PF) Inj 0.9%","drug_information":{"unit":2.5,"type":"ML"},"code_information":[{"code":"7319","type":"CDM"},{"code":"8290306546","type":"NDC"}],"standard_charges":[{"gross_charge":31.69,"discounted_cash":17.43,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Sodium Chloride Inj 0.9%,Sodium chloride flush IV,Sodium Chloride Preservative Free (PF) Inj 0.9%","drug_information":{"unit":2.5,"type":"ML"},"code_information":[{"code":"7319","type":"CDM"},{"code":"8290306544","type":"NDC"}],"standard_charges":[{"gross_charge":33.02,"discounted_cash":18.16,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Sodium Chloride Preservative Free (PF) Inj 0.9%","drug_information":{"unit":2.5,"type":"ML"},"code_information":[{"code":"7319","type":"CDM"},{"code":"409488820","type":"NDC"}],"standard_charges":[{"gross_charge":32.6,"discounted_cash":17.93,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Sodium Chloride Preservative Free (PF) Inj 0.9%","drug_information":{"unit":2.5,"type":"ML"},"code_information":[{"code":"7319","type":"CDM"},{"code":"63323018610","type":"NDC"}],"standard_charges":[{"gross_charge":32.55,"discounted_cash":17.90,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Sodium Chloride IV Soln 4 mEq/ML (23.4%)","drug_information":{"unit":200.0,"type":"ML"},"code_information":[{"code":"7322","type":"CDM"},{"code":"63323008863","type":"NDC"}],"standard_charges":[{"gross_charge":200.99,"discounted_cash":110.54,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Sodium Chloride IV Soln 4 mEq/ML (23.4%)","drug_information":{"unit":30.0,"type":"ML"},"code_information":[{"code":"7322","type":"CDM"},{"code":"63323009330","type":"NDC"}],"standard_charges":[{"gross_charge":71.85,"discounted_cash":39.52,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Sodium Chloride Soln Nebu 0.9%","drug_information":{"unit":3.0,"type":"ML"},"code_information":[{"code":"7325","type":"CDM"},{"code":"378698501","type":"NDC"}],"standard_charges":[{"gross_charge":9.9,"discounted_cash":5.44,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Sodium Chloride Soln Nebu 0.9%","drug_information":{"unit":3.0,"type":"ML"},"code_information":[{"code":"7325","type":"CDM"},{"code":"378698789","type":"NDC"}],"standard_charges":[{"gross_charge":8.84,"discounted_cash":4.86,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Sodium Chloride Soln Nebu 3%","drug_information":{"unit":4.0,"type":"ML"},"code_information":[{"code":"7327","type":"CDM"},{"code":"70756066360","type":"NDC"}],"standard_charges":[{"gross_charge":11.74,"discounted_cash":6.46,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Sodium Chloride Tab 1 GM","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"7328","type":"CDM"},{"code":"904723961","type":"NDC"}],"standard_charges":[{"gross_charge":9.21,"discounted_cash":5.07,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Atropine Sulfate Ophth Soln 1%","drug_information":{"unit":5.0,"type":"ML"},"code_information":[{"code":"736","type":"CDM"},{"code":"65081701","type":"NDC"}],"standard_charges":[{"gross_charge":216.49,"discounted_cash":119.07,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Sodium Thiosulfate IV Soln 250 MG/ML (25%)","drug_information":{"unit":50.0,"type":"ML"},"code_information":[{"code":"7364","type":"CDM"},{"code":"60267070550","type":"NDC"}],"standard_charges":[{"gross_charge":477.6,"discounted_cash":262.68,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Spironolactone Tab 25 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"7437","type":"CDM"},{"code":"60687046501","type":"NDC"}],"standard_charges":[{"gross_charge":9.01,"discounted_cash":4.96,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Spironolactone Tab 25 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"7437","type":"CDM"},{"code":"68382066001","type":"NDC"}],"standard_charges":[{"gross_charge":10.05,"discounted_cash":5.53,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Water For Injection","drug_information":{"unit":10.0,"type":"ML"},"code_information":[{"code":"7484","type":"CDM"},{"code":"63323018507","type":"NDC"}],"standard_charges":[{"gross_charge":57.7,"discounted_cash":31.74,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Water For Injection","drug_information":{"unit":1000.0,"type":"ML"},"code_information":[{"code":"7484","type":"CDM"},{"code":"264785000","type":"NDC"}],"standard_charges":[{"gross_charge":68.18,"discounted_cash":37.50,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Water For Injection","drug_information":{"unit":50.0,"type":"ML"},"code_information":[{"code":"7484","type":"CDM"},{"code":"409488724","type":"NDC"}],"standard_charges":[{"gross_charge":68.6,"discounted_cash":37.73,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Water For Injection","drug_information":{"unit":20.0,"type":"ML"},"code_information":[{"code":"7484","type":"CDM"},{"code":"409488720","type":"NDC"}],"standard_charges":[{"gross_charge":56.81,"discounted_cash":31.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Water For Injection","drug_information":{"unit":50.0,"type":"ML"},"code_information":[{"code":"7484","type":"CDM"},{"code":"63323018550","type":"NDC"}],"standard_charges":[{"gross_charge":76.17,"discounted_cash":41.89,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Water For Injection","drug_information":{"unit":10.0,"type":"ML"},"code_information":[{"code":"7484","type":"CDM"},{"code":"63323018510","type":"NDC"}],"standard_charges":[{"gross_charge":57.7,"discounted_cash":31.74,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Water For Injection","drug_information":{"unit":2000.0,"type":"ML"},"code_information":[{"code":"7484","type":"CDM"},{"code":"264738550","type":"NDC"}],"standard_charges":[{"gross_charge":83.48,"discounted_cash":45.91,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Water For Injection","drug_information":{"unit":500.0,"type":"ML"},"code_information":[{"code":"7484","type":"CDM"},{"code":"264785010","type":"NDC"}],"standard_charges":[{"gross_charge":66.65,"discounted_cash":36.66,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Water For Irrigation, Sterile Irrigation Soln","drug_information":{"unit":1000.0,"type":"ML"},"code_information":[{"code":"7485","type":"CDM"},{"code":"264210100","type":"NDC"}],"standard_charges":[{"gross_charge":39.25,"discounted_cash":21.59,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Succinylcholine Chloride Inj 20 MG/ML","drug_information":{"unit":5.0,"type":"ML"},"code_information":[{"code":"7536","type":"CDM"},{"code":"69374030005","type":"NDC"}],"standard_charges":[{"gross_charge":64.5,"discounted_cash":35.48,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Succinylcholine Chloride Inj 20 MG/ML","drug_information":{"unit":10.0,"type":"ML"},"code_information":[{"code":"7536","type":"CDM"},{"code":"71288071911","type":"NDC"}],"standard_charges":[{"gross_charge":63.0,"discounted_cash":34.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Succinylcholine Chloride Inj 20 MG/ML","drug_information":{"unit":10.0,"type":"ML"},"code_information":[{"code":"7536","type":"CDM"},{"code":"71288071910","type":"NDC"}],"standard_charges":[{"gross_charge":63.0,"discounted_cash":34.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Sulfadiazine Tab 500 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"7554","type":"CDM"},{"code":"42806075760","type":"NDC"}],"standard_charges":[{"gross_charge":63.1,"discounted_cash":34.70,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Sulfamethoxazole-Trimethoprim IV Soln 400-80 MG/5ML","drug_information":{"unit":10.0,"type":"ML"},"code_information":[{"code":"7556","type":"CDM"},{"code":"70069036201","type":"NDC"}],"standard_charges":[{"gross_charge":89.56,"discounted_cash":49.26,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Sulfamethoxazole-Trimethoprim IV Soln 400-80 MG/5ML","drug_information":{"unit":10.0,"type":"ML"},"code_information":[{"code":"7556","type":"CDM"},{"code":"70069036210","type":"NDC"}],"standard_charges":[{"gross_charge":89.56,"discounted_cash":49.26,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Sulfamethoxazole-Trimethoprim Tab 400-80 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"7557","type":"CDM"},{"code":"57237023201","type":"NDC"}],"standard_charges":[{"gross_charge":10.96,"discounted_cash":6.03,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Sulfasalazine Tab 500 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"7562","type":"CDM"},{"code":"59762500005","type":"NDC"}],"standard_charges":[{"gross_charge":9.04,"discounted_cash":4.97,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Hyaluronidase Human Inj 150 Unit/ML","drug_information":{"unit":1.0,"type":"ML"},"code_information":[{"code":"76523","type":"CDM"},{"code":"18657011704","type":"NDC"}],"standard_charges":[{"gross_charge":161.57,"discounted_cash":88.86,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Cholecalciferol Tab 25 MCG (1000 Unit)","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"76535","type":"CDM"},{"code":"20555003300","type":"NDC"}],"standard_charges":[{"gross_charge":4.07,"discounted_cash":2.24,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Antihemophilic Factor Recomb (rAHF-PFM) For Inj 1000 Unit","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"76567","type":"CDM"},{"code":"26382425","type":"NDC"}],"standard_charges":[{"gross_charge":42.13,"discounted_cash":23.17,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Guaifenesin Liquid 100 MG/5ML","drug_information":{"unit":5.0,"type":"ML"},"code_information":[{"code":"76993","type":"CDM"},{"code":"60687085240","type":"NDC"}],"standard_charges":[{"gross_charge":5.16,"discounted_cash":2.84,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Guaifenesin Liquid 100 MG/5ML","drug_information":{"unit":5.0,"type":"ML"},"code_information":[{"code":"76993","type":"CDM"},{"code":"60687085217","type":"NDC"}],"standard_charges":[{"gross_charge":5.16,"discounted_cash":2.84,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Aprepitant Capsule 40 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"77008","type":"CDM"},{"code":"13668059181","type":"NDC"}],"standard_charges":[{"gross_charge":309.35,"discounted_cash":170.14,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Tamoxifen Citrate Tab 10 MG (Base Equivalent)","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"7711","type":"CDM"},{"code":"378014491","type":"NDC"}],"standard_charges":[{"gross_charge":57.29,"discounted_cash":31.51,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Tamoxifen Citrate Tab 10 MG (Base Equivalent)","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"7711","type":"CDM"},{"code":"591247260","type":"NDC"}],"standard_charges":[{"gross_charge":57.29,"discounted_cash":31.51,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Levetiracetam Inj 500 MG/5ML (100 MG/ML)","drug_information":{"unit":2.5,"type":"ML"},"code_information":[{"code":"77239","type":"CDM"},{"code":"55150017705","type":"NDC"}],"standard_charges":[{"gross_charge":39.01,"discounted_cash":21.46,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Levetiracetam Inj 500 MG/5ML (100 MG/ML)","drug_information":{"unit":2.5,"type":"ML"},"code_information":[{"code":"77239","type":"CDM"},{"code":"409201125","type":"NDC"}],"standard_charges":[{"gross_charge":34.72,"discounted_cash":19.10,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Levetiracetam Inj 500 MG/5ML (100 MG/ML)","drug_information":{"unit":2.5,"type":"ML"},"code_information":[{"code":"77239","type":"CDM"},{"code":"409201105","type":"NDC"}],"standard_charges":[{"gross_charge":34.72,"discounted_cash":19.10,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Caffeine Citrate Oral Soln 60 MG/3ML (10 MG/ML Base Equiv)","drug_information":{"unit":3.0,"type":"ML"},"code_information":[{"code":"77453","type":"CDM"},{"code":"51754050103","type":"NDC"}],"standard_charges":[{"gross_charge":63.44,"discounted_cash":34.89,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Temazepam Cap 15 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"7753","type":"CDM"},{"code":"228207610","type":"NDC"}],"standard_charges":[{"gross_charge":11.27,"discounted_cash":6.20,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Tetanus Immune Globulin (Human) IM Soln Pref Syr 250 Unit/ML","drug_information":{"unit":1.0,"type":"ML"},"code_information":[{"code":"7789","type":"CDM"},{"code":"13533063402","type":"NDC"}],"standard_charges":[{"gross_charge":1160.55,"discounted_cash":638.30,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Tetracaine HCl Ophth Soln 0.5%","drug_information":{"unit":4.0,"type":"ML"},"code_information":[{"code":"7795","type":"CDM"},{"code":"65074114","type":"NDC"}],"standard_charges":[{"gross_charge":72.13,"discounted_cash":39.67,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Theophylline Soln 80 MG/15ML","drug_information":{"unit":15.0,"type":"ML"},"code_information":[{"code":"7821","type":"CDM"},{"code":"54838055680","type":"NDC"}],"standard_charges":[{"gross_charge":32.75,"discounted_cash":18.01,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Micafungin Sodium For IV Soln 100 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"78725","type":"CDM"},{"code":"25021019111","type":"NDC"}],"standard_charges":[{"gross_charge":329.66,"discounted_cash":181.31,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Micafungin Sodium For IV Soln 100 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"78725","type":"CDM"},{"code":"25021019110","type":"NDC"}],"standard_charges":[{"gross_charge":329.66,"discounted_cash":181.31,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Metoclopramide HCl Soln 5 MG/5ML (10 MG/10ML) (Base Equiv)","drug_information":{"unit":2.5,"type":"ML"},"code_information":[{"code":"78748","type":"CDM"},{"code":"66689003101","type":"NDC"}],"standard_charges":[{"gross_charge":42.52,"discounted_cash":23.39,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Thiamine HCl Inj 100 MG/ML","drug_information":{"unit":0.5,"type":"ML"},"code_information":[{"code":"7876","type":"CDM"},{"code":"63323001302","type":"NDC"}],"standard_charges":[{"gross_charge":40.85,"discounted_cash":22.47,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Thiamine HCl Inj 100 MG/ML","drug_information":{"unit":0.5,"type":"ML"},"code_information":[{"code":"7876","type":"CDM"},{"code":"63323001301","type":"NDC"}],"standard_charges":[{"gross_charge":40.85,"discounted_cash":22.47,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Paliperidone Tab ER 24HR 3 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"79353","type":"CDM"},{"code":"65162028103","type":"NDC"}],"standard_charges":[{"gross_charge":75.31,"discounted_cash":41.42,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Thyroid Tab 60 MG (1 Grain)","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"7947","type":"CDM"},{"code":"456045901","type":"NDC"}],"standard_charges":[{"gross_charge":13.19,"discounted_cash":7.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Antihemophilic Factor Recomb (rAHF-PFM) For Inj 2000 Unit","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"79697","type":"CDM"},{"code":"26382650","type":"NDC"}],"standard_charges":[{"gross_charge":59.13,"discounted_cash":32.52,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Mesalamine Tab Delayed Release 1.2 GM","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"79782","type":"CDM"},{"code":"60687039795","type":"NDC"}],"standard_charges":[{"gross_charge":42.32,"discounted_cash":23.28,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Mesalamine Tab Delayed Release 1.2 GM","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"79782","type":"CDM"},{"code":"60687039725","type":"NDC"}],"standard_charges":[{"gross_charge":42.32,"discounted_cash":23.28,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Hc Eye Foreign Body","code_information":[{"code":"800000","type":"CDM"},{"code":"320","type":"RC"},{"code":"70030","type":"HCPCS"}],"standard_charges":[{"gross_charge":503.0,"discounted_cash":276.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Wrist 2 Vw","code_information":[{"code":"800001","type":"CDM"},{"code":"320","type":"RC"},{"code":"73100","type":"HCPCS"}],"standard_charges":[{"gross_charge":553.0,"discounted_cash":304.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Fluoro Guidance For Needle Placment","code_information":[{"code":"800010","type":"CDM"},{"code":"320","type":"RC"},{"code":"77002","type":"HCPCS"}],"standard_charges":[{"gross_charge":664.0,"discounted_cash":365.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Intraluminal Dilatation","code_information":[{"code":"800011","type":"CDM"},{"code":"320","type":"RC"},{"code":"74360","type":"HCPCS"}],"standard_charges":[{"gross_charge":503.0,"discounted_cash":276.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Xray Colon  Single Contrast","code_information":[{"code":"800016","type":"CDM"},{"code":"320","type":"RC"},{"code":"74270","type":"HCPCS"}],"standard_charges":[{"gross_charge":503.0,"discounted_cash":276.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Wrist 3+ Vw","code_information":[{"code":"800022","type":"CDM"},{"code":"320","type":"RC"},{"code":"73110","type":"HCPCS"}],"standard_charges":[{"gross_charge":553.0,"discounted_cash":304.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Fl Arthrogram Wrist","code_information":[{"code":"800034","type":"CDM"},{"code":"322","type":"RC"},{"code":"73115","type":"HCPCS"}],"standard_charges":[{"gross_charge":1863.0,"discounted_cash":1024.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Hand 2 Vw","code_information":[{"code":"800054","type":"CDM"},{"code":"320","type":"RC"},{"code":"73120","type":"HCPCS"}],"standard_charges":[{"gross_charge":553.0,"discounted_cash":304.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Xray Pharynx W Contrast","code_information":[{"code":"800057","type":"CDM"},{"code":"320","type":"RC"},{"code":"74210","type":"HCPCS"}],"standard_charges":[{"gross_charge":503.0,"discounted_cash":276.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Op Psychotherapy W Pt 60 Min","code_information":[{"code":"800059","type":"CDM"},{"code":"914","type":"RC"},{"code":"90837","type":"HCPCS"}],"standard_charges":[{"gross_charge":165.0,"discounted_cash":90.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Us Guidance For Needle Placement","code_information":[{"code":"800062","type":"CDM"},{"code":"402","type":"RC"},{"code":"76942","type":"HCPCS"}],"standard_charges":[{"gross_charge":744.0,"discounted_cash":409.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ct Angio Abd Aorta Bil Low Ext W/Wo","code_information":[{"code":"800063","type":"CDM"},{"code":"352","type":"RC"},{"code":"75635","type":"HCPCS"}],"standard_charges":[{"gross_charge":3079.0,"discounted_cash":1693.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ct Colonography Screen","code_information":[{"code":"800064","type":"CDM"},{"code":"352","type":"RC"},{"code":"74263","type":"HCPCS"}],"standard_charges":[{"gross_charge":2807.0,"discounted_cash":1543.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Nasal Bones","code_information":[{"code":"800076","type":"CDM"},{"code":"320","type":"RC"},{"code":"70160","type":"HCPCS"}],"standard_charges":[{"gross_charge":553.0,"discounted_cash":304.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Hand 3+ Vw","code_information":[{"code":"800077","type":"CDM"},{"code":"320","type":"RC"},{"code":"73130","type":"HCPCS"}],"standard_charges":[{"gross_charge":553.0,"discounted_cash":304.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ct Colonography Diagnostic","code_information":[{"code":"800078","type":"CDM"},{"code":"352","type":"RC"},{"code":"74261","type":"HCPCS"}],"standard_charges":[{"gross_charge":2724.0,"discounted_cash":1498.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Replc Non Tun Cvc Wo Port Same Acc","code_information":[{"code":"800099","type":"CDM"},{"code":"361","type":"RC"},{"code":"36580","type":"HCPCS"}],"standard_charges":[{"gross_charge":2287.0,"discounted_cash":1257.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Repl Tun Cvc Wo Pt/Pp Same Acc","code_information":[{"code":"800100","type":"CDM"},{"code":"361","type":"RC"},{"code":"36581","type":"HCPCS"}],"standard_charges":[{"gross_charge":4507.0,"discounted_cash":2478.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Mri Brain Functional W/O Phys","code_information":[{"code":"800106","type":"CDM"},{"code":"611","type":"RC"},{"code":"70554","type":"HCPCS"}],"standard_charges":[{"gross_charge":3318.0,"discounted_cash":1824.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Insert Tun Cvc Wo Pt/Pp 5+Yrs","code_information":[{"code":"800147","type":"CDM"},{"code":"361","type":"RC"},{"code":"36558","type":"HCPCS"}],"standard_charges":[{"gross_charge":4767.0,"discounted_cash":2621.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Insert Tun Cvad W Sq Pt 5+Yrs","code_information":[{"code":"800148","type":"CDM"},{"code":"361","type":"RC"},{"code":"36561","type":"HCPCS"}],"standard_charges":[{"gross_charge":7823.0,"discounted_cash":4302.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Insert Picc Wo Sq Pt < 5 Yrs Wo Img","code_information":[{"code":"800149","type":"CDM"},{"code":"361","type":"RC"},{"code":"36568","type":"HCPCS"}],"standard_charges":[{"gross_charge":2861.0,"discounted_cash":1573.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Us Soft Tissue Lesion(S)","code_information":[{"code":"800150","type":"CDM"},{"code":"402","type":"RC"},{"code":"76999","type":"HCPCS"}],"standard_charges":[{"gross_charge":729.0,"discounted_cash":400.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Nm Pet/Ct Limited Area","code_information":[{"code":"800151","type":"CDM"},{"code":"404","type":"RC"},{"code":"78814","type":"HCPCS"}],"standard_charges":[{"gross_charge":6343.0,"discounted_cash":3488.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Primary Trombectmy Mech Artery Init Vsl","code_information":[{"code":"800154","type":"CDM"},{"code":"361","type":"RC"},{"code":"37184","type":"HCPCS"}],"standard_charges":[{"gross_charge":6626.0,"discounted_cash":3644.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Endo Rep Thor Aor Wo Subclav","code_information":[{"code":"800159","type":"CDM"},{"code":"360","type":"RC"},{"code":"33881","type":"HCPCS"}],"standard_charges":[{"gross_charge":13095.0,"discounted_cash":7202.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Endo Rpr Ds Thor Aort No Sbcla S And I","code_information":[{"code":"800160","type":"CDM"},{"code":"320","type":"RC"},{"code":"75957","type":"HCPCS"}],"standard_charges":[{"gross_charge":1290.0,"discounted_cash":709.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Place Dis Ext Prosth Delayed","code_information":[{"code":"800161","type":"CDM"},{"code":"360","type":"RC"},{"code":"33886","type":"HCPCS"}],"standard_charges":[{"gross_charge":9646.0,"discounted_cash":5305.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Fl Arthrogram Hip","code_information":[{"code":"800164","type":"CDM"},{"code":"322","type":"RC"},{"code":"73525","type":"HCPCS"}],"standard_charges":[{"gross_charge":2236.0,"discounted_cash":1229.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Prx Ext Prosth Endo Rpr Delayd S And I","code_information":[{"code":"800165","type":"CDM"},{"code":"320","type":"RC"},{"code":"75959","type":"HCPCS"}],"standard_charges":[{"gross_charge":5777.0,"discounted_cash":3177.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ct Cereb Perfus Analy W/C & Postp","code_information":[{"code":"800167","type":"CDM"},{"code":"351","type":"RC"},{"code":"0042T","type":"HCPCS"}],"standard_charges":[{"gross_charge":2411.0,"discounted_cash":1326.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Mri Brain Limited","code_information":[{"code":"800175","type":"CDM"},{"code":"611","type":"RC"},{"code":"70551","type":"HCPCS"}],"standard_charges":[{"gross_charge":3040.0,"discounted_cash":1672.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Mri Chest Limited","code_information":[{"code":"800176","type":"CDM"},{"code":"610","type":"RC"},{"code":"71550","type":"HCPCS"}],"standard_charges":[{"gross_charge":3600.0,"discounted_cash":1980.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Mri C Spine Limited Post Contrast","code_information":[{"code":"800178","type":"CDM"},{"code":"612","type":"RC"},{"code":"72142","type":"HCPCS"}],"standard_charges":[{"gross_charge":3407.0,"discounted_cash":1873.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Mri Pelvis Non Contrast Limited","code_information":[{"code":"800181","type":"CDM"},{"code":"610","type":"RC"},{"code":"72195","type":"HCPCS"}],"standard_charges":[{"gross_charge":3852.0,"discounted_cash":2118.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Knee 1 Or 2 Vw","code_information":[{"code":"800197","type":"CDM"},{"code":"320","type":"RC"},{"code":"73560","type":"HCPCS"}],"standard_charges":[{"gross_charge":553.0,"discounted_cash":304.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Knee 3 Vw","code_information":[{"code":"800200","type":"CDM"},{"code":"320","type":"RC"},{"code":"73562","type":"HCPCS"}],"standard_charges":[{"gross_charge":553.0,"discounted_cash":304.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Xr Knee 4+ Vw","code_information":[{"code":"800202","type":"CDM"},{"code":"320","type":"RC"},{"code":"73564","type":"HCPCS"}],"standard_charges":[{"gross_charge":553.0,"discounted_cash":304.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Knees Ap Bilateral Standing","code_information":[{"code":"800204","type":"CDM"},{"code":"320","type":"RC"},{"code":"73565","type":"HCPCS"}],"standard_charges":[{"gross_charge":553.0,"discounted_cash":304.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Fl Arthrogram Knee","code_information":[{"code":"800205","type":"CDM"},{"code":"322","type":"RC"},{"code":"73580","type":"HCPCS"}],"standard_charges":[{"gross_charge":1863.0,"discounted_cash":1024.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Tibia And Fibula 2 Vw","code_information":[{"code":"800207","type":"CDM"},{"code":"320","type":"RC"},{"code":"73590","type":"HCPCS"}],"standard_charges":[{"gross_charge":553.0,"discounted_cash":304.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Xr Lower Extremity Infant 2+ Vw","code_information":[{"code":"800209","type":"CDM"},{"code":"320","type":"RC"},{"code":"73592","type":"HCPCS"}],"standard_charges":[{"gross_charge":553.0,"discounted_cash":304.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ankle 2 Vw","code_information":[{"code":"800211","type":"CDM"},{"code":"320","type":"RC"},{"code":"73600","type":"HCPCS"}],"standard_charges":[{"gross_charge":553.0,"discounted_cash":304.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ankle 3+ Vw","code_information":[{"code":"800213","type":"CDM"},{"code":"320","type":"RC"},{"code":"73610","type":"HCPCS"}],"standard_charges":[{"gross_charge":553.0,"discounted_cash":304.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Fl Arthrogram Ankle","code_information":[{"code":"800215","type":"CDM"},{"code":"322","type":"RC"},{"code":"73615","type":"HCPCS"}],"standard_charges":[{"gross_charge":1863.0,"discounted_cash":1024.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Foot 2 Vw","code_information":[{"code":"800217","type":"CDM"},{"code":"320","type":"RC"},{"code":"73620","type":"HCPCS"}],"standard_charges":[{"gross_charge":553.0,"discounted_cash":304.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Foot 3+ Vw","code_information":[{"code":"800219","type":"CDM"},{"code":"320","type":"RC"},{"code":"73630","type":"HCPCS"}],"standard_charges":[{"gross_charge":553.0,"discounted_cash":304.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Orbits 4+ Vw","code_information":[{"code":"800220","type":"CDM"},{"code":"320","type":"RC"},{"code":"70200","type":"HCPCS"}],"standard_charges":[{"gross_charge":553.0,"discounted_cash":304.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Calcaneus 2+ Vw","code_information":[{"code":"800222","type":"CDM"},{"code":"320","type":"RC"},{"code":"73650","type":"HCPCS"}],"standard_charges":[{"gross_charge":553.0,"discounted_cash":304.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Toes 2+ Vw","code_information":[{"code":"800224","type":"CDM"},{"code":"320","type":"RC"},{"code":"73660","type":"HCPCS"}],"standard_charges":[{"gross_charge":553.0,"discounted_cash":304.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Cholangiogram Operative","code_information":[{"code":"800229","type":"CDM"},{"code":"320","type":"RC"},{"code":"74300","type":"HCPCS"}],"standard_charges":[{"gross_charge":503.0,"discounted_cash":276.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Fl Urethrogram Retrograde","code_information":[{"code":"800232","type":"CDM"},{"code":"320","type":"RC"},{"code":"74450","type":"HCPCS"}],"standard_charges":[{"gross_charge":832.0,"discounted_cash":457.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Fl Hysterosalpingogram","code_information":[{"code":"800235","type":"CDM"},{"code":"320","type":"RC"},{"code":"74740","type":"HCPCS"}],"standard_charges":[{"gross_charge":832.0,"discounted_cash":457.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Fb Exam Nose To Rectum Child Sgl Vw","code_information":[{"code":"800237","type":"CDM"},{"code":"320","type":"RC"},{"code":"76010","type":"HCPCS"}],"standard_charges":[{"gross_charge":503.0,"discounted_cash":276.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Xr Sinuses < 3Vw","code_information":[{"code":"800238","type":"CDM"},{"code":"320","type":"RC"},{"code":"70210","type":"HCPCS"}],"standard_charges":[{"gross_charge":553.0,"discounted_cash":304.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Xr Bone Age Study","code_information":[{"code":"800239","type":"CDM"},{"code":"320","type":"RC"},{"code":"77072","type":"HCPCS"}],"standard_charges":[{"gross_charge":553.0,"discounted_cash":304.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Bone Survey Limited","code_information":[{"code":"800240","type":"CDM"},{"code":"320","type":"RC"},{"code":"77074","type":"HCPCS"}],"standard_charges":[{"gross_charge":553.0,"discounted_cash":304.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Bone Survey Complete","code_information":[{"code":"800241","type":"CDM"},{"code":"320","type":"RC"},{"code":"77075","type":"HCPCS"}],"standard_charges":[{"gross_charge":553.0,"discounted_cash":304.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Xrays Bone Survey Infant","code_information":[{"code":"800242","type":"CDM"},{"code":"320","type":"RC"},{"code":"77076","type":"HCPCS"}],"standard_charges":[{"gross_charge":553.0,"discounted_cash":304.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Joint Survey 1 Vw 2+ Joints","code_information":[{"code":"800243","type":"CDM"},{"code":"320","type":"RC"},{"code":"77077","type":"HCPCS"}],"standard_charges":[{"gross_charge":553.0,"discounted_cash":304.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ct Head Non Contrast","code_information":[{"code":"800249","type":"CDM"},{"code":"351","type":"RC"},{"code":"70450","type":"HCPCS"}],"standard_charges":[{"gross_charge":2500.0,"discounted_cash":1375.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ct Head With Contrast","code_information":[{"code":"800250","type":"CDM"},{"code":"351","type":"RC"},{"code":"70460","type":"HCPCS"}],"standard_charges":[{"gross_charge":2625.0,"discounted_cash":1443.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ct Head With & Without Contrast","code_information":[{"code":"800251","type":"CDM"},{"code":"351","type":"RC"},{"code":"70470","type":"HCPCS"}],"standard_charges":[{"gross_charge":2756.0,"discounted_cash":1515.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ct Orbit Post Fossa Ear Non Contrast","code_information":[{"code":"800252","type":"CDM"},{"code":"351","type":"RC"},{"code":"70480","type":"HCPCS"}],"standard_charges":[{"gross_charge":2400.0,"discounted_cash":1320.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ct Orbit Post Fossa Ear With Contrast","code_information":[{"code":"800253","type":"CDM"},{"code":"351","type":"RC"},{"code":"70481","type":"HCPCS"}],"standard_charges":[{"gross_charge":2520.0,"discounted_cash":1386.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ct Orbit Post Fossa Ear With & Without Contrast","code_information":[{"code":"800254","type":"CDM"},{"code":"351","type":"RC"},{"code":"70482","type":"HCPCS"}],"standard_charges":[{"gross_charge":2646.0,"discounted_cash":1455.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ct Sinus Facial Bones Non Contrast","code_information":[{"code":"800255","type":"CDM"},{"code":"351","type":"RC"},{"code":"70486","type":"HCPCS"}],"standard_charges":[{"gross_charge":2485.0,"discounted_cash":1366.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ct Maxillofacial W Contrast","code_information":[{"code":"800256","type":"CDM"},{"code":"351","type":"RC"},{"code":"70487","type":"HCPCS"}],"standard_charges":[{"gross_charge":2609.0,"discounted_cash":1434.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Sinuses 3+ Vw","code_information":[{"code":"800257","type":"CDM"},{"code":"320","type":"RC"},{"code":"70220","type":"HCPCS"}],"standard_charges":[{"gross_charge":553.0,"discounted_cash":304.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ct Maxillofacial W & Wo Contrast","code_information":[{"code":"800258","type":"CDM"},{"code":"351","type":"RC"},{"code":"70488","type":"HCPCS"}],"standard_charges":[{"gross_charge":2739.0,"discounted_cash":1506.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ct Soft Tissue Neck Non Contrast","code_information":[{"code":"800259","type":"CDM"},{"code":"351","type":"RC"},{"code":"70490","type":"HCPCS"}],"standard_charges":[{"gross_charge":2390.0,"discounted_cash":1314.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ct Soft Tissue Neck With Contrast","code_information":[{"code":"800260","type":"CDM"},{"code":"351","type":"RC"},{"code":"70491","type":"HCPCS"}],"standard_charges":[{"gross_charge":2510.0,"discounted_cash":1380.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ct Soft Tissue Neck With & Without Contrast","code_information":[{"code":"800261","type":"CDM"},{"code":"351","type":"RC"},{"code":"70492","type":"HCPCS"}],"standard_charges":[{"gross_charge":2636.0,"discounted_cash":1449.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ct Angio Neck","code_information":[{"code":"800263","type":"CDM"},{"code":"350","type":"RC"},{"code":"70498","type":"HCPCS"}],"standard_charges":[{"gross_charge":2500.0,"discounted_cash":1375.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Mandible < 4 Vw","code_information":[{"code":"800264","type":"CDM"},{"code":"320","type":"RC"},{"code":"70100","type":"HCPCS"}],"standard_charges":[{"gross_charge":553.0,"discounted_cash":304.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ct Chest Non  Contrast","code_information":[{"code":"800266","type":"CDM"},{"code":"352","type":"RC"},{"code":"71250","type":"HCPCS"}],"standard_charges":[{"gross_charge":2827.0,"discounted_cash":1554.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ct Chest With Contrast","code_information":[{"code":"800267","type":"CDM"},{"code":"352","type":"RC"},{"code":"71260","type":"HCPCS"}],"standard_charges":[{"gross_charge":2969.0,"discounted_cash":1632.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ct Chest With & Without  Contrast","code_information":[{"code":"800268","type":"CDM"},{"code":"352","type":"RC"},{"code":"71270","type":"HCPCS"}],"standard_charges":[{"gross_charge":3117.0,"discounted_cash":1714.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ct Cervical Spine Non Contrast","code_information":[{"code":"800270","type":"CDM"},{"code":"352","type":"RC"},{"code":"72125","type":"HCPCS"}],"standard_charges":[{"gross_charge":2500.0,"discounted_cash":1375.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ct Cervical Spine With Contrast","code_information":[{"code":"800271","type":"CDM"},{"code":"352","type":"RC"},{"code":"72126","type":"HCPCS"}],"standard_charges":[{"gross_charge":2625.0,"discounted_cash":1443.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ct Cervical Spine With & Without Contrast","code_information":[{"code":"800272","type":"CDM"},{"code":"352","type":"RC"},{"code":"72127","type":"HCPCS"}],"standard_charges":[{"gross_charge":2756.0,"discounted_cash":1515.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Skull < 4 Vw","code_information":[{"code":"800273","type":"CDM"},{"code":"320","type":"RC"},{"code":"70250","type":"HCPCS"}],"standard_charges":[{"gross_charge":553.0,"discounted_cash":304.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ct Thoracic Spine Non Contrast","code_information":[{"code":"800274","type":"CDM"},{"code":"352","type":"RC"},{"code":"72128","type":"HCPCS"}],"standard_charges":[{"gross_charge":2719.0,"discounted_cash":1495.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ct Thoracic Spine With Contrast","code_information":[{"code":"800275","type":"CDM"},{"code":"352","type":"RC"},{"code":"72129","type":"HCPCS"}],"standard_charges":[{"gross_charge":2855.0,"discounted_cash":1570.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ct Thoracic Spine With & Without Contrast","code_information":[{"code":"800276","type":"CDM"},{"code":"352","type":"RC"},{"code":"72130","type":"HCPCS"}],"standard_charges":[{"gross_charge":2998.0,"discounted_cash":1648.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ct Lumbar Spine Non Contrast","code_information":[{"code":"800277","type":"CDM"},{"code":"352","type":"RC"},{"code":"72131","type":"HCPCS"}],"standard_charges":[{"gross_charge":2719.0,"discounted_cash":1495.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ct Lumbar Spine With Contrast","code_information":[{"code":"800278","type":"CDM"},{"code":"352","type":"RC"},{"code":"72132","type":"HCPCS"}],"standard_charges":[{"gross_charge":2855.0,"discounted_cash":1570.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ct Lumbar Spine With & Without Contrast","code_information":[{"code":"800279","type":"CDM"},{"code":"352","type":"RC"},{"code":"72133","type":"HCPCS"}],"standard_charges":[{"gross_charge":2998.0,"discounted_cash":1648.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ct Angio Pelvis","code_information":[{"code":"800280","type":"CDM"},{"code":"352","type":"RC"},{"code":"72191","type":"HCPCS"}],"standard_charges":[{"gross_charge":2724.0,"discounted_cash":1498.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ct Pelvis Wo Contrast","code_information":[{"code":"800281","type":"CDM"},{"code":"352","type":"RC"},{"code":"72192","type":"HCPCS"}],"standard_charges":[{"gross_charge":2699.0,"discounted_cash":1484.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ct Pelvis With Iv Contrast","code_information":[{"code":"800282","type":"CDM"},{"code":"352","type":"RC"},{"code":"72193","type":"HCPCS"}],"standard_charges":[{"gross_charge":2833.0,"discounted_cash":1558.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ct Pelvis With & Without Iv Contrast","code_information":[{"code":"800283","type":"CDM"},{"code":"352","type":"RC"},{"code":"72194","type":"HCPCS"}],"standard_charges":[{"gross_charge":2975.0,"discounted_cash":1636.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Skull Complete 4+ Vw","code_information":[{"code":"800284","type":"CDM"},{"code":"320","type":"RC"},{"code":"70260","type":"HCPCS"}],"standard_charges":[{"gross_charge":553.0,"discounted_cash":304.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ct Upper Extremity Non Contrast","code_information":[{"code":"800285","type":"CDM"},{"code":"352","type":"RC"},{"code":"73200","type":"HCPCS"}],"standard_charges":[{"gross_charge":2699.0,"discounted_cash":1484.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ct Upper Extremity With  Contrast","code_information":[{"code":"800287","type":"CDM"},{"code":"352","type":"RC"},{"code":"73201","type":"HCPCS"}],"standard_charges":[{"gross_charge":2833.0,"discounted_cash":1558.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ct Upper Extremity W And Wo Contrast","code_information":[{"code":"800289","type":"CDM"},{"code":"352","type":"RC"},{"code":"73202","type":"HCPCS"}],"standard_charges":[{"gross_charge":2975.0,"discounted_cash":1636.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ct Angio Upper Extrem W And Wo Contrast","code_information":[{"code":"800291","type":"CDM"},{"code":"352","type":"RC"},{"code":"73206","type":"HCPCS"}],"standard_charges":[{"gross_charge":2724.0,"discounted_cash":1498.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ct Lower Extremity Non Contrast","code_information":[{"code":"800293","type":"CDM"},{"code":"352","type":"RC"},{"code":"73700","type":"HCPCS"}],"standard_charges":[{"gross_charge":2699.0,"discounted_cash":1484.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ct Lower Extremity With  Contrast","code_information":[{"code":"800296","type":"CDM"},{"code":"352","type":"RC"},{"code":"73701","type":"HCPCS"}],"standard_charges":[{"gross_charge":2833.0,"discounted_cash":1558.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ct Lower Extremity With & Without Contrast","code_information":[{"code":"800298","type":"CDM"},{"code":"352","type":"RC"},{"code":"73702","type":"HCPCS"}],"standard_charges":[{"gross_charge":2975.0,"discounted_cash":1636.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ct Abdomen With Iv Contrast","code_information":[{"code":"800303","type":"CDM"},{"code":"352","type":"RC"},{"code":"74160","type":"HCPCS"}],"standard_charges":[{"gross_charge":2969.0,"discounted_cash":1632.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ct Abdomen With & Without Iv Contrast","code_information":[{"code":"800304","type":"CDM"},{"code":"352","type":"RC"},{"code":"74170","type":"HCPCS"}],"standard_charges":[{"gross_charge":3117.0,"discounted_cash":1714.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ct Guided Stereotactic Localization","code_information":[{"code":"800312","type":"CDM"},{"code":"350","type":"RC"},{"code":"77011","type":"HCPCS"}],"standard_charges":[{"gross_charge":2807.0,"discounted_cash":1543.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ct Guided Needle Placement","code_information":[{"code":"800313","type":"CDM"},{"code":"350","type":"RC"},{"code":"77012","type":"HCPCS"}],"standard_charges":[{"gross_charge":2724.0,"discounted_cash":1498.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ct Guidance Tissue Ablation","code_information":[{"code":"800314","type":"CDM"},{"code":"350","type":"RC"},{"code":"77013","type":"HCPCS"}],"standard_charges":[{"gross_charge":2724.0,"discounted_cash":1498.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ct Guided Placement Rad Therapy Fields","code_information":[{"code":"800316","type":"CDM"},{"code":"333","type":"RC"},{"code":"77014","type":"HCPCS"}],"standard_charges":[{"gross_charge":1085.0,"discounted_cash":596.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ct Scan Limited Localized F/U Study","code_information":[{"code":"800317","type":"CDM"},{"code":"352","type":"RC"},{"code":"76380","type":"HCPCS"}],"standard_charges":[{"gross_charge":975.0,"discounted_cash":536.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Noncdm Charge Record","code_information":[{"code":"800319","type":"CDM"},{"code":"402","type":"RC"},{"code":"76872","type":"HCPCS"}],"standard_charges":[{"gross_charge":805.95,"discounted_cash":443.27,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Hc Mri Temporomandibular Joints","code_information":[{"code":"800321","type":"CDM"},{"code":"610","type":"RC"},{"code":"70336","type":"HCPCS"}],"standard_charges":[{"gross_charge":3886.0,"discounted_cash":2137.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Mri Orbit Face Neck Non Contrast","code_information":[{"code":"800323","type":"CDM"},{"code":"610","type":"RC"},{"code":"70540","type":"HCPCS"}],"standard_charges":[{"gross_charge":3016.0,"discounted_cash":1658.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Mri Orbit Face Neck With  Contrast","code_information":[{"code":"800324","type":"CDM"},{"code":"610","type":"RC"},{"code":"70542","type":"HCPCS"}],"standard_charges":[{"gross_charge":3167.0,"discounted_cash":1741.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Mri Orbit Face Neck With & Without Contrast","code_information":[{"code":"800325","type":"CDM"},{"code":"610","type":"RC"},{"code":"70543","type":"HCPCS"}],"standard_charges":[{"gross_charge":3326.0,"discounted_cash":1829.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Mra Angio Head Non Contrast","code_information":[{"code":"800326","type":"CDM"},{"code":"615","type":"RC"},{"code":"70544","type":"HCPCS"}],"standard_charges":[{"gross_charge":3064.0,"discounted_cash":1685.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Mra Angio Head With  Contrast","code_information":[{"code":"800327","type":"CDM"},{"code":"615","type":"RC"},{"code":"70545","type":"HCPCS"}],"standard_charges":[{"gross_charge":3217.0,"discounted_cash":1769.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Mra Angio Head With & Without Contrast","code_information":[{"code":"800328","type":"CDM"},{"code":"615","type":"RC"},{"code":"70546","type":"HCPCS"}],"standard_charges":[{"gross_charge":3377.0,"discounted_cash":1857.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Mra Angio Neck Non Contrast","code_information":[{"code":"800329","type":"CDM"},{"code":"615","type":"RC"},{"code":"70547","type":"HCPCS"}],"standard_charges":[{"gross_charge":3007.0,"discounted_cash":1653.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Mra Angio Neck With  Contrast","code_information":[{"code":"800330","type":"CDM"},{"code":"615","type":"RC"},{"code":"70548","type":"HCPCS"}],"standard_charges":[{"gross_charge":3157.0,"discounted_cash":1736.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Mra Angio Neck With & Without Contrast","code_information":[{"code":"800331","type":"CDM"},{"code":"615","type":"RC"},{"code":"70549","type":"HCPCS"}],"standard_charges":[{"gross_charge":3315.0,"discounted_cash":1823.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Mri Brain Non Contrast","code_information":[{"code":"800332","type":"CDM"},{"code":"611","type":"RC"},{"code":"70551","type":"HCPCS"}],"standard_charges":[{"gross_charge":3040.0,"discounted_cash":1672.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Temporomandibular Joints Bilateral","code_information":[{"code":"800333","type":"CDM"},{"code":"320","type":"RC"},{"code":"70330","type":"HCPCS"}],"standard_charges":[{"gross_charge":553.0,"discounted_cash":304.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Mri Brain With  Contrast","code_information":[{"code":"800334","type":"CDM"},{"code":"611","type":"RC"},{"code":"70552","type":"HCPCS"}],"standard_charges":[{"gross_charge":3192.0,"discounted_cash":1755.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Mri Brain With & Without Contrast","code_information":[{"code":"800335","type":"CDM"},{"code":"611","type":"RC"},{"code":"70553","type":"HCPCS"}],"standard_charges":[{"gross_charge":3352.0,"discounted_cash":1843.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Mri Chest Non Contrast","code_information":[{"code":"800336","type":"CDM"},{"code":"610","type":"RC"},{"code":"71550","type":"HCPCS"}],"standard_charges":[{"gross_charge":3600.0,"discounted_cash":1980.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Mri Chest With  Contrast","code_information":[{"code":"800337","type":"CDM"},{"code":"610","type":"RC"},{"code":"71551","type":"HCPCS"}],"standard_charges":[{"gross_charge":3780.0,"discounted_cash":2079.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Mri Chest With & Without Contrast","code_information":[{"code":"800338","type":"CDM"},{"code":"610","type":"RC"},{"code":"71552","type":"HCPCS"}],"standard_charges":[{"gross_charge":3970.0,"discounted_cash":2183.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Mri Spine Cervical Non Contrast","code_information":[{"code":"800340","type":"CDM"},{"code":"612","type":"RC"},{"code":"72141","type":"HCPCS"}],"standard_charges":[{"gross_charge":3244.0,"discounted_cash":1784.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Mri Spine Cervical With  Contrast","code_information":[{"code":"800342","type":"CDM"},{"code":"612","type":"RC"},{"code":"72142","type":"HCPCS"}],"standard_charges":[{"gross_charge":3407.0,"discounted_cash":1873.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Mri Spine Thoracic Non Contrast","code_information":[{"code":"800343","type":"CDM"},{"code":"612","type":"RC"},{"code":"72146","type":"HCPCS"}],"standard_charges":[{"gross_charge":3990.0,"discounted_cash":2194.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Mri Spine Thoracic With Contrast","code_information":[{"code":"800344","type":"CDM"},{"code":"612","type":"RC"},{"code":"72147","type":"HCPCS"}],"standard_charges":[{"gross_charge":4189.0,"discounted_cash":2303.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Mri Spine Lumbar Non Contrast","code_information":[{"code":"800345","type":"CDM"},{"code":"612","type":"RC"},{"code":"72148","type":"HCPCS"}],"standard_charges":[{"gross_charge":4104.0,"discounted_cash":2257.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Mri Spine Lumbar With  Contrast","code_information":[{"code":"800346","type":"CDM"},{"code":"612","type":"RC"},{"code":"72149","type":"HCPCS"}],"standard_charges":[{"gross_charge":4309.0,"discounted_cash":2369.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Mri Spine Cervical With & Without Contrast","code_information":[{"code":"800347","type":"CDM"},{"code":"612","type":"RC"},{"code":"72156","type":"HCPCS"}],"standard_charges":[{"gross_charge":3577.0,"discounted_cash":1967.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Mri Spine Thoracic With & Without Contrast","code_information":[{"code":"800348","type":"CDM"},{"code":"612","type":"RC"},{"code":"72157","type":"HCPCS"}],"standard_charges":[{"gross_charge":4399.0,"discounted_cash":2419.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Mri Spine Lumbar With & Without Contrast","code_information":[{"code":"800349","type":"CDM"},{"code":"612","type":"RC"},{"code":"72158","type":"HCPCS"}],"standard_charges":[{"gross_charge":4525.0,"discounted_cash":2488.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Mri Pelvis Non Contrast","code_information":[{"code":"800351","type":"CDM"},{"code":"610","type":"RC"},{"code":"72195","type":"HCPCS"}],"standard_charges":[{"gross_charge":3852.0,"discounted_cash":2118.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Mri Pelvis With  Contrast","code_information":[{"code":"800352","type":"CDM"},{"code":"610","type":"RC"},{"code":"72196","type":"HCPCS"}],"standard_charges":[{"gross_charge":4045.0,"discounted_cash":2224.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Mri Pelvis With & Without Contrast","code_information":[{"code":"800353","type":"CDM"},{"code":"610","type":"RC"},{"code":"72197","type":"HCPCS"}],"standard_charges":[{"gross_charge":4248.0,"discounted_cash":2336.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Mri Upper Ext Non Joint Non Contrast","code_information":[{"code":"800355","type":"CDM"},{"code":"610","type":"RC"},{"code":"73218","type":"HCPCS"}],"standard_charges":[{"gross_charge":3990.0,"discounted_cash":2194.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Mri Upper Ext Non Joint With Contrast","code_information":[{"code":"800357","type":"CDM"},{"code":"610","type":"RC"},{"code":"73219","type":"HCPCS"}],"standard_charges":[{"gross_charge":4189.0,"discounted_cash":2303.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Mri Upper Ext Non Joint With & Without Contrast","code_information":[{"code":"800359","type":"CDM"},{"code":"610","type":"RC"},{"code":"73220","type":"HCPCS"}],"standard_charges":[{"gross_charge":4399.0,"discounted_cash":2419.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Mri Upper Ext Any Joint Non Contrast","code_information":[{"code":"800361","type":"CDM"},{"code":"610","type":"RC"},{"code":"73221","type":"HCPCS"}],"standard_charges":[{"gross_charge":4146.0,"discounted_cash":2280.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Mandible 4+ Vw","code_information":[{"code":"800362","type":"CDM"},{"code":"320","type":"RC"},{"code":"70110","type":"HCPCS"}],"standard_charges":[{"gross_charge":553.0,"discounted_cash":304.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Panorex","code_information":[{"code":"800363","type":"CDM"},{"code":"320","type":"RC"},{"code":"70355","type":"HCPCS"}],"standard_charges":[{"gross_charge":553.0,"discounted_cash":304.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Mri Upper Ext Any Joint With Contrast","code_information":[{"code":"800365","type":"CDM"},{"code":"610","type":"RC"},{"code":"73222","type":"HCPCS"}],"standard_charges":[{"gross_charge":4354.0,"discounted_cash":2394.7,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Mri Upper Ext Any Joint With & Without Contrast","code_information":[{"code":"800367","type":"CDM"},{"code":"610","type":"RC"},{"code":"73223","type":"HCPCS"}],"standard_charges":[{"gross_charge":4571.0,"discounted_cash":2514.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Mri Lower Ext Non Joint Non Contrast","code_information":[{"code":"800370","type":"CDM"},{"code":"610","type":"RC"},{"code":"73718","type":"HCPCS"}],"standard_charges":[{"gross_charge":4050.0,"discounted_cash":2227.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Neck Soft Tissue","code_information":[{"code":"800374","type":"CDM"},{"code":"320","type":"RC"},{"code":"70360","type":"HCPCS"}],"standard_charges":[{"gross_charge":503.0,"discounted_cash":276.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Mri Lower Ext Non Joint With & Without Contrast","code_information":[{"code":"800375","type":"CDM"},{"code":"610","type":"RC"},{"code":"73720","type":"HCPCS"}],"standard_charges":[{"gross_charge":4456.0,"discounted_cash":2450.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Mri Lower Ext Any Joint Non Contrast","code_information":[{"code":"800377","type":"CDM"},{"code":"610","type":"RC"},{"code":"73721","type":"HCPCS"}],"standard_charges":[{"gross_charge":4176.0,"discounted_cash":2296.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Mri Lower Ext Any Joint With Contrast","code_information":[{"code":"800379","type":"CDM"},{"code":"610","type":"RC"},{"code":"73722","type":"HCPCS"}],"standard_charges":[{"gross_charge":4385.0,"discounted_cash":2411.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Mri Lower Ext Any Jnt W And Wo Contrast","code_information":[{"code":"800381","type":"CDM"},{"code":"610","type":"RC"},{"code":"73723","type":"HCPCS"}],"standard_charges":[{"gross_charge":4604.0,"discounted_cash":2532.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Mri Abdomen Non Contrast","code_information":[{"code":"800384","type":"CDM"},{"code":"610","type":"RC"},{"code":"74181","type":"HCPCS"}],"standard_charges":[{"gross_charge":3810.0,"discounted_cash":2095.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Mri Abdomen With  Contrast","code_information":[{"code":"800386","type":"CDM"},{"code":"610","type":"RC"},{"code":"74182","type":"HCPCS"}],"standard_charges":[{"gross_charge":4001.0,"discounted_cash":2200.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Mri Abdomen With & Without  Contrast","code_information":[{"code":"800387","type":"CDM"},{"code":"610","type":"RC"},{"code":"74183","type":"HCPCS"}],"standard_charges":[{"gross_charge":4201.0,"discounted_cash":2310.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Fl Sialogram","code_information":[{"code":"800396","type":"CDM"},{"code":"320","type":"RC"},{"code":"70390","type":"HCPCS"}],"standard_charges":[{"gross_charge":853.0,"discounted_cash":469.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Mri Spectroscopy","code_information":[{"code":"800397","type":"CDM"},{"code":"610","type":"RC"},{"code":"76390","type":"HCPCS"}],"standard_charges":[{"gross_charge":4069.0,"discounted_cash":2237.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Nm Thyroid Uptake And Scan","code_information":[{"code":"800406","type":"CDM"},{"code":"341","type":"RC"},{"code":"78014","type":"HCPCS"}],"standard_charges":[{"gross_charge":3520.0,"discounted_cash":1936.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Nm Thyroid Scan Only","code_information":[{"code":"800408","type":"CDM"},{"code":"341","type":"RC"},{"code":"78013","type":"HCPCS"}],"standard_charges":[{"gross_charge":3520.0,"discounted_cash":1936.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Nm Thyroid Ca  Mets Scan Whole Body","code_information":[{"code":"800412","type":"CDM"},{"code":"341","type":"RC"},{"code":"78018","type":"HCPCS"}],"standard_charges":[{"gross_charge":3520.0,"discounted_cash":1936.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Nm Parathyroid Scan","code_information":[{"code":"800415","type":"CDM"},{"code":"341","type":"RC"},{"code":"78070","type":"HCPCS"}],"standard_charges":[{"gross_charge":1657.0,"discounted_cash":911.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Nm Bone Marrow Scan Limited Area","code_information":[{"code":"800417","type":"CDM"},{"code":"341","type":"RC"},{"code":"78102","type":"HCPCS"}],"standard_charges":[{"gross_charge":3520.0,"discounted_cash":1936.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Nm Bone Marrow Scan Whole Body","code_information":[{"code":"800419","type":"CDM"},{"code":"341","type":"RC"},{"code":"78104","type":"HCPCS"}],"standard_charges":[{"gross_charge":3520.0,"discounted_cash":1936.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Nm Lymphoscintigraphy","code_information":[{"code":"800430","type":"CDM"},{"code":"341","type":"RC"},{"code":"78195","type":"HCPCS"}],"standard_charges":[{"gross_charge":3520.0,"discounted_cash":1936.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Nm Liver Scan W Vascular Flow","code_information":[{"code":"800432","type":"CDM"},{"code":"341","type":"RC"},{"code":"78202","type":"HCPCS"}],"standard_charges":[{"gross_charge":4103.0,"discounted_cash":2256.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Nm Liver Spleen Scan","code_information":[{"code":"800435","type":"CDM"},{"code":"341","type":"RC"},{"code":"78215","type":"HCPCS"}],"standard_charges":[{"gross_charge":3520.0,"discounted_cash":1936.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Nm Liver Spleen Scan W Vascular Flow","code_information":[{"code":"800436","type":"CDM"},{"code":"341","type":"RC"},{"code":"78216","type":"HCPCS"}],"standard_charges":[{"gross_charge":3520.0,"discounted_cash":1936.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Nm Esophagus Motility","code_information":[{"code":"800443","type":"CDM"},{"code":"341","type":"RC"},{"code":"78258","type":"HCPCS"}],"standard_charges":[{"gross_charge":3520.0,"discounted_cash":1936.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Nm Gastroesophageal Reflux Study","code_information":[{"code":"800445","type":"CDM"},{"code":"341","type":"RC"},{"code":"78262","type":"HCPCS"}],"standard_charges":[{"gross_charge":3520.0,"discounted_cash":1936.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Nm Gastric Emptying","code_information":[{"code":"800446","type":"CDM"},{"code":"341","type":"RC"},{"code":"78264","type":"HCPCS"}],"standard_charges":[{"gross_charge":3520.0,"discounted_cash":1936.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Nm Gi Blood Loss","code_information":[{"code":"800453","type":"CDM"},{"code":"341","type":"RC"},{"code":"78278","type":"HCPCS"}],"standard_charges":[{"gross_charge":3520.0,"discounted_cash":1936.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Nm Meckels","code_information":[{"code":"800454","type":"CDM"},{"code":"341","type":"RC"},{"code":"78290","type":"HCPCS"}],"standard_charges":[{"gross_charge":3520.0,"discounted_cash":1936.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Nm Peritoneal Venous Shunt","code_information":[{"code":"800455","type":"CDM"},{"code":"341","type":"RC"},{"code":"78291","type":"HCPCS"}],"standard_charges":[{"gross_charge":3520.0,"discounted_cash":1936.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Nm Bone Scan Limited Area","code_information":[{"code":"800457","type":"CDM"},{"code":"341","type":"RC"},{"code":"78300","type":"HCPCS"}],"standard_charges":[{"gross_charge":3520.0,"discounted_cash":1936.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Nm Bone Scan Whole Body","code_information":[{"code":"800461","type":"CDM"},{"code":"341","type":"RC"},{"code":"78306","type":"HCPCS"}],"standard_charges":[{"gross_charge":3520.0,"discounted_cash":1936.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Nm Bone Scan 3 Phase","code_information":[{"code":"800462","type":"CDM"},{"code":"341","type":"RC"},{"code":"78315","type":"HCPCS"}],"standard_charges":[{"gross_charge":3520.0,"discounted_cash":1936.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Nm Myocard Perfusion Spect","code_information":[{"code":"800474","type":"CDM"},{"code":"341","type":"RC"},{"code":"78451","type":"HCPCS"}],"standard_charges":[{"gross_charge":3706.0,"discounted_cash":2038.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Nm Myocard Perfusion Spect Stress And Rest","code_information":[{"code":"800475","type":"CDM"},{"code":"341","type":"RC"},{"code":"78452","type":"HCPCS"}],"standard_charges":[{"gross_charge":4446.0,"discounted_cash":2445.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Nm Myocard Infarct Spect","code_information":[{"code":"800479","type":"CDM"},{"code":"341","type":"RC"},{"code":"78469","type":"HCPCS"}],"standard_charges":[{"gross_charge":4103.0,"discounted_cash":2256.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Nm Cardiac Muga Scan","code_information":[{"code":"800480","type":"CDM"},{"code":"341","type":"RC"},{"code":"78472","type":"HCPCS"}],"standard_charges":[{"gross_charge":3706.0,"discounted_cash":2038.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Myocardial Pet Perfus Sngl","code_information":[{"code":"800485","type":"CDM"},{"code":"404","type":"RC"},{"code":"78491","type":"HCPCS"}],"standard_charges":[{"gross_charge":6769.0,"discounted_cash":3722.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Nm Lung Scan Perfusion Particulate","code_information":[{"code":"800491","type":"CDM"},{"code":"341","type":"RC"},{"code":"78580","type":"HCPCS"}],"standard_charges":[{"gross_charge":3520.0,"discounted_cash":1936.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Nm Brain Imaging Complete W Vascular Flow","code_information":[{"code":"800504","type":"CDM"},{"code":"341","type":"RC"},{"code":"78606","type":"HCPCS"}],"standard_charges":[{"gross_charge":3520.0,"discounted_cash":1936.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Nm Pet Brain Metabolic Eval Imaging","code_information":[{"code":"800506","type":"CDM"},{"code":"404","type":"RC"},{"code":"78608","type":"HCPCS"}],"standard_charges":[{"gross_charge":6650.0,"discounted_cash":3657.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Nm Brain Imaging Vascular Flow Only","code_information":[{"code":"800509","type":"CDM"},{"code":"341","type":"RC"},{"code":"78610","type":"HCPCS"}],"standard_charges":[{"gross_charge":3520.0,"discounted_cash":1936.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Nm Cisternogram","code_information":[{"code":"800511","type":"CDM"},{"code":"341","type":"RC"},{"code":"78630","type":"HCPCS"}],"standard_charges":[{"gross_charge":3520.0,"discounted_cash":1936.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Nm Csf Shunt","code_information":[{"code":"800513","type":"CDM"},{"code":"341","type":"RC"},{"code":"78645","type":"HCPCS"}],"standard_charges":[{"gross_charge":1556.0,"discounted_cash":855.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Nm Csf Leak Detection","code_information":[{"code":"800514","type":"CDM"},{"code":"341","type":"RC"},{"code":"78650","type":"HCPCS"}],"standard_charges":[{"gross_charge":3520.0,"discounted_cash":1936.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ribs Unilateral 2 Vw","code_information":[{"code":"800516","type":"CDM"},{"code":"320","type":"RC"},{"code":"71100","type":"HCPCS"}],"standard_charges":[{"gross_charge":553.0,"discounted_cash":304.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Nm Renogram W Flow And Function","code_information":[{"code":"800520","type":"CDM"},{"code":"341","type":"RC"},{"code":"78707","type":"HCPCS"}],"standard_charges":[{"gross_charge":3451.0,"discounted_cash":1898.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Nm Renogram W Pharm Single","code_information":[{"code":"800521","type":"CDM"},{"code":"341","type":"RC"},{"code":"78708","type":"HCPCS"}],"standard_charges":[{"gross_charge":3520.0,"discounted_cash":1936.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Nm Renogram With & Without  Pharm Multiple","code_information":[{"code":"800522","type":"CDM"},{"code":"341","type":"RC"},{"code":"78709","type":"HCPCS"}],"standard_charges":[{"gross_charge":3706.0,"discounted_cash":2038.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Nm Cystogram Reflux Study","code_information":[{"code":"800528","type":"CDM"},{"code":"341","type":"RC"},{"code":"78740","type":"HCPCS"}],"standard_charges":[{"gross_charge":3520.0,"discounted_cash":1936.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Nm Testicular Imaging W Vascular Flow","code_information":[{"code":"800530","type":"CDM"},{"code":"341","type":"RC"},{"code":"78761","type":"HCPCS"}],"standard_charges":[{"gross_charge":3520.0,"discounted_cash":1936.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Tumor Infection Scan 1 Area 1 Day","code_information":[{"code":"800531","type":"CDM"},{"code":"341","type":"RC"},{"code":"78800","type":"HCPCS"}],"standard_charges":[{"gross_charge":1269.0,"discounted_cash":697.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Tumor Infect Scan Mult Area Or Day","code_information":[{"code":"800532","type":"CDM"},{"code":"341","type":"RC"},{"code":"78801","type":"HCPCS"}],"standard_charges":[{"gross_charge":1427.0,"discounted_cash":784.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Nm Tumor Local Whole Body Gallium","code_information":[{"code":"800533","type":"CDM"},{"code":"341","type":"RC"},{"code":"78804","type":"HCPCS"}],"standard_charges":[{"gross_charge":3679.0,"discounted_cash":2023.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Rp Localzn Tmr Spect 1 Area 1 Day","code_information":[{"code":"800534","type":"CDM"},{"code":"341","type":"RC"},{"code":"78803","type":"HCPCS"}],"standard_charges":[{"gross_charge":3664.0,"discounted_cash":2015.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Tumor Infection Scan Wb Mult Day","code_information":[{"code":"800535","type":"CDM"},{"code":"341","type":"RC"},{"code":"78804","type":"HCPCS"}],"standard_charges":[{"gross_charge":4590.0,"discounted_cash":2524.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ribs Unilateral W Pa Chest","code_information":[{"code":"800537","type":"CDM"},{"code":"320","type":"RC"},{"code":"71101","type":"HCPCS"}],"standard_charges":[{"gross_charge":553.0,"discounted_cash":304.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ribs Bilateral 3 Vw","code_information":[{"code":"800551","type":"CDM"},{"code":"320","type":"RC"},{"code":"71110","type":"HCPCS"}],"standard_charges":[{"gross_charge":553.0,"discounted_cash":304.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ribs Bilateral W Pa Chest","code_information":[{"code":"800553","type":"CDM"},{"code":"320","type":"RC"},{"code":"71111","type":"HCPCS"}],"standard_charges":[{"gross_charge":553.0,"discounted_cash":304.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Echo Exam Of Head","code_information":[{"code":"800554","type":"CDM"},{"code":"402","type":"RC"},{"code":"76506","type":"HCPCS"}],"standard_charges":[{"gross_charge":744.0,"discounted_cash":409.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Sternum 2+ Vw","code_information":[{"code":"800555","type":"CDM"},{"code":"320","type":"RC"},{"code":"71120","type":"HCPCS"}],"standard_charges":[{"gross_charge":553.0,"discounted_cash":304.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Us Head Neck Tissues Real Time","code_information":[{"code":"800556","type":"CDM"},{"code":"402","type":"RC"},{"code":"76536","type":"HCPCS"}],"standard_charges":[{"gross_charge":744.0,"discounted_cash":409.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Us Chest","code_information":[{"code":"800557","type":"CDM"},{"code":"450","type":"RC"},{"code":"76604","type":"HCPCS"}],"standard_charges":[{"gross_charge":856.0,"discounted_cash":470.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Us Abdomen Complete","code_information":[{"code":"800560","type":"CDM"},{"code":"402","type":"RC"},{"code":"76700","type":"HCPCS"}],"standard_charges":[{"gross_charge":1226.0,"discounted_cash":674.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Us Abdomen Limited","code_information":[{"code":"800561","type":"CDM"},{"code":"402","type":"RC"},{"code":"76705","type":"HCPCS"}],"standard_charges":[{"gross_charge":729.0,"discounted_cash":400.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Hc Us Retroperitoneal Complete","code_information":[{"code":"800562","type":"CDM"},{"code":"402","type":"RC"},{"code":"76770","type":"HCPCS"}],"standard_charges":[{"gross_charge":890.0,"discounted_cash":489.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Us Retroperitoneal Limited","code_information":[{"code":"800563","type":"CDM"},{"code":"402","type":"RC"},{"code":"76775","type":"HCPCS"}],"standard_charges":[{"gross_charge":729.0,"discounted_cash":400.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Us Renal Transplant","code_information":[{"code":"800564","type":"CDM"},{"code":"402","type":"RC"},{"code":"76776","type":"HCPCS"}],"standard_charges":[{"gross_charge":744.0,"discounted_cash":409.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Us Spinal Canal And Contents","code_information":[{"code":"800565","type":"CDM"},{"code":"402","type":"RC"},{"code":"76800","type":"HCPCS"}],"standard_charges":[{"gross_charge":744.0,"discounted_cash":409.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Us Ob < 14 Wks Single Gest","code_information":[{"code":"800567","type":"CDM"},{"code":"402","type":"RC"},{"code":"76801","type":"HCPCS"}],"standard_charges":[{"gross_charge":838.0,"discounted_cash":460.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Us Ob < 14 Wks Ea Additional Gest","code_information":[{"code":"800568","type":"CDM"},{"code":"402","type":"RC"},{"code":"76802","type":"HCPCS"}],"standard_charges":[{"gross_charge":744.0,"discounted_cash":409.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Us Ob 14+ Wks Single Gest","code_information":[{"code":"800569","type":"CDM"},{"code":"402","type":"RC"},{"code":"76805","type":"HCPCS"}],"standard_charges":[{"gross_charge":729.0,"discounted_cash":400.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Us Ob 14+ Wks Additional Gest","code_information":[{"code":"800570","type":"CDM"},{"code":"402","type":"RC"},{"code":"76810","type":"HCPCS"}],"standard_charges":[{"gross_charge":744.0,"discounted_cash":409.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Us Ob Detail Fetal Anatomy Single Gest","code_information":[{"code":"800571","type":"CDM"},{"code":"402","type":"RC"},{"code":"76811","type":"HCPCS"}],"standard_charges":[{"gross_charge":729.0,"discounted_cash":400.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Us Ob Detail Fetal Anatomy Additional Gest","code_information":[{"code":"800572","type":"CDM"},{"code":"402","type":"RC"},{"code":"76812","type":"HCPCS"}],"standard_charges":[{"gross_charge":744.0,"discounted_cash":409.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Us Pregnant Uterus Limited 1+ Fetuses","code_information":[{"code":"800573","type":"CDM"},{"code":"402","type":"RC"},{"code":"76815","type":"HCPCS"}],"standard_charges":[{"gross_charge":744.0,"discounted_cash":409.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Us Pregnant Uterus Transvaginal","code_information":[{"code":"800575","type":"CDM"},{"code":"402","type":"RC"},{"code":"76817","type":"HCPCS"}],"standard_charges":[{"gross_charge":744.0,"discounted_cash":409.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Us Fetal Bpp W/O Nst","code_information":[{"code":"800577","type":"CDM"},{"code":"402","type":"RC"},{"code":"76819","type":"HCPCS"}],"standard_charges":[{"gross_charge":744.0,"discounted_cash":409.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Echo Doppler Fetal Wave Sd Complete","code_information":[{"code":"800580","type":"CDM"},{"code":"402","type":"RC"},{"code":"76827","type":"HCPCS"}],"standard_charges":[{"gross_charge":548.0,"discounted_cash":301.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Us Transvaginal Non Ob","code_information":[{"code":"800582","type":"CDM"},{"code":"402","type":"RC"},{"code":"76830","type":"HCPCS"}],"standard_charges":[{"gross_charge":744.0,"discounted_cash":409.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Us Hystosonogram","code_information":[{"code":"800583","type":"CDM"},{"code":"402","type":"RC"},{"code":"76831","type":"HCPCS"}],"standard_charges":[{"gross_charge":744.0,"discounted_cash":409.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Us Pelvis Complete","code_information":[{"code":"800584","type":"CDM"},{"code":"402","type":"RC"},{"code":"76856","type":"HCPCS"}],"standard_charges":[{"gross_charge":729.0,"discounted_cash":400.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Spine 1 View","code_information":[{"code":"800585","type":"CDM"},{"code":"320","type":"RC"},{"code":"72020","type":"HCPCS"}],"standard_charges":[{"gross_charge":553.0,"discounted_cash":304.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Us Pelvis Limited","code_information":[{"code":"800586","type":"CDM"},{"code":"402","type":"RC"},{"code":"76857","type":"HCPCS"}],"standard_charges":[{"gross_charge":729.0,"discounted_cash":400.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Us Scrotum And Testicles","code_information":[{"code":"800587","type":"CDM"},{"code":"450","type":"RC"},{"code":"76870","type":"HCPCS"}],"standard_charges":[{"gross_charge":838.0,"discounted_cash":460.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Us Joint Complete","code_information":[{"code":"800588","type":"CDM"},{"code":"402","type":"RC"},{"code":"76881","type":"HCPCS"}],"standard_charges":[{"gross_charge":744.0,"discounted_cash":409.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Us Infant Hips W Manipulation","code_information":[{"code":"800589","type":"CDM"},{"code":"402","type":"RC"},{"code":"76885","type":"HCPCS"}],"standard_charges":[{"gross_charge":729.0,"discounted_cash":400.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Us Guide Comp Repair Pseudo-Aneur/Av Fist","code_information":[{"code":"800593","type":"CDM"},{"code":"402","type":"RC"},{"code":"76936","type":"HCPCS"}],"standard_charges":[{"gross_charge":829.0,"discounted_cash":455.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Us Guide Vascular Access","code_information":[{"code":"800594","type":"CDM"},{"code":"402","type":"RC"},{"code":"76937","type":"HCPCS"}],"standard_charges":[{"gross_charge":464.0,"discounted_cash":255.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Cervical Spine 2 Or 3 Vw","code_information":[{"code":"800596","type":"CDM"},{"code":"320","type":"RC"},{"code":"72040","type":"HCPCS"}],"standard_charges":[{"gross_charge":553.0,"discounted_cash":304.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Us Guide Cvs","code_information":[{"code":"800599","type":"CDM"},{"code":"402","type":"RC"},{"code":"76945","type":"HCPCS"}],"standard_charges":[{"gross_charge":673.0,"discounted_cash":370.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Us Guide Intraoperative","code_information":[{"code":"800604","type":"CDM"},{"code":"402","type":"RC"},{"code":"76998","type":"HCPCS"}],"standard_charges":[{"gross_charge":744.0,"discounted_cash":409.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Dexa Bone Density Axial Skeleton","code_information":[{"code":"800606","type":"CDM"},{"code":"320","type":"RC"},{"code":"77080","type":"HCPCS"}],"standard_charges":[{"gross_charge":553.0,"discounted_cash":304.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Dexa Bone Density Peripheral","code_information":[{"code":"800609","type":"CDM"},{"code":"320","type":"RC"},{"code":"77081","type":"HCPCS"}],"standard_charges":[{"gross_charge":553.0,"discounted_cash":304.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Mammo Mammary Duct Single","code_information":[{"code":"800612","type":"CDM"},{"code":"320","type":"RC"},{"code":"77053","type":"HCPCS"}],"standard_charges":[{"gross_charge":806.0,"discounted_cash":443.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Cervical Spine Min 4+ Vw","code_information":[{"code":"800613","type":"CDM"},{"code":"320","type":"RC"},{"code":"72050","type":"HCPCS"}],"standard_charges":[{"gross_charge":553.0,"discounted_cash":304.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Mammo Ductogram Multiple","code_information":[{"code":"800614","type":"CDM"},{"code":"320","type":"RC"},{"code":"77054","type":"HCPCS"}],"standard_charges":[{"gross_charge":806.0,"discounted_cash":443.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Cervical Spine W Obl And Flex/Ext","code_information":[{"code":"800619","type":"CDM"},{"code":"320","type":"RC"},{"code":"72052","type":"HCPCS"}],"standard_charges":[{"gross_charge":553.0,"discounted_cash":304.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Thoracic Spine 2 Vw","code_information":[{"code":"800625","type":"CDM"},{"code":"320","type":"RC"},{"code":"72070","type":"HCPCS"}],"standard_charges":[{"gross_charge":553.0,"discounted_cash":304.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Thoracic Spine 3 Vw","code_information":[{"code":"800628","type":"CDM"},{"code":"320","type":"RC"},{"code":"72072","type":"HCPCS"}],"standard_charges":[{"gross_charge":553.0,"discounted_cash":304.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Mammo Exam Breast Specimen","code_information":[{"code":"800630","type":"CDM"},{"code":"320","type":"RC"},{"code":"76098","type":"HCPCS"}],"standard_charges":[{"gross_charge":1554.0,"discounted_cash":854.7,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Thoracic Spine 4+ Vw","code_information":[{"code":"800639","type":"CDM"},{"code":"320","type":"RC"},{"code":"72074","type":"HCPCS"}],"standard_charges":[{"gross_charge":553.0,"discounted_cash":304.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ir Ureteral Urethra Neph Dilitation","code_information":[{"code":"800642","type":"CDM"},{"code":"320","type":"RC"},{"code":"74485","type":"HCPCS"}],"standard_charges":[{"gross_charge":462.0,"discounted_cash":254.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Aortagram Thoracic Serial","code_information":[{"code":"800644","type":"CDM"},{"code":"323","type":"RC"},{"code":"75605","type":"HCPCS"}],"standard_charges":[{"gross_charge":6216.0,"discounted_cash":3418.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Angio Aortobifemoral W Cath","code_information":[{"code":"800646","type":"CDM"},{"code":"323","type":"RC"},{"code":"75630","type":"HCPCS"}],"standard_charges":[{"gross_charge":5372.0,"discounted_cash":2954.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Thoracolumbar Spine 2 Vw","code_information":[{"code":"800649","type":"CDM"},{"code":"320","type":"RC"},{"code":"72080","type":"HCPCS"}],"standard_charges":[{"gross_charge":553.0,"discounted_cash":304.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Angio Spinal Sel","code_information":[{"code":"800661","type":"CDM"},{"code":"323","type":"RC"},{"code":"75705","type":"HCPCS"}],"standard_charges":[{"gross_charge":11387.0,"discounted_cash":6262.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Lumbar Spine 2 Or 3 Vw","code_information":[{"code":"800671","type":"CDM"},{"code":"320","type":"RC"},{"code":"72100","type":"HCPCS"}],"standard_charges":[{"gross_charge":553.0,"discounted_cash":304.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Angio Pulmonary Nonsel Cath/Ven","code_information":[{"code":"800677","type":"CDM"},{"code":"323","type":"RC"},{"code":"75746","type":"HCPCS"}],"standard_charges":[{"gross_charge":1990.0,"discounted_cash":1094.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Angio Selective Each Additional Vessel","code_information":[{"code":"800679","type":"CDM"},{"code":"323","type":"RC"},{"code":"75774","type":"HCPCS"}],"standard_charges":[{"gross_charge":2821.0,"discounted_cash":1551.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Fl Shuntogram Non Vascular","code_information":[{"code":"800681","type":"CDM"},{"code":"320","type":"RC"},{"code":"75809","type":"HCPCS"}],"standard_charges":[{"gross_charge":404.0,"discounted_cash":222.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Venogram Extremity Bilateral","code_information":[{"code":"800685","type":"CDM"},{"code":"320","type":"RC"},{"code":"75822","type":"HCPCS"}],"standard_charges":[{"gross_charge":3400.0,"discounted_cash":1870.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ir Venogram Renal Unilat Sel","code_information":[{"code":"800688","type":"CDM"},{"code":"320","type":"RC"},{"code":"75831","type":"HCPCS"}],"standard_charges":[{"gross_charge":3539.0,"discounted_cash":1946.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Venogram Renal Bilateral Sel","code_information":[{"code":"800690","type":"CDM"},{"code":"320","type":"RC"},{"code":"75833","type":"HCPCS"}],"standard_charges":[{"gross_charge":8146.0,"discounted_cash":4480.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ir Venogram Sinus/Jug","code_information":[{"code":"800694","type":"CDM"},{"code":"320","type":"RC"},{"code":"75860","type":"HCPCS"}],"standard_charges":[{"gross_charge":1994.0,"discounted_cash":1096.7,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Lumbar Spine 4+ Vw","code_information":[{"code":"800698","type":"CDM"},{"code":"320","type":"RC"},{"code":"72110","type":"HCPCS"}],"standard_charges":[{"gross_charge":553.0,"discounted_cash":304.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Xhepatic Portogram W Dynamic S And I","code_information":[{"code":"800699","type":"CDM"},{"code":"320","type":"RC"},{"code":"75885","type":"HCPCS"}],"standard_charges":[{"gross_charge":13567.0,"discounted_cash":7461.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Venogram Hepatic W Hemodynamics","code_information":[{"code":"800701","type":"CDM"},{"code":"320","type":"RC"},{"code":"75889","type":"HCPCS"}],"standard_charges":[{"gross_charge":6762.0,"discounted_cash":3719.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Venogram Hepatic Wo Hemo Eval","code_information":[{"code":"800702","type":"CDM"},{"code":"320","type":"RC"},{"code":"75891","type":"HCPCS"}],"standard_charges":[{"gross_charge":6010.0,"discounted_cash":3305.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Transcath Embolization S And I","code_information":[{"code":"800704","type":"CDM"},{"code":"320","type":"RC"},{"code":"75894","type":"HCPCS"}],"standard_charges":[{"gross_charge":1590.0,"discounted_cash":874.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Facial Bones < 3 Vw","code_information":[{"code":"800709","type":"CDM"},{"code":"320","type":"RC"},{"code":"70140","type":"HCPCS"}],"standard_charges":[{"gross_charge":553.0,"discounted_cash":304.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Lumbar Spine W Bending Vw","code_information":[{"code":"800710","type":"CDM"},{"code":"320","type":"RC"},{"code":"72114","type":"HCPCS"}],"standard_charges":[{"gross_charge":553.0,"discounted_cash":304.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ir Removal Intracath Obst Mat","code_information":[{"code":"800711","type":"CDM"},{"code":"320","type":"RC"},{"code":"75902","type":"HCPCS"}],"standard_charges":[{"gross_charge":348.0,"discounted_cash":191.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Xr Lumbar Spine Bending Only 2-3 Vw","code_information":[{"code":"800721","type":"CDM"},{"code":"320","type":"RC"},{"code":"72120","type":"HCPCS"}],"standard_charges":[{"gross_charge":553.0,"discounted_cash":304.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Transcath Biopsy S And I","code_information":[{"code":"800725","type":"CDM"},{"code":"320","type":"RC"},{"code":"75970","type":"HCPCS"}],"standard_charges":[{"gross_charge":806.0,"discounted_cash":443.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Rad Guidance Perc Drain Placement S And I","code_information":[{"code":"800730","type":"CDM"},{"code":"320","type":"RC"},{"code":"75989","type":"HCPCS"}],"standard_charges":[{"gross_charge":970.0,"discounted_cash":533.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Pelvis 1 Or 2 Vw","code_information":[{"code":"800731","type":"CDM"},{"code":"320","type":"RC"},{"code":"72170","type":"HCPCS"}],"standard_charges":[{"gross_charge":553.0,"discounted_cash":304.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Fluoro Guidance For Spinal Inj","code_information":[{"code":"800737","type":"CDM"},{"code":"320","type":"RC"},{"code":"77003","type":"HCPCS"}],"standard_charges":[{"gross_charge":664.0,"discounted_cash":365.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Pelvis 3+ Vw","code_information":[{"code":"800740","type":"CDM"},{"code":"320","type":"RC"},{"code":"72190","type":"HCPCS"}],"standard_charges":[{"gross_charge":553.0,"discounted_cash":304.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Xray Discography Cerv/Thor Spine S And I","code_information":[{"code":"800750","type":"CDM"},{"code":"320","type":"RC"},{"code":"72285","type":"HCPCS"}],"standard_charges":[{"gross_charge":6108.0,"discounted_cash":3359.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Sacroiliac Joints < 3 Vw","code_information":[{"code":"800751","type":"CDM"},{"code":"320","type":"RC"},{"code":"72200","type":"HCPCS"}],"standard_charges":[{"gross_charge":553.0,"discounted_cash":304.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Xray Discography Lumbar S And I","code_information":[{"code":"800752","type":"CDM"},{"code":"320","type":"RC"},{"code":"72295","type":"HCPCS"}],"standard_charges":[{"gross_charge":6108.0,"discounted_cash":3359.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Peritoneogram S And I","code_information":[{"code":"800753","type":"CDM"},{"code":"320","type":"RC"},{"code":"74190","type":"HCPCS"}],"standard_charges":[{"gross_charge":1695.0,"discounted_cash":932.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Xray Esophagus Sngl Contrast","code_information":[{"code":"800754","type":"CDM"},{"code":"320","type":"RC"},{"code":"74220","type":"HCPCS"}],"standard_charges":[{"gross_charge":503.0,"discounted_cash":276.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Swallow Funct W Video  W Contrast","code_information":[{"code":"800755","type":"CDM"},{"code":"320","type":"RC"},{"code":"74230","type":"HCPCS"}],"standard_charges":[{"gross_charge":503.0,"discounted_cash":276.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Xray Upper Gi Double Contrast","code_information":[{"code":"800759","type":"CDM"},{"code":"320","type":"RC"},{"code":"74246","type":"HCPCS"}],"standard_charges":[{"gross_charge":503.0,"discounted_cash":276.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Sacroiliac Joints 3+ Vw","code_information":[{"code":"800760","type":"CDM"},{"code":"320","type":"RC"},{"code":"72202","type":"HCPCS"}],"standard_charges":[{"gross_charge":553.0,"discounted_cash":304.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Xray Colon Double Contrast","code_information":[{"code":"800766","type":"CDM"},{"code":"320","type":"RC"},{"code":"74280","type":"HCPCS"}],"standard_charges":[{"gross_charge":503.0,"discounted_cash":276.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Fluoro B.E. Reductn Intuss","code_information":[{"code":"800767","type":"CDM"},{"code":"320","type":"RC"},{"code":"74283","type":"HCPCS"}],"standard_charges":[{"gross_charge":664.0,"discounted_cash":365.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Sacrum And Coccyx","code_information":[{"code":"800768","type":"CDM"},{"code":"320","type":"RC"},{"code":"72220","type":"HCPCS"}],"standard_charges":[{"gross_charge":553.0,"discounted_cash":304.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Cholecystography Oral Contrast","code_information":[{"code":"800769","type":"CDM"},{"code":"320","type":"RC"},{"code":"74290","type":"HCPCS"}],"standard_charges":[{"gross_charge":503.0,"discounted_cash":276.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Fl Ercp Biliary Only","code_information":[{"code":"800772","type":"CDM"},{"code":"320","type":"RC"},{"code":"74328","type":"HCPCS"}],"standard_charges":[{"gross_charge":503.0,"discounted_cash":276.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Fl Ercp Pancreas Only","code_information":[{"code":"800773","type":"CDM"},{"code":"320","type":"RC"},{"code":"74329","type":"HCPCS"}],"standard_charges":[{"gross_charge":503.0,"discounted_cash":276.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Fl Ercp Biliary And Pancreatic","code_information":[{"code":"800774","type":"CDM"},{"code":"320","type":"RC"},{"code":"74330","type":"HCPCS"}],"standard_charges":[{"gross_charge":503.0,"discounted_cash":276.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Fluoro Iv Pyelogram (Ivp)","code_information":[{"code":"800776","type":"CDM"},{"code":"320","type":"RC"},{"code":"74400","type":"HCPCS"}],"standard_charges":[{"gross_charge":796.0,"discounted_cash":437.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Fluoro Iv Pyelogram+Tomography","code_information":[{"code":"800778","type":"CDM"},{"code":"320","type":"RC"},{"code":"74415","type":"HCPCS"}],"standard_charges":[{"gross_charge":853.0,"discounted_cash":469.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Xray Clavicle Complete","code_information":[{"code":"800779","type":"CDM"},{"code":"320","type":"RC"},{"code":"73000","type":"HCPCS"}],"standard_charges":[{"gross_charge":553.0,"discounted_cash":304.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Fluoro Retrograde Pyelogram W/Wo Kub","code_information":[{"code":"800780","type":"CDM"},{"code":"320","type":"RC"},{"code":"74420","type":"HCPCS"}],"standard_charges":[{"gross_charge":500.0,"discounted_cash":275.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Cystogram 3 Views S And I","code_information":[{"code":"800782","type":"CDM"},{"code":"320","type":"RC"},{"code":"74430","type":"HCPCS"}],"standard_charges":[{"gross_charge":858.0,"discounted_cash":471.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Venogram Extremity Unilateral","code_information":[{"code":"800784","type":"CDM"},{"code":"320","type":"RC"},{"code":"75820","type":"HCPCS"}],"standard_charges":[{"gross_charge":3400.0,"discounted_cash":1870.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Fluoro Cvad","code_information":[{"code":"800787","type":"CDM"},{"code":"320","type":"RC"},{"code":"77001","type":"HCPCS"}],"standard_charges":[{"gross_charge":664.0,"discounted_cash":365.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Fluoro < 1 Hour","code_information":[{"code":"800788","type":"CDM"},{"code":"320","type":"RC"},{"code":"76000","type":"HCPCS"}],"standard_charges":[{"gross_charge":1098.0,"discounted_cash":603.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ct Abdomen Pelvis Wwo Contrast","code_information":[{"code":"800794","type":"CDM"},{"code":"352","type":"RC"},{"code":"74178","type":"HCPCS"}],"standard_charges":[{"gross_charge":3271.0,"discounted_cash":1799.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ct Abdomen Pelvis Wo Contrast","code_information":[{"code":"800795","type":"CDM"},{"code":"352","type":"RC"},{"code":"74176","type":"HCPCS"}],"standard_charges":[{"gross_charge":2967.0,"discounted_cash":1631.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ct Abdomen Non Iv Contrast","code_information":[{"code":"800796","type":"CDM"},{"code":"352","type":"RC"},{"code":"74150","type":"HCPCS"}],"standard_charges":[{"gross_charge":2827.0,"discounted_cash":1554.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ct Angio Head With And Without Contrast","code_information":[{"code":"800797","type":"CDM"},{"code":"350","type":"RC"},{"code":"70496","type":"HCPCS"}],"standard_charges":[{"gross_charge":2500.0,"discounted_cash":1375.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Scapula","code_information":[{"code":"800799","type":"CDM"},{"code":"320","type":"RC"},{"code":"73010","type":"HCPCS"}],"standard_charges":[{"gross_charge":553.0,"discounted_cash":304.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ct Abdomen Pelvis W Contrast","code_information":[{"code":"800803","type":"CDM"},{"code":"352","type":"RC"},{"code":"74177","type":"HCPCS"}],"standard_charges":[{"gross_charge":3115.0,"discounted_cash":1713.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Xray Abd Acute Series W Pa Chest","code_information":[{"code":"800805","type":"CDM"},{"code":"320","type":"RC"},{"code":"74022","type":"HCPCS"}],"standard_charges":[{"gross_charge":503.0,"discounted_cash":276.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Facial Bones 3+ Vw","code_information":[{"code":"800808","type":"CDM"},{"code":"320","type":"RC"},{"code":"70150","type":"HCPCS"}],"standard_charges":[{"gross_charge":553.0,"discounted_cash":304.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ankle Single View","code_information":[{"code":"800817","type":"CDM"},{"code":"320","type":"RC"},{"code":"73600","type":"HCPCS"}],"standard_charges":[{"gross_charge":553.0,"discounted_cash":304.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Shoulder 1 Vw","code_information":[{"code":"800819","type":"CDM"},{"code":"320","type":"RC"},{"code":"73020","type":"HCPCS"}],"standard_charges":[{"gross_charge":553.0,"discounted_cash":304.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Bone Length Studies","code_information":[{"code":"800823","type":"CDM"},{"code":"320","type":"RC"},{"code":"77073","type":"HCPCS"}],"standard_charges":[{"gross_charge":553.0,"discounted_cash":304.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Shoulder 2+ Vw","code_information":[{"code":"800834","type":"CDM"},{"code":"320","type":"RC"},{"code":"73030","type":"HCPCS"}],"standard_charges":[{"gross_charge":553.0,"discounted_cash":304.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Fl Arthrogram Shoulder","code_information":[{"code":"800851","type":"CDM"},{"code":"322","type":"RC"},{"code":"73040","type":"HCPCS"}],"standard_charges":[{"gross_charge":1126.0,"discounted_cash":619.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Xray Finger(S) Single Vw","code_information":[{"code":"800858","type":"CDM"},{"code":"320","type":"RC"},{"code":"73140","type":"HCPCS"}],"standard_charges":[{"gross_charge":553.0,"discounted_cash":304.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Xray Finger(S) Min 2 Vw","code_information":[{"code":"800859","type":"CDM"},{"code":"320","type":"RC"},{"code":"73140","type":"HCPCS"}],"standard_charges":[{"gross_charge":553.0,"discounted_cash":304.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Forearm Single View Reduced Service","code_information":[{"code":"800867","type":"CDM"},{"code":"320","type":"RC"},{"code":"73090","type":"HCPCS"}],"standard_charges":[{"gross_charge":553.0,"discounted_cash":304.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Xr Hand 1 Vw","code_information":[{"code":"800869","type":"CDM"},{"code":"320","type":"RC"},{"code":"73120","type":"HCPCS"}],"standard_charges":[{"gross_charge":553.0,"discounted_cash":304.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Acromioclavicular Joints Bilateral","code_information":[{"code":"800871","type":"CDM"},{"code":"320","type":"RC"},{"code":"73050","type":"HCPCS"}],"standard_charges":[{"gross_charge":553.0,"discounted_cash":304.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Humerus 2+ Vw","code_information":[{"code":"800881","type":"CDM"},{"code":"320","type":"RC"},{"code":"73060","type":"HCPCS"}],"standard_charges":[{"gross_charge":553.0,"discounted_cash":304.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Tib Fib Single View","code_information":[{"code":"800890","type":"CDM"},{"code":"320","type":"RC"},{"code":"73590","type":"HCPCS"}],"standard_charges":[{"gross_charge":553.0,"discounted_cash":304.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Toe Single View","code_information":[{"code":"800893","type":"CDM"},{"code":"320","type":"RC"},{"code":"73660","type":"HCPCS"}],"standard_charges":[{"gross_charge":553.0,"discounted_cash":304.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Elbow 2 Vw","code_information":[{"code":"800900","type":"CDM"},{"code":"320","type":"RC"},{"code":"73070","type":"HCPCS"}],"standard_charges":[{"gross_charge":553.0,"discounted_cash":304.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ir Endo Rep Thor Aor Lt Subcl","code_information":[{"code":"800913","type":"CDM"},{"code":"360","type":"RC"},{"code":"33880","type":"HCPCS"}],"standard_charges":[{"gross_charge":15051.0,"discounted_cash":8278.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Fistula Or Sinus Tract Study S And I","code_information":[{"code":"800917","type":"CDM"},{"code":"320","type":"RC"},{"code":"76080","type":"HCPCS"}],"standard_charges":[{"gross_charge":1695.0,"discounted_cash":932.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Elbow 3+ Vw","code_information":[{"code":"800918","type":"CDM"},{"code":"320","type":"RC"},{"code":"73080","type":"HCPCS"}],"standard_charges":[{"gross_charge":553.0,"discounted_cash":304.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ir Fl Gi Tube Placement","code_information":[{"code":"800919","type":"CDM"},{"code":"320","type":"RC"},{"code":"74340","type":"HCPCS"}],"standard_charges":[{"gross_charge":503.0,"discounted_cash":276.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Fl Arthrogram Elbow","code_information":[{"code":"800935","type":"CDM"},{"code":"322","type":"RC"},{"code":"73085","type":"HCPCS"}],"standard_charges":[{"gross_charge":2236.0,"discounted_cash":1229.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Urography Antegrade Rad S And I","code_information":[{"code":"800938","type":"CDM"},{"code":"320","type":"RC"},{"code":"74425","type":"HCPCS"}],"standard_charges":[{"gross_charge":666.0,"discounted_cash":366.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Change Drain Tube W Contrast S And I","code_information":[{"code":"800942","type":"CDM"},{"code":"320","type":"RC"},{"code":"75984","type":"HCPCS"}],"standard_charges":[{"gross_charge":728.0,"discounted_cash":400.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ir Perc Remov/Repl Ureteral Stent","code_information":[{"code":"800946","type":"CDM"},{"code":"360","type":"RC"},{"code":"50382","type":"HCPCS"}],"standard_charges":[{"gross_charge":4878.0,"discounted_cash":2682.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Remov/Repl Extern Ureter Stent W Fl","code_information":[{"code":"800952","type":"CDM"},{"code":"361","type":"RC"},{"code":"50387","type":"HCPCS"}],"standard_charges":[{"gross_charge":4377.0,"discounted_cash":2407.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Forearm 2 Vw","code_information":[{"code":"800953","type":"CDM"},{"code":"320","type":"RC"},{"code":"73090","type":"HCPCS"}],"standard_charges":[{"gross_charge":553.0,"discounted_cash":304.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ir Remove Nephro Tube With Fluoro","code_information":[{"code":"800955","type":"CDM"},{"code":"361","type":"RC"},{"code":"50389","type":"HCPCS"}],"standard_charges":[{"gross_charge":1611.0,"discounted_cash":886.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ir Ureterostomy Tube Change","code_information":[{"code":"800957","type":"CDM"},{"code":"361","type":"RC"},{"code":"50688","type":"HCPCS"}],"standard_charges":[{"gross_charge":2894.0,"discounted_cash":1591.7,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Venogram Ivc","code_information":[{"code":"800961","type":"CDM"},{"code":"320","type":"RC"},{"code":"75825","type":"HCPCS"}],"standard_charges":[{"gross_charge":4546.0,"discounted_cash":2500.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Venogram Svc","code_information":[{"code":"800962","type":"CDM"},{"code":"320","type":"RC"},{"code":"75827","type":"HCPCS"}],"standard_charges":[{"gross_charge":3300.0,"discounted_cash":1815.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Upper Extremity Infant 2+ Vw","code_information":[{"code":"800972","type":"CDM"},{"code":"320","type":"RC"},{"code":"73092","type":"HCPCS"}],"standard_charges":[{"gross_charge":553.0,"discounted_cash":304.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Fl Cisternography","code_information":[{"code":"800973","type":"CDM"},{"code":"320","type":"RC"},{"code":"70015","type":"HCPCS"}],"standard_charges":[{"gross_charge":1600.0,"discounted_cash":880.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Voiding Cystogram S And I","code_information":[{"code":"800975","type":"CDM"},{"code":"320","type":"RC"},{"code":"74455","type":"HCPCS"}],"standard_charges":[{"gross_charge":832.0,"discounted_cash":457.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Xray Small Bowel Single Contrast","code_information":[{"code":"800988","type":"CDM"},{"code":"320","type":"RC"},{"code":"74250","type":"HCPCS"}],"standard_charges":[{"gross_charge":503.0,"discounted_cash":276.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Xray Upper Gi Single Contrast","code_information":[{"code":"800991","type":"CDM"},{"code":"320","type":"RC"},{"code":"74240","type":"HCPCS"}],"standard_charges":[{"gross_charge":503.0,"discounted_cash":276.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Inj Transfor Epid C/T Ea Addl","code_information":[{"code":"801041","type":"CDM"},{"code":"361","type":"RC"},{"code":"64480","type":"HCPCS"}],"standard_charges":[{"gross_charge":2867.0,"discounted_cash":1576.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Art Cath Sample/Monitor/Transfuse Percu","code_information":[{"code":"801045","type":"CDM"},{"code":"361","type":"RC"},{"code":"36620","type":"HCPCS"}],"standard_charges":[{"gross_charge":314.0,"discounted_cash":172.7,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Inj Perc Pseudoaneurysm Extrem","code_information":[{"code":"801049","type":"CDM"},{"code":"361","type":"RC"},{"code":"36002","type":"HCPCS"}],"standard_charges":[{"gross_charge":2722.0,"discounted_cash":1497.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Mri Mra Pelvis W/O Contrast","code_information":[{"code":"801059","type":"CDM"},{"code":"618","type":"RC"},{"code":"C8919","type":"HCPCS"}],"standard_charges":[{"gross_charge":3719.0,"discounted_cash":2045.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Mri Mra Pelvis W/O Fol W/Contr","code_information":[{"code":"801060","type":"CDM"},{"code":"618","type":"RC"},{"code":"C8920","type":"HCPCS"}],"standard_charges":[{"gross_charge":4192.0,"discounted_cash":2305.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Us Measure Bladder Capacity","code_information":[{"code":"801065","type":"CDM"},{"code":"761","type":"RC"},{"code":"51798","type":"HCPCS"}],"standard_charges":[{"gross_charge":160.0,"discounted_cash":88.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Inj Aa Strd Axillary Nerve W Img","code_information":[{"code":"801077","type":"CDM"},{"code":"361","type":"RC"},{"code":"64417","type":"HCPCS"}],"standard_charges":[{"gross_charge":2736.0,"discounted_cash":1504.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Inj For Sentinel Node Id","code_information":[{"code":"801081","type":"CDM"},{"code":"361","type":"RC"},{"code":"38792","type":"HCPCS"}],"standard_charges":[{"gross_charge":1495.0,"discounted_cash":822.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Repl Picc Wo Pt Pp Same Acc W Img","code_information":[{"code":"801082","type":"CDM"},{"code":"361","type":"RC"},{"code":"36584","type":"HCPCS"}],"standard_charges":[{"gross_charge":3330.0,"discounted_cash":1831.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Insert Picc W Port >=5Yrs","code_information":[{"code":"801090","type":"CDM"},{"code":"361","type":"RC"},{"code":"36571","type":"HCPCS"}],"standard_charges":[{"gross_charge":4536.0,"discounted_cash":2494.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Repr Tun Nontun Cvac Wo Pt/Pp","code_information":[{"code":"801092","type":"CDM"},{"code":"361","type":"RC"},{"code":"36575","type":"HCPCS"}],"standard_charges":[{"gross_charge":1299.0,"discounted_cash":714.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Repl Tun Cvc W Pt Same Acc","code_information":[{"code":"801096","type":"CDM"},{"code":"361","type":"RC"},{"code":"36582","type":"HCPCS"}],"standard_charges":[{"gross_charge":6469.0,"discounted_cash":3557.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Nm Radiopharm Therapy Rma Iv Inf","code_information":[{"code":"801108","type":"CDM"},{"code":"342","type":"RC"},{"code":"79403","type":"HCPCS"}],"standard_charges":[{"gross_charge":4476.0,"discounted_cash":2461.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Nm Radiopharm Therapy By Oral Adm","code_information":[{"code":"801118","type":"CDM"},{"code":"342","type":"RC"},{"code":"79005","type":"HCPCS"}],"standard_charges":[{"gross_charge":3520.0,"discounted_cash":1936.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Nm Radiopharm Therapy By Iv Admin","code_information":[{"code":"801119","type":"CDM"},{"code":"342","type":"RC"},{"code":"79101","type":"HCPCS"}],"standard_charges":[{"gross_charge":3520.0,"discounted_cash":1936.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Nm Radiophrm Ther Intra-Art Admin","code_information":[{"code":"801120","type":"CDM"},{"code":"342","type":"RC"},{"code":"79445","type":"HCPCS"}],"standard_charges":[{"gross_charge":992.0,"discounted_cash":545.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ablation Endoven Laser Extrem Vein Init","code_information":[{"code":"801121","type":"CDM"},{"code":"361","type":"RC"},{"code":"36478","type":"HCPCS"}],"standard_charges":[{"gross_charge":5887.0,"discounted_cash":3237.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Noncdm Charge Record","code_information":[{"code":"801122","type":"CDM"},{"code":"361","type":"RC"},{"code":"36475","type":"HCPCS"}],"standard_charges":[{"gross_charge":6410.0,"discounted_cash":3525.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Hc Nm Pet/Ct Skull To Mid Thigh","code_information":[{"code":"801127","type":"CDM"},{"code":"404","type":"RC"},{"code":"78815","type":"HCPCS"}],"standard_charges":[{"gross_charge":6650.0,"discounted_cash":3657.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Chemo Admin Push Technique","code_information":[{"code":"801131","type":"CDM"},{"code":"331","type":"RC"},{"code":"96420","type":"HCPCS"}],"standard_charges":[{"gross_charge":1112.0,"discounted_cash":611.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Recon 3D Non Indep Wk Sta","code_information":[{"code":"801137","type":"CDM"},{"code":"350","type":"RC"},{"code":"76376","type":"HCPCS"}],"standard_charges":[{"gross_charge":785.0,"discounted_cash":431.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Recon 3D With Indep Wk Sta","code_information":[{"code":"801138","type":"CDM"},{"code":"350","type":"RC"},{"code":"76377","type":"HCPCS"}],"standard_charges":[{"gross_charge":1044.0,"discounted_cash":574.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Rpr Endovasc Thoracic Ao Descending","code_information":[{"code":"801139","type":"CDM"},{"code":"320","type":"RC"},{"code":"75956","type":"HCPCS"}],"standard_charges":[{"gross_charge":1290.0,"discounted_cash":709.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Inj Cont Exist Cva Dev W Fluor","code_information":[{"code":"801156","type":"CDM"},{"code":"361","type":"RC"},{"code":"36598","type":"HCPCS"}],"standard_charges":[{"gross_charge":696.0,"discounted_cash":382.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Cath Sel Seg/Subseq Pulm Art","code_information":[{"code":"801204","type":"CDM"},{"code":"361","type":"RC"},{"code":"36015","type":"HCPCS"}],"standard_charges":[{"gross_charge":3023.0,"discounted_cash":1662.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Mra Upper Extrem W Contrast","code_information":[{"code":"801324","type":"CDM"},{"code":"618","type":"RC"},{"code":"C8934","type":"HCPCS"}],"standard_charges":[{"gross_charge":4536.0,"discounted_cash":2494.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Mra Upper Extrem Wo Cont","code_information":[{"code":"801325","type":"CDM"},{"code":"618","type":"RC"},{"code":"C8935","type":"HCPCS"}],"standard_charges":[{"gross_charge":4320.0,"discounted_cash":2376.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Biopsy Soft Tissue Neck Or Thorax","code_information":[{"code":"801379","type":"CDM"},{"code":"361","type":"RC"},{"code":"21550","type":"HCPCS"}],"standard_charges":[{"gross_charge":2590.0,"discounted_cash":1424.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ct Angio Chest W Contrast","code_information":[{"code":"801402","type":"CDM"},{"code":"350","type":"RC"},{"code":"71275","type":"HCPCS"}],"standard_charges":[{"gross_charge":3079.0,"discounted_cash":1693.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Mra Abd W/Contrast","code_information":[{"code":"801521","type":"CDM"},{"code":"618","type":"RC"},{"code":"C8900","type":"HCPCS"}],"standard_charges":[{"gross_charge":4410.0,"discounted_cash":2425.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Mri Mra Abd W/O Contrst","code_information":[{"code":"801522","type":"CDM"},{"code":"618","type":"RC"},{"code":"C8901","type":"HCPCS"}],"standard_charges":[{"gross_charge":4200.0,"discounted_cash":2310.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Mri Mra Abd W/O Fol W/Contrast","code_information":[{"code":"801523","type":"CDM"},{"code":"618","type":"RC"},{"code":"C8902","type":"HCPCS"}],"standard_charges":[{"gross_charge":4631.0,"discounted_cash":2547.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Mri Breast W Contrast Unilat","code_information":[{"code":"801524","type":"CDM"},{"code":"614","type":"RC"},{"code":"C8903","type":"HCPCS"}],"standard_charges":[{"gross_charge":4284.0,"discounted_cash":2356.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Mri Breast Wo Followed W Contrast Unilat","code_information":[{"code":"801526","type":"CDM"},{"code":"614","type":"RC"},{"code":"C8905","type":"HCPCS"}],"standard_charges":[{"gross_charge":4499.0,"discounted_cash":2474.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Mri Breast W/Contrast Bilat","code_information":[{"code":"801527","type":"CDM"},{"code":"614","type":"RC"},{"code":"C8906","type":"HCPCS"}],"standard_charges":[{"gross_charge":8002.0,"discounted_cash":4401.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Mri Mra Chest W/Contrast","code_information":[{"code":"801529","type":"CDM"},{"code":"618","type":"RC"},{"code":"C8909","type":"HCPCS"}],"standard_charges":[{"gross_charge":4315.0,"discounted_cash":2373.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Mri Mra Chest W/O Contrst","code_information":[{"code":"801530","type":"CDM"},{"code":"618","type":"RC"},{"code":"C8910","type":"HCPCS"}],"standard_charges":[{"gross_charge":4110.0,"discounted_cash":2260.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Mri Mra Chest W/O Fol W/Contrast","code_information":[{"code":"801531","type":"CDM"},{"code":"618","type":"RC"},{"code":"C8911","type":"HCPCS"}],"standard_charges":[{"gross_charge":4531.0,"discounted_cash":2492.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Mra Lwr Ext W/Contrast","code_information":[{"code":"801532","type":"CDM"},{"code":"616","type":"RC"},{"code":"C8912","type":"HCPCS"}],"standard_charges":[{"gross_charge":4284.0,"discounted_cash":2356.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Mra Lwr Ext W/O Contrst","code_information":[{"code":"801533","type":"CDM"},{"code":"616","type":"RC"},{"code":"C8913","type":"HCPCS"}],"standard_charges":[{"gross_charge":4080.0,"discounted_cash":2244.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Mra Lwr Ext W/O Fol W/Contras","code_information":[{"code":"801534","type":"CDM"},{"code":"616","type":"RC"},{"code":"C8914","type":"HCPCS"}],"standard_charges":[{"gross_charge":4499.0,"discounted_cash":2474.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ct Angio Abdomen W/Wo Contrast","code_information":[{"code":"801673","type":"CDM"},{"code":"352","type":"RC"},{"code":"74175","type":"HCPCS"}],"standard_charges":[{"gross_charge":3079.0,"discounted_cash":1693.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Sp Rem Obstr Mat Cvc Sep Access","code_information":[{"code":"801765","type":"CDM"},{"code":"320","type":"RC"},{"code":"75901","type":"HCPCS"}],"standard_charges":[{"gross_charge":1788.0,"discounted_cash":983.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Mri Breast W/Wo Contrast Bilatera","code_information":[{"code":"801804","type":"CDM"},{"code":"614","type":"RC"},{"code":"C8908","type":"HCPCS"}],"standard_charges":[{"gross_charge":8401.0,"discounted_cash":4620.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Us Chest","code_information":[{"code":"801836","type":"CDM"},{"code":"402","type":"RC"},{"code":"76604","type":"HCPCS"}],"standard_charges":[{"gross_charge":744.0,"discounted_cash":409.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Us Preg Uterus Follow Up Per Fetus","code_information":[{"code":"801853","type":"CDM"},{"code":"402","type":"RC"},{"code":"76816","type":"HCPCS"}],"standard_charges":[{"gross_charge":744.0,"discounted_cash":409.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Tumor Infection Scan Wb 1 Day","code_information":[{"code":"801965","type":"CDM"},{"code":"341","type":"RC"},{"code":"78802","type":"HCPCS"}],"standard_charges":[{"gross_charge":3520.0,"discounted_cash":1936.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Perc Transhep Port W/O Hemod","code_information":[{"code":"801974","type":"CDM"},{"code":"320","type":"RC"},{"code":"75887","type":"HCPCS"}],"standard_charges":[{"gross_charge":7206.0,"discounted_cash":3963.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Cardiac Angio W Coro Eval","code_information":[{"code":"801986","type":"CDM"},{"code":"350","type":"RC"},{"code":"75574","type":"HCPCS"}],"standard_charges":[{"gross_charge":2807.0,"discounted_cash":1543.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"},{"gross_charge":2807.0,"discounted_cash":1543.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Hc Punc Shunt Or Rsvr For Asp Inj Px","code_information":[{"code":"802064","type":"CDM"},{"code":"361","type":"RC"},{"code":"61070","type":"HCPCS"}],"standard_charges":[{"gross_charge":2406.0,"discounted_cash":1323.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Dermabond Skin Adhesive","code_information":[{"code":"802287","type":"CDM"},{"code":"272","type":"RC"}],"standard_charges":[{"gross_charge":913.95,"discounted_cash":502.67,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Mammotome Probe 11G W/Vacuum","code_information":[{"code":"802328","type":"CDM"},{"code":"272","type":"RC"}],"standard_charges":[{"gross_charge":1052.47,"discounted_cash":578.86,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc 111 In Dtpa Per 0.5 Mci","code_information":[{"code":"802666","type":"CDM"},{"code":"343","type":"RC"},{"code":"A9548","type":"HCPCS"}],"standard_charges":[{"gross_charge":1158.0,"discounted_cash":636.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc 123I Cap Per 100 Uci","code_information":[{"code":"802669","type":"CDM"},{"code":"343","type":"RC"},{"code":"A9516","type":"HCPCS"}],"standard_charges":[{"gross_charge":118.0,"discounted_cash":64.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc 131I Therapy Cap Per Mci","code_information":[{"code":"802672","type":"CDM"},{"code":"344","type":"RC"},{"code":"A9517","type":"HCPCS"}],"standard_charges":[{"gross_charge":91.0,"discounted_cash":50.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Xe133 Gas Dx Per 10 Mci","code_information":[{"code":"802673","type":"CDM"},{"code":"343","type":"RC"},{"code":"A9558","type":"HCPCS"}],"standard_charges":[{"gross_charge":84.0,"discounted_cash":46.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Y90 Yttrium Zevalin Per Dose To 40Mci","code_information":[{"code":"802679","type":"CDM"},{"code":"344","type":"RC"},{"code":"A9543","type":"HCPCS"}],"standard_charges":[{"gross_charge":116173.0,"discounted_cash":63895.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Tc99M Maa Per Dose Up To 10Cmi","code_information":[{"code":"802681","type":"CDM"},{"code":"343","type":"RC"},{"code":"A9540","type":"HCPCS"}],"standard_charges":[{"gross_charge":867.0,"discounted_cash":476.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc 99Mtc Mag3 Per Dose To 15Mci","code_information":[{"code":"802682","type":"CDM"},{"code":"343","type":"RC"},{"code":"A9562","type":"HCPCS"}],"standard_charges":[{"gross_charge":822.0,"discounted_cash":452.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Tc99M Mebrofenin Per Dose To 15Mci","code_information":[{"code":"802683","type":"CDM"},{"code":"343","type":"RC"},{"code":"A9537","type":"HCPCS"}],"standard_charges":[{"gross_charge":220.0,"discounted_cash":121.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc 99Mtc Tagged Wbc's (Ceretec)","code_information":[{"code":"802684","type":"CDM"},{"code":"343","type":"RC"},{"code":"A9569","type":"HCPCS"}],"standard_charges":[{"gross_charge":1427.0,"discounted_cash":784.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Fdg Per Dose To 45Mci","code_information":[{"code":"802687","type":"CDM"},{"code":"343","type":"RC"},{"code":"A9552","type":"HCPCS"}],"standard_charges":[{"gross_charge":2517.0,"discounted_cash":1384.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Indium In-111 Auto Wbc Per Dse","code_information":[{"code":"802689","type":"CDM"},{"code":"343","type":"RC"},{"code":"A9570","type":"HCPCS"}],"standard_charges":[{"gross_charge":1789.0,"discounted_cash":983.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Myoview Per Dose","code_information":[{"code":"802690","type":"CDM"},{"code":"343","type":"RC"},{"code":"A9502","type":"HCPCS"}],"standard_charges":[{"gross_charge":323.0,"discounted_cash":177.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Tc 99M Ceretec Per Dose To 25Mci","code_information":[{"code":"802691","type":"CDM"},{"code":"343","type":"RC"},{"code":"A9521","type":"HCPCS"}],"standard_charges":[{"gross_charge":1304.0,"discounted_cash":717.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Tc99M Dtpa Aerosol Per Dose To 75 Mci","code_information":[{"code":"802692","type":"CDM"},{"code":"343","type":"RC"},{"code":"A9567","type":"HCPCS"}],"standard_charges":[{"gross_charge":316.0,"discounted_cash":173.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Tc 99M Filtered Sulfur Colloid <=20Mci","code_information":[{"code":"802693","type":"CDM"},{"code":"343","type":"RC"},{"code":"A9541","type":"HCPCS"}],"standard_charges":[{"gross_charge":215.0,"discounted_cash":118.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Tc99M Sestamibi Per Dose","code_information":[{"code":"802695","type":"CDM"},{"code":"343","type":"RC"},{"code":"A9500","type":"HCPCS"}],"standard_charges":[{"gross_charge":347.0,"discounted_cash":190.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Tc99M Tagged Rbc's Per Dose To 30Mci","code_information":[{"code":"802696","type":"CDM"},{"code":"343","type":"RC"},{"code":"A9560","type":"HCPCS"}],"standard_charges":[{"gross_charge":446.0,"discounted_cash":245.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Tc-99M Dtpa Per Dose Up To 25 Mci","code_information":[{"code":"802699","type":"CDM"},{"code":"343","type":"RC"},{"code":"A9539","type":"HCPCS"}],"standard_charges":[{"gross_charge":314.0,"discounted_cash":172.7,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Tc99M Medronate <= 30 Mci","code_information":[{"code":"802700","type":"CDM"},{"code":"343","type":"RC"},{"code":"A9503","type":"HCPCS"}],"standard_charges":[{"gross_charge":181.0,"discounted_cash":99.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Tc-99M Perctechnetate Per Mci","code_information":[{"code":"802701","type":"CDM"},{"code":"343","type":"RC"},{"code":"A9512","type":"HCPCS"}],"standard_charges":[{"gross_charge":21.0,"discounted_cash":11.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Tl-201 Per Mci","code_information":[{"code":"802704","type":"CDM"},{"code":"343","type":"RC"},{"code":"A9505","type":"HCPCS"}],"standard_charges":[{"gross_charge":75.0,"discounted_cash":41.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Perc Ablat Renal Tumor Uni Cryo","code_information":[{"code":"802712","type":"CDM"},{"code":"361","type":"RC"},{"code":"50593","type":"HCPCS"}],"standard_charges":[{"gross_charge":17787.0,"discounted_cash":9782.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Arthrocentesis Joint Major Wo Us","code_information":[{"code":"802715","type":"CDM"},{"code":"361","type":"RC"},{"code":"20610","type":"HCPCS"}],"standard_charges":[{"gross_charge":1554.0,"discounted_cash":854.7,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Aspiration Punc Absc Hem Cyst","code_information":[{"code":"802717","type":"CDM"},{"code":"361","type":"RC"},{"code":"10160","type":"HCPCS"}],"standard_charges":[{"gross_charge":1003.0,"discounted_cash":551.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Puncture Aspiration Cyst Breast","code_information":[{"code":"802718","type":"CDM"},{"code":"361","type":"RC"},{"code":"19000","type":"HCPCS"}],"standard_charges":[{"gross_charge":1540.0,"discounted_cash":847.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Aspiration Renal Cyst Pelvis","code_information":[{"code":"802719","type":"CDM"},{"code":"361","type":"RC"},{"code":"50390","type":"HCPCS"}],"standard_charges":[{"gross_charge":2941.0,"discounted_cash":1617.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Biopsy Abd Retroperiton Mass","code_information":[{"code":"802722","type":"CDM"},{"code":"361","type":"RC"},{"code":"49180","type":"HCPCS"}],"standard_charges":[{"gross_charge":4533.0,"discounted_cash":2493.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Biopsy Bone Deep","code_information":[{"code":"802723","type":"CDM"},{"code":"361","type":"RC"},{"code":"20225","type":"HCPCS"}],"standard_charges":[{"gross_charge":4017.0,"discounted_cash":2209.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Biopsy Bone Superfical","code_information":[{"code":"802724","type":"CDM"},{"code":"361","type":"RC"},{"code":"20220","type":"HCPCS"}],"standard_charges":[{"gross_charge":2121.0,"discounted_cash":1166.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Biopsy Kidney Needle","code_information":[{"code":"802727","type":"CDM"},{"code":"361","type":"RC"},{"code":"50200","type":"HCPCS"}],"standard_charges":[{"gross_charge":2544.0,"discounted_cash":1399.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Biopsy Liver Needle","code_information":[{"code":"802728","type":"CDM"},{"code":"361","type":"RC"},{"code":"47000","type":"HCPCS"}],"standard_charges":[{"gross_charge":5423.0,"discounted_cash":2982.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Biopsy Lymph Node Superficial By Needle","code_information":[{"code":"802730","type":"CDM"},{"code":"361","type":"RC"},{"code":"38505","type":"HCPCS"}],"standard_charges":[{"gross_charge":2532.0,"discounted_cash":1392.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Biopsy Muscle Percutaneous Needle","code_information":[{"code":"802731","type":"CDM"},{"code":"361","type":"RC"},{"code":"20206","type":"HCPCS"}],"standard_charges":[{"gross_charge":2096.0,"discounted_cash":1152.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Biopsy Pancreas Needle","code_information":[{"code":"802732","type":"CDM"},{"code":"361","type":"RC"},{"code":"48102","type":"HCPCS"}],"standard_charges":[{"gross_charge":1901.0,"discounted_cash":1045.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Biopsy Pleura","code_information":[{"code":"802733","type":"CDM"},{"code":"361","type":"RC"},{"code":"32400","type":"HCPCS"}],"standard_charges":[{"gross_charge":688.0,"discounted_cash":378.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Noncdm Charge Record","code_information":[{"code":"802734","type":"CDM"},{"code":"361","type":"RC"},{"code":"55700","type":"HCPCS"}],"standard_charges":[{"gross_charge":667.86,"discounted_cash":367.32,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Hc Biopsy Thyroid Perc Core Needle","code_information":[{"code":"802736","type":"CDM"},{"code":"361","type":"RC"},{"code":"60100","type":"HCPCS"}],"standard_charges":[{"gross_charge":1986.0,"discounted_cash":1092.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Biopsy Transcatheter","code_information":[{"code":"802737","type":"CDM"},{"code":"361","type":"RC"},{"code":"37200","type":"HCPCS"}],"standard_charges":[{"gross_charge":5254.0,"discounted_cash":2889.7,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Chorionic Villius Sampling","code_information":[{"code":"802745","type":"CDM"},{"code":"361","type":"RC"},{"code":"59015","type":"HCPCS"}],"standard_charges":[{"gross_charge":2774.0,"discounted_cash":1525.7,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Drainage Gallbladder","code_information":[{"code":"802752","type":"CDM"},{"code":"360","type":"RC"},{"code":"47490","type":"HCPCS"}],"standard_charges":[{"gross_charge":4349.0,"discounted_cash":2391.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Exchg Drain Cath With Rad Guidance","code_information":[{"code":"802763","type":"CDM"},{"code":"361","type":"RC"},{"code":"49423","type":"HCPCS"}],"standard_charges":[{"gross_charge":2012.0,"discounted_cash":1106.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Egd Flex Transoral W Plcmt Gtube Perc","code_information":[{"code":"802767","type":"CDM"},{"code":"750","type":"RC"},{"code":"43246","type":"HCPCS"}],"standard_charges":[{"gross_charge":2103.0,"discounted_cash":1156.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Inj Aa Strd  Intercostal Nerv Addl Lvl","code_information":[{"code":"802768","type":"CDM"},{"code":"361","type":"RC"},{"code":"64421","type":"HCPCS"}],"standard_charges":[{"gross_charge":1575.0,"discounted_cash":866.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Inj Aa Strd Intercostal Nerve Sngl","code_information":[{"code":"802769","type":"CDM"},{"code":"361","type":"RC"},{"code":"64420","type":"HCPCS"}],"standard_charges":[{"gross_charge":1726.0,"discounted_cash":949.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Inj Anes Cervical Plexus","code_information":[{"code":"802772","type":"CDM"},{"code":"361","type":"RC"},{"code":"64999","type":"HCPCS"}],"standard_charges":[{"gross_charge":866.0,"discounted_cash":476.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Inj Contrast Via Prev Catheter","code_information":[{"code":"802773","type":"CDM"},{"code":"361","type":"RC"},{"code":"49424","type":"HCPCS"}],"standard_charges":[{"gross_charge":613.0,"discounted_cash":337.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Inj Facet Jnt C/T 2Nd Lvl","code_information":[{"code":"802775","type":"CDM"},{"code":"361","type":"RC"},{"code":"64491","type":"HCPCS"}],"standard_charges":[{"gross_charge":3596.0,"discounted_cash":1977.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Inj Sacroiliac Joint","code_information":[{"code":"802778","type":"CDM"},{"code":"361","type":"RC"},{"code":"G0260","type":"HCPCS"}],"standard_charges":[{"gross_charge":3066.0,"discounted_cash":1686.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Inj Transfor Epid Cer/Thor Sng","code_information":[{"code":"802780","type":"CDM"},{"code":"361","type":"RC"},{"code":"64479","type":"HCPCS"}],"standard_charges":[{"gross_charge":3553.0,"discounted_cash":1954.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Inject For Extremity Venogram","code_information":[{"code":"802783","type":"CDM"},{"code":"361","type":"RC"},{"code":"36005","type":"HCPCS"}],"standard_charges":[{"gross_charge":721.0,"discounted_cash":396.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Injection Arthrogram Ankle","code_information":[{"code":"802786","type":"CDM"},{"code":"361","type":"RC"},{"code":"27648","type":"HCPCS"}],"standard_charges":[{"gross_charge":594.0,"discounted_cash":326.7,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Injection Arthrogram Elbow","code_information":[{"code":"802787","type":"CDM"},{"code":"361","type":"RC"},{"code":"24220","type":"HCPCS"}],"standard_charges":[{"gross_charge":253.0,"discounted_cash":139.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Injection Arthrogram Hip","code_information":[{"code":"802788","type":"CDM"},{"code":"361","type":"RC"},{"code":"27093","type":"HCPCS"}],"standard_charges":[{"gross_charge":1062.0,"discounted_cash":584.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Injection Arthrogram Knee","code_information":[{"code":"802789","type":"CDM"},{"code":"361","type":"RC"},{"code":"27369","type":"HCPCS"}],"standard_charges":[{"gross_charge":848.0,"discounted_cash":466.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Injection Arthrogram Shoulder","code_information":[{"code":"802790","type":"CDM"},{"code":"361","type":"RC"},{"code":"23350","type":"HCPCS"}],"standard_charges":[{"gross_charge":733.0,"discounted_cash":403.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Injection Arthrogram Wrist","code_information":[{"code":"802791","type":"CDM"},{"code":"361","type":"RC"},{"code":"25246","type":"HCPCS"}],"standard_charges":[{"gross_charge":236.0,"discounted_cash":129.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Noncdm Charge Record","code_information":[{"code":"802793","type":"CDM"},{"code":"361","type":"RC"},{"code":"54235","type":"HCPCS"}],"standard_charges":[{"gross_charge":345.0,"discounted_cash":189.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Hc Injection Cystogram","code_information":[{"code":"802794","type":"CDM"},{"code":"361","type":"RC"},{"code":"51600","type":"HCPCS"}],"standard_charges":[{"gross_charge":1526.0,"discounted_cash":839.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Inj For Discography Lumbar Ea Level","code_information":[{"code":"802796","type":"CDM"},{"code":"361","type":"RC"},{"code":"62290","type":"HCPCS"}],"standard_charges":[{"gross_charge":3158.0,"discounted_cash":1736.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Injection Hysterosalpingogram","code_information":[{"code":"802800","type":"CDM"},{"code":"361","type":"RC"},{"code":"58340","type":"HCPCS"}],"standard_charges":[{"gross_charge":432.0,"discounted_cash":237.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Injection Ilial Conduit","code_information":[{"code":"802801","type":"CDM"},{"code":"361","type":"RC"},{"code":"50690","type":"HCPCS"}],"standard_charges":[{"gross_charge":432.0,"discounted_cash":237.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Injection Mammary Duct","code_information":[{"code":"802803","type":"CDM"},{"code":"320","type":"RC"},{"code":"19030","type":"HCPCS"}],"standard_charges":[{"gross_charge":420.0,"discounted_cash":231.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Injection Myelogram Lumbar","code_information":[{"code":"802804","type":"CDM"},{"code":"361","type":"RC"},{"code":"62284","type":"HCPCS"}],"standard_charges":[{"gross_charge":4117.0,"discounted_cash":2264.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Plcmt Cath Pulm Artery Selective","code_information":[{"code":"802807","type":"CDM"},{"code":"361","type":"RC"},{"code":"36014","type":"HCPCS"}],"standard_charges":[{"gross_charge":3316.0,"discounted_cash":1823.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Injection Sinus Tract","code_information":[{"code":"802809","type":"CDM"},{"code":"361","type":"RC"},{"code":"20501","type":"HCPCS"}],"standard_charges":[{"gross_charge":234.0,"discounted_cash":128.7,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Injection Uretherography","code_information":[{"code":"802811","type":"CDM"},{"code":"361","type":"RC"},{"code":"50684","type":"HCPCS"}],"standard_charges":[{"gross_charge":809.0,"discounted_cash":444.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Injection Urethrogram Retrogra","code_information":[{"code":"802812","type":"CDM"},{"code":"361","type":"RC"},{"code":"51610","type":"HCPCS"}],"standard_charges":[{"gross_charge":610.0,"discounted_cash":335.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Plcmt Cath Vein 1St Order","code_information":[{"code":"802813","type":"CDM"},{"code":"361","type":"RC"},{"code":"36011","type":"HCPCS"}],"standard_charges":[{"gross_charge":2714.0,"discounted_cash":1492.7,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Insert Needle Catheter Extremi","code_information":[{"code":"802815","type":"CDM"},{"code":"361","type":"RC"},{"code":"36140","type":"HCPCS"}],"standard_charges":[{"gross_charge":4301.0,"discounted_cash":2365.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Insertion Aorta Catheter","code_information":[{"code":"802818","type":"CDM"},{"code":"361","type":"RC"},{"code":"36200","type":"HCPCS"}],"standard_charges":[{"gross_charge":2975.0,"discounted_cash":1636.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Insertion Aorta Translumbar","code_information":[{"code":"802819","type":"CDM"},{"code":"361","type":"RC"},{"code":"36160","type":"HCPCS"}],"standard_charges":[{"gross_charge":5044.0,"discounted_cash":2774.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Introduction Of Long Gi Tube","code_information":[{"code":"802825","type":"CDM"},{"code":"361","type":"RC"},{"code":"44500","type":"HCPCS"}],"standard_charges":[{"gross_charge":365.0,"discounted_cash":200.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Insertion Pulmonary Art Cathet","code_information":[{"code":"802827","type":"CDM"},{"code":"361","type":"RC"},{"code":"36013","type":"HCPCS"}],"standard_charges":[{"gross_charge":2941.0,"discounted_cash":1617.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Insertion Vena Cava Catheter","code_information":[{"code":"802830","type":"CDM"},{"code":"361","type":"RC"},{"code":"36010","type":"HCPCS"}],"standard_charges":[{"gross_charge":1860.0,"discounted_cash":1023.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Plcmt Cath Vein 2Nd Order","code_information":[{"code":"802831","type":"CDM"},{"code":"361","type":"RC"},{"code":"36012","type":"HCPCS"}],"standard_charges":[{"gross_charge":3484.0,"discounted_cash":1916.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Lumbar Puncture","code_information":[{"code":"802833","type":"CDM"},{"code":"361","type":"RC"},{"code":"62270","type":"HCPCS"}],"standard_charges":[{"gross_charge":2557.0,"discounted_cash":1406.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Opn Fem Art For End Prs Gr Uni","code_information":[{"code":"802837","type":"CDM"},{"code":"360","type":"RC"},{"code":"34812","type":"HCPCS"}],"standard_charges":[{"gross_charge":5072.0,"discounted_cash":2789.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Perc Radio Ablation Renal Uni","code_information":[{"code":"802841","type":"CDM"},{"code":"360","type":"RC"},{"code":"50592","type":"HCPCS"}],"standard_charges":[{"gross_charge":15235.0,"discounted_cash":8379.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Percutaneous Portal Vein Cath","code_information":[{"code":"802846","type":"CDM"},{"code":"361","type":"RC"},{"code":"36481","type":"HCPCS"}],"standard_charges":[{"gross_charge":1121.0,"discounted_cash":616.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Repositioning Of Gastric Tube","code_information":[{"code":"802854","type":"CDM"},{"code":"361","type":"RC"},{"code":"43761","type":"HCPCS"}],"standard_charges":[{"gross_charge":1047.0,"discounted_cash":575.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Place Cath Select Art 3Rd Ord Thoracic","code_information":[{"code":"802857","type":"CDM"},{"code":"361","type":"RC"},{"code":"36217","type":"HCPCS"}],"standard_charges":[{"gross_charge":5693.0,"discounted_cash":3131.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Sel Cath Placement-2Nd Ord Ad","code_information":[{"code":"802859","type":"CDM"},{"code":"361","type":"RC"},{"code":"36216","type":"HCPCS"}],"standard_charges":[{"gross_charge":3528.0,"discounted_cash":1940.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Unlisted Vascular Procedure","code_information":[{"code":"802865","type":"CDM"},{"code":"360","type":"RC"},{"code":"37799","type":"HCPCS"}],"standard_charges":[{"gross_charge":3237.0,"discounted_cash":1780.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Fetal Doppler Umbilical Art","code_information":[{"code":"802875","type":"CDM"},{"code":"402","type":"RC"},{"code":"76820","type":"HCPCS"}],"standard_charges":[{"gross_charge":882.0,"discounted_cash":485.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Fetal Doppler Mid Cerebral Art","code_information":[{"code":"802876","type":"CDM"},{"code":"402","type":"RC"},{"code":"76821","type":"HCPCS"}],"standard_charges":[{"gross_charge":882.0,"discounted_cash":485.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Us Art Doppler Abd Pelv Retrop Sc Cmplt","code_information":[{"code":"802888","type":"CDM"},{"code":"921","type":"RC"},{"code":"93975","type":"HCPCS"}],"standard_charges":[{"gross_charge":2908.0,"discounted_cash":1599.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Us Ltd Doppler Abd Pelv Scrot Retrop","code_information":[{"code":"802889","type":"CDM"},{"code":"921","type":"RC"},{"code":"93976","type":"HCPCS"}],"standard_charges":[{"gross_charge":1245.0,"discounted_cash":684.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Us Preg Uterus Nuchl Meas Sgl/1St","code_information":[{"code":"802892","type":"CDM"},{"code":"402","type":"RC"},{"code":"76813","type":"HCPCS"}],"standard_charges":[{"gross_charge":530.0,"discounted_cash":291.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Mri Car Func Morph Wo Cont","code_information":[{"code":"802911","type":"CDM"},{"code":"610","type":"RC"},{"code":"75557","type":"HCPCS"}],"standard_charges":[{"gross_charge":3828.0,"discounted_cash":2105.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Mri Car Func Morph Wo W Cont","code_information":[{"code":"802912","type":"CDM"},{"code":"610","type":"RC"},{"code":"75561","type":"HCPCS"}],"standard_charges":[{"gross_charge":4192.0,"discounted_cash":2305.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Biopsy Bone Marrow Ndl Trochar","code_information":[{"code":"802916","type":"CDM"},{"code":"361","type":"RC"},{"code":"38221","type":"HCPCS"}],"standard_charges":[{"gross_charge":3420.0,"discounted_cash":1881.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ct Chest Low Dose For Lung Ca Screen","code_information":[{"code":"802942","type":"CDM"},{"code":"352","type":"RC"},{"code":"71271","type":"HCPCS"}],"standard_charges":[{"gross_charge":206.0,"discounted_cash":113.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Us Scrotum And Contents","code_information":[{"code":"802946","type":"CDM"},{"code":"402","type":"RC"},{"code":"76870","type":"HCPCS"}],"standard_charges":[{"gross_charge":729.0,"discounted_cash":400.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Aspiration Bone Marrow","code_information":[{"code":"802957","type":"CDM"},{"code":"361","type":"RC"},{"code":"38220","type":"HCPCS"}],"standard_charges":[{"gross_charge":2886.0,"discounted_cash":1587.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Art Duplex Le Or Bypass Graft/Uni","code_information":[{"code":"802971","type":"CDM"},{"code":"921","type":"RC"},{"code":"93926","type":"HCPCS"}],"standard_charges":[{"gross_charge":1319.0,"discounted_cash":725.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Art Duplex Ue Or Bypass Graft/Bil","code_information":[{"code":"802972","type":"CDM"},{"code":"921","type":"RC"},{"code":"93930","type":"HCPCS"}],"standard_charges":[{"gross_charge":1453.0,"discounted_cash":799.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Reposition Cent Ven Cath W/Fl","code_information":[{"code":"802984","type":"CDM"},{"code":"361","type":"RC"},{"code":"36597","type":"HCPCS"}],"standard_charges":[{"gross_charge":5477.0,"discounted_cash":3012.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Inj Aa Strd Suprascapular Nerve","code_information":[{"code":"802985","type":"CDM"},{"code":"361","type":"RC"},{"code":"64418","type":"HCPCS"}],"standard_charges":[{"gross_charge":1558.0,"discounted_cash":856.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Noncdm Charge Record","code_information":[{"code":"802988","type":"CDM"},{"code":"610","type":"RC"},{"code":"77021","type":"HCPCS"}],"standard_charges":[{"gross_charge":1965.0,"discounted_cash":1080.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Hc Insert Picc Wo Sq Pt >=5Yrs Wo Img","code_information":[{"code":"803000","type":"CDM"},{"code":"361","type":"RC"},{"code":"36569","type":"HCPCS"}],"standard_charges":[{"gross_charge":2412.0,"discounted_cash":1326.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Embolization Trncth Occ Non Cn","code_information":[{"code":"803022","type":"CDM"},{"code":"361","type":"RC"},{"code":"61626","type":"HCPCS"}],"standard_charges":[{"gross_charge":7968.0,"discounted_cash":4382.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Embolization Trncth Occl Cns","code_information":[{"code":"803023","type":"CDM"},{"code":"360","type":"RC"},{"code":"61624","type":"HCPCS"}],"standard_charges":[{"gross_charge":1760.0,"discounted_cash":968.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Transcath Stent Cca W Emb Prot","code_information":[{"code":"803025","type":"CDM"},{"code":"360","type":"RC"},{"code":"37215","type":"HCPCS"}],"standard_charges":[{"gross_charge":13290.0,"discounted_cash":7309.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Transcath Stent Cca Wo Emb Prt","code_information":[{"code":"803026","type":"CDM"},{"code":"360","type":"RC"},{"code":"37216","type":"HCPCS"}],"standard_charges":[{"gross_charge":13162.0,"discounted_cash":7239.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Mri For Treatment Planning","code_information":[{"code":"803031","type":"CDM"},{"code":"610","type":"RC"},{"code":"76498","type":"HCPCS"}],"standard_charges":[{"gross_charge":4192.0,"discounted_cash":2305.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ct Angio Lower Extrem W And Wo Contrast","code_information":[{"code":"803035","type":"CDM"},{"code":"350","type":"RC"},{"code":"73706","type":"HCPCS"}],"standard_charges":[{"gross_charge":2724.0,"discounted_cash":1498.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Us Penile Duplex Complete","code_information":[{"code":"803056","type":"CDM"},{"code":"921","type":"RC"},{"code":"93980","type":"HCPCS"}],"standard_charges":[{"gross_charge":1064.0,"discounted_cash":585.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Puncture Aspiration Cyst Breast Ea Addl","code_information":[{"code":"803067","type":"CDM"},{"code":"361","type":"RC"},{"code":"19001","type":"HCPCS"}],"standard_charges":[{"gross_charge":1124.0,"discounted_cash":618.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Insrt Tips Trnsv Intrhep Shunt","code_information":[{"code":"803068","type":"CDM"},{"code":"360","type":"RC"},{"code":"37182","type":"HCPCS"}],"standard_charges":[{"gross_charge":19331.0,"discounted_cash":10632.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Inj Transforam Nerve L/S Sngl","code_information":[{"code":"803076","type":"CDM"},{"code":"361","type":"RC"},{"code":"64483","type":"HCPCS"}],"standard_charges":[{"gross_charge":4049.0,"discounted_cash":2226.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Inj Transformal Nerve L/S Addl","code_information":[{"code":"803077","type":"CDM"},{"code":"361","type":"RC"},{"code":"64484","type":"HCPCS"}],"standard_charges":[{"gross_charge":2730.0,"discounted_cash":1501.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Myocardial Pet Metab Eval Sngl","code_information":[{"code":"803120","type":"CDM"},{"code":"404","type":"RC"},{"code":"78459","type":"HCPCS"}],"standard_charges":[{"gross_charge":4319.0,"discounted_cash":2375.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Nm Pet Ct Whole Body","code_information":[{"code":"803121","type":"CDM"},{"code":"404","type":"RC"},{"code":"78816","type":"HCPCS"}],"standard_charges":[{"gross_charge":6769.0,"discounted_cash":3722.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Perc Duod Or Jej Tube Plmnt","code_information":[{"code":"803139","type":"CDM"},{"code":"361","type":"RC"},{"code":"49441","type":"HCPCS"}],"standard_charges":[{"gross_charge":2178.0,"discounted_cash":1197.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Perc Exchange G To Gj Tube","code_information":[{"code":"803141","type":"CDM"},{"code":"361","type":"RC"},{"code":"49446","type":"HCPCS"}],"standard_charges":[{"gross_charge":2834.0,"discounted_cash":1558.7,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Perc G Tube Replacement","code_information":[{"code":"803142","type":"CDM"},{"code":"361","type":"RC"},{"code":"49450","type":"HCPCS"}],"standard_charges":[{"gross_charge":3092.0,"discounted_cash":1700.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Perc Duod Or Jej Tube Rp","code_information":[{"code":"803143","type":"CDM"},{"code":"361","type":"RC"},{"code":"49451","type":"HCPCS"}],"standard_charges":[{"gross_charge":787.0,"discounted_cash":432.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Perc Gj Tube Replacement","code_information":[{"code":"803144","type":"CDM"},{"code":"361","type":"RC"},{"code":"49452","type":"HCPCS"}],"standard_charges":[{"gross_charge":1185.0,"discounted_cash":651.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Inj Contrast Eval Existing Gi Tube","code_information":[{"code":"803145","type":"CDM"},{"code":"361","type":"RC"},{"code":"49465","type":"HCPCS"}],"standard_charges":[{"gross_charge":422.0,"discounted_cash":232.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Mech Remv Obst Material Cvad","code_information":[{"code":"803161","type":"CDM"},{"code":"361","type":"RC"},{"code":"36596","type":"HCPCS"}],"standard_charges":[{"gross_charge":1951.0,"discounted_cash":1073.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ct Screen Cardiac Scoring","code_information":[{"code":"803162","type":"CDM"},{"code":"352","type":"RC"},{"code":"75571","type":"HCPCS"}],"standard_charges":[{"gross_charge":25.0,"discounted_cash":13.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Op Psychotherapy For Crisis Initial 60 Min","code_information":[{"code":"803174","type":"CDM"},{"code":"914","type":"RC"},{"code":"90839","type":"HCPCS"}],"standard_charges":[{"gross_charge":215.0,"discounted_cash":118.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Biopsy Salivary Gland","code_information":[{"code":"803179","type":"CDM"},{"code":"361","type":"RC"},{"code":"42400","type":"HCPCS"}],"standard_charges":[{"gross_charge":2697.0,"discounted_cash":1483.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Inj Facet Jnt C/T Sngl Lvl Bilat","code_information":[{"code":"803197","type":"CDM"},{"code":"361","type":"RC"},{"code":"64490","type":"HCPCS"}],"standard_charges":[{"gross_charge":8174.0,"discounted_cash":4495.7,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Doppler Echo Complete","code_information":[{"code":"803207","type":"CDM"},{"code":"483","type":"RC"},{"code":"93320","type":"HCPCS"}],"standard_charges":[{"gross_charge":772.0,"discounted_cash":424.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Cystostomy Tube Change Simple","code_information":[{"code":"803372","type":"CDM"},{"code":"361","type":"RC"},{"code":"51705","type":"HCPCS"}],"standard_charges":[{"gross_charge":1169.0,"discounted_cash":642.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Tte Follow Up Or Limited Wo Contrast","code_information":[{"code":"803382","type":"CDM"},{"code":"483","type":"RC"},{"code":"93308","type":"HCPCS"}],"standard_charges":[{"gross_charge":1186.0,"discounted_cash":652.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Us Preg Uterus Lmtd One Or > Gest","code_information":[{"code":"803383","type":"CDM"},{"code":"450","type":"RC"},{"code":"76815","type":"HCPCS"}],"standard_charges":[{"gross_charge":856.0,"discounted_cash":470.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Us Retroperitoneal Limited","code_information":[{"code":"803384","type":"CDM"},{"code":"450","type":"RC"},{"code":"76775","type":"HCPCS"}],"standard_charges":[{"gross_charge":838.0,"discounted_cash":460.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Injct Chemo Into Cns Via Lp","code_information":[{"code":"803387","type":"CDM"},{"code":"331","type":"RC"},{"code":"96450","type":"HCPCS"}],"standard_charges":[{"gross_charge":716.0,"discounted_cash":393.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Tissue Marker Implantable Any Type","code_information":[{"code":"803393","type":"CDM"},{"code":"278","type":"RC"},{"code":"A4648","type":"HCPCS"}],"standard_charges":[{"gross_charge":428.91,"discounted_cash":235.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."},{"gross_charge":427.85,"discounted_cash":235.32,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."},{"gross_charge":412.89,"discounted_cash":227.09,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Noncdm Charge Record","code_information":[{"code":"803394","type":"CDM"},{"code":"360","type":"RC"},{"code":"55876","type":"HCPCS"}],"standard_charges":[{"gross_charge":692.28,"discounted_cash":380.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Hc Cryo Probe","code_information":[{"code":"803452","type":"CDM"},{"code":"272","type":"RC"},{"code":"C2618","type":"HCPCS"}],"standard_charges":[{"gross_charge":3252.8,"discounted_cash":1789.04,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ablation Tx Rf Pulm Tumor Perc Unilat","code_information":[{"code":"803461","type":"CDM"},{"code":"361","type":"RC"},{"code":"32998","type":"HCPCS"}],"standard_charges":[{"gross_charge":16376.0,"discounted_cash":9006.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Interdiscal Perq Aspir Dx","code_information":[{"code":"803513","type":"CDM"},{"code":"361","type":"RC"},{"code":"62267","type":"HCPCS"}],"standard_charges":[{"gross_charge":1011.0,"discounted_cash":556.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Inj Trans Nerve C/T Sngl Bil","code_information":[{"code":"803624","type":"CDM"},{"code":"361","type":"RC"},{"code":"64479","type":"HCPCS"}],"standard_charges":[{"gross_charge":7107.0,"discounted_cash":3908.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Inj Trans Nerve L/S Sngl Bilat","code_information":[{"code":"803625","type":"CDM"},{"code":"361","type":"RC"},{"code":"64483","type":"HCPCS"}],"standard_charges":[{"gross_charge":8100.0,"discounted_cash":4455.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ir Perc Trans Mec Thrmb Vein","code_information":[{"code":"803628","type":"CDM"},{"code":"361","type":"RC"},{"code":"37187","type":"HCPCS"}],"standard_charges":[{"gross_charge":6326.0,"discounted_cash":3479.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Inj Sacroiliac Jt Bilat","code_information":[{"code":"803665","type":"CDM"},{"code":"361","type":"RC"},{"code":"G0260","type":"HCPCS"}],"standard_charges":[{"gross_charge":6132.0,"discounted_cash":3372.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Thoracostomy W Tube Open","code_information":[{"code":"803669","type":"CDM"},{"code":"361","type":"RC"},{"code":"32551","type":"HCPCS"}],"standard_charges":[{"gross_charge":2102.0,"discounted_cash":1156.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ct Cardiac Non Coronary Eval","code_information":[{"code":"803690","type":"CDM"},{"code":"350","type":"RC"},{"code":"75572","type":"HCPCS"}],"standard_charges":[{"gross_charge":2807.0,"discounted_cash":1543.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ct Cardiac W Cont Congenital","code_information":[{"code":"803691","type":"CDM"},{"code":"350","type":"RC"},{"code":"75573","type":"HCPCS"}],"standard_charges":[{"gross_charge":2807.0,"discounted_cash":1543.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Inj Facet Jnt C/T Sngl Lvl","code_information":[{"code":"803704","type":"CDM"},{"code":"361","type":"RC"},{"code":"64490","type":"HCPCS"}],"standard_charges":[{"gross_charge":4086.0,"discounted_cash":2247.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ir Perc Trans Mec Thrmb Vein Sub","code_information":[{"code":"803705","type":"CDM"},{"code":"361","type":"RC"},{"code":"37188","type":"HCPCS"}],"standard_charges":[{"gross_charge":4764.0,"discounted_cash":2620.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Nasogastric Tube Plcmnt","code_information":[{"code":"803710","type":"CDM"},{"code":"361","type":"RC"},{"code":"43752","type":"HCPCS"}],"standard_charges":[{"gross_charge":1095.0,"discounted_cash":602.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Perc Augment Sacral Bilat W Guidance","code_information":[{"code":"803717","type":"CDM"},{"code":"361","type":"RC"},{"code":"0201T","type":"HCPCS"}],"standard_charges":[{"gross_charge":11363.0,"discounted_cash":6249.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Lumbar Puncture Drain Wo Ct Fl","code_information":[{"code":"803729","type":"CDM"},{"code":"361","type":"RC"},{"code":"62272","type":"HCPCS"}],"standard_charges":[{"gross_charge":2244.0,"discounted_cash":1234.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Inj Trans Nerve/Epi C/T Bilat Ea Addl","code_information":[{"code":"803732","type":"CDM"},{"code":"361","type":"RC"},{"code":"64480","type":"HCPCS"}],"standard_charges":[{"gross_charge":5735.0,"discounted_cash":3154.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Remove Tunnel Pleural Cath","code_information":[{"code":"803757","type":"CDM"},{"code":"361","type":"RC"},{"code":"32552","type":"HCPCS"}],"standard_charges":[{"gross_charge":1082.0,"discounted_cash":595.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Rmv Perm Intraperitoneal Cath","code_information":[{"code":"803760","type":"CDM"},{"code":"360","type":"RC"},{"code":"49422","type":"HCPCS"}],"standard_charges":[{"gross_charge":11750.0,"discounted_cash":6462.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Mech Rvml Cath Obs Mat Cvad","code_information":[{"code":"803764","type":"CDM"},{"code":"361","type":"RC"},{"code":"36595","type":"HCPCS"}],"standard_charges":[{"gross_charge":5890.0,"discounted_cash":3239.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Us Preg Uterus Follow Up Ea Addl Gest","code_information":[{"code":"803770","type":"CDM"},{"code":"402","type":"RC"},{"code":"76816","type":"HCPCS"}],"standard_charges":[{"gross_charge":744.0,"discounted_cash":409.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Plcmt Mark Perq Abd Pelv","code_information":[{"code":"803802","type":"CDM"},{"code":"360","type":"RC"},{"code":"49411","type":"HCPCS"}],"standard_charges":[{"gross_charge":2299.0,"discounted_cash":1264.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Rmvl Electrd Sng/Dl Defib Via Tv Extract","code_information":[{"code":"803805","type":"CDM"},{"code":"481","type":"RC"},{"code":"33244","type":"HCPCS"}],"standard_charges":[{"gross_charge":4168.0,"discounted_cash":2292.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Insert Gastro Tube Perc W/Fluoro","code_information":[{"code":"803806","type":"CDM"},{"code":"361","type":"RC"},{"code":"49440","type":"HCPCS"}],"standard_charges":[{"gross_charge":2026.0,"discounted_cash":1114.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Design Mlc Device For Imrt","code_information":[{"code":"803807","type":"CDM"},{"code":"333","type":"RC"},{"code":"77338","type":"HCPCS"}],"standard_charges":[{"gross_charge":4226.0,"discounted_cash":2324.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Humerus Reduced Service","code_information":[{"code":"803816","type":"CDM"},{"code":"320","type":"RC"},{"code":"73060","type":"HCPCS"}],"standard_charges":[{"gross_charge":553.0,"discounted_cash":304.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Wrist 2 Vw Reduced Service","code_information":[{"code":"803818","type":"CDM"},{"code":"320","type":"RC"},{"code":"73100","type":"HCPCS"}],"standard_charges":[{"gross_charge":553.0,"discounted_cash":304.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Foot 2 Vw Reduced Service","code_information":[{"code":"803826","type":"CDM"},{"code":"320","type":"RC"},{"code":"73620","type":"HCPCS"}],"standard_charges":[{"gross_charge":553.0,"discounted_cash":304.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Plcmt Mark Perq Thoracic","code_information":[{"code":"803852","type":"CDM"},{"code":"361","type":"RC"},{"code":"32553","type":"HCPCS"}],"standard_charges":[{"gross_charge":2354.0,"discounted_cash":1294.7,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Inj Eval Shunt Peritoneal Venous","code_information":[{"code":"803854","type":"CDM"},{"code":"361","type":"RC"},{"code":"49427","type":"HCPCS"}],"standard_charges":[{"gross_charge":112.0,"discounted_cash":61.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Noncdm Charge Record","code_information":[{"code":"803855","type":"CDM"},{"code":"361","type":"RC"},{"code":"52351","type":"HCPCS"}],"standard_charges":[{"gross_charge":2374.8,"discounted_cash":1306.14,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Hc Aspirate Or Inject Cyst Thyroid","code_information":[{"code":"803857","type":"CDM"},{"code":"361","type":"RC"},{"code":"60300","type":"HCPCS"}],"standard_charges":[{"gross_charge":1340.0,"discounted_cash":737.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Destr Celiac Plexus W Neuro","code_information":[{"code":"803858","type":"CDM"},{"code":"361","type":"RC"},{"code":"64680","type":"HCPCS"}],"standard_charges":[{"gross_charge":2848.0,"discounted_cash":1566.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Inj Iobenguane I-123 Dx To 15 Mci","code_information":[{"code":"803886","type":"CDM"},{"code":"343","type":"RC"},{"code":"A9582","type":"HCPCS"}],"standard_charges":[{"gross_charge":4894.0,"discounted_cash":2691.7,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ivc Filter Removal","code_information":[{"code":"803945","type":"CDM"},{"code":"361","type":"RC"},{"code":"37193","type":"HCPCS"}],"standard_charges":[{"gross_charge":5277.0,"discounted_cash":2902.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Nm Lung Quant Perf Only","code_information":[{"code":"803947","type":"CDM"},{"code":"341","type":"RC"},{"code":"78597","type":"HCPCS"}],"standard_charges":[{"gross_charge":3520.0,"discounted_cash":1936.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ct Angio Abdomen Pelvis W Wo Con","code_information":[{"code":"803948","type":"CDM"},{"code":"352","type":"RC"},{"code":"74174","type":"HCPCS"}],"standard_charges":[{"gross_charge":3079.0,"discounted_cash":1693.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ct Colonography Diag W Contrast","code_information":[{"code":"803954","type":"CDM"},{"code":"352","type":"RC"},{"code":"74262","type":"HCPCS"}],"standard_charges":[{"gross_charge":2997.0,"discounted_cash":1648.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Parathyroid Planar W Spect & Ct","code_information":[{"code":"803964","type":"CDM"},{"code":"341","type":"RC"},{"code":"78072","type":"HCPCS"}],"standard_charges":[{"gross_charge":3520.0,"discounted_cash":1936.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Unlisted Procedure Abd Peritoneum","code_information":[{"code":"804007","type":"CDM"},{"code":"361","type":"RC"},{"code":"49999","type":"HCPCS"}],"standard_charges":[{"gross_charge":3694.0,"discounted_cash":2031.7,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Trazodone HCl Tab 100 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"8083","type":"CDM"},{"code":"60687045401","type":"NDC"}],"standard_charges":[{"gross_charge":8.99,"discounted_cash":4.94,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Trazodone HCl Tab 100 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"8083","type":"CDM"},{"code":"60687045411","type":"NDC"}],"standard_charges":[{"gross_charge":8.99,"discounted_cash":4.94,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Trazodone HCl Tab 150 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"8084","type":"CDM"},{"code":"50268077611","type":"NDC"}],"standard_charges":[{"gross_charge":13.66,"discounted_cash":7.51,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Trazodone HCl Tab 150 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"8084","type":"CDM"},{"code":"50268077615","type":"NDC"}],"standard_charges":[{"gross_charge":13.66,"discounted_cash":7.51,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Trazodone HCl Tab 50 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"8085","type":"CDM"},{"code":"904686861","type":"NDC"}],"standard_charges":[{"gross_charge":8.66,"discounted_cash":4.76,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Hydrochlorothiazide Tab 12.5 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"80852","type":"CDM"},{"code":"23155076401","type":"NDC"}],"standard_charges":[{"gross_charge":11.67,"discounted_cash":6.42,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Noncdm Charge Record","code_information":[{"code":"8100019","type":"CDM"},{"code":"361","type":"RC"},{"code":"51728","type":"HCPCS"}],"standard_charges":[{"gross_charge":1359.6,"discounted_cash":747.78,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Hc Applic Unna Boot","code_information":[{"code":"810002","type":"CDM"},{"code":"361","type":"RC"},{"code":"29580","type":"HCPCS"}],"standard_charges":[{"gross_charge":650.0,"discounted_cash":357.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Valvuloplasty Perc Balloon Mitral","code_information":[{"code":"8100029","type":"CDM"},{"code":"481","type":"RC"},{"code":"92987","type":"HCPCS"}],"standard_charges":[{"gross_charge":19778.0,"discounted_cash":10877.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Interrogate Device Subq Card Rhythm Mon","code_information":[{"code":"8100033","type":"CDM"},{"code":"480","type":"RC"},{"code":"93291","type":"HCPCS"}],"standard_charges":[{"gross_charge":242.0,"discounted_cash":133.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Interr Subq Card Rhythm Remote <=30 Day","code_information":[{"code":"8100034","type":"CDM"},{"code":"480","type":"RC"},{"code":"93298","type":"HCPCS"}],"standard_charges":[{"gross_charge":306.0,"discounted_cash":168.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Cystourethroscopy Ureter Catheter","code_information":[{"code":"8100036","type":"CDM"},{"code":"450","type":"RC"},{"code":"52005","type":"HCPCS"}],"standard_charges":[{"gross_charge":4901.0,"discounted_cash":2695.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Plcmt Endovasc Occlusion Device Iliac","code_information":[{"code":"8100048","type":"CDM"},{"code":"360","type":"RC"},{"code":"34808","type":"HCPCS"}],"standard_charges":[{"gross_charge":4891.0,"discounted_cash":2690.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Blood Transfusion Service","code_information":[{"code":"810006","type":"CDM"},{"code":"391","type":"RC"},{"code":"36430","type":"HCPCS"}],"standard_charges":[{"gross_charge":999.0,"discounted_cash":549.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Collection Blood Capillary Specimen","code_information":[{"code":"810008","type":"CDM"},{"code":"300","type":"RC"},{"code":"36416","type":"HCPCS"}],"standard_charges":[{"gross_charge":27.0,"discounted_cash":14.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Xofigo Ra223 Per Uci","code_information":[{"code":"8100086","type":"CDM"},{"code":"344","type":"RC"},{"code":"A9606","type":"HCPCS"}],"standard_charges":[{"gross_charge":285.0,"discounted_cash":156.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ablate Tumor Bone Radiofreq Perc W Guide","code_information":[{"code":"8100088","type":"CDM"},{"code":"361","type":"RC"},{"code":"20982","type":"HCPCS"}],"standard_charges":[{"gross_charge":16142.0,"discounted_cash":8878.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Strapping Knee Pt","code_information":[{"code":"8100090","type":"CDM"},{"code":"420","type":"RC"},{"code":"29530","type":"HCPCS"}],"standard_charges":[{"gross_charge":486.0,"discounted_cash":267.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Debrid Of Nail(S) 1-5","code_information":[{"code":"810013","type":"CDM"},{"code":"361","type":"RC"},{"code":"11720","type":"HCPCS"}],"standard_charges":[{"gross_charge":392.0,"discounted_cash":215.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Debrid Of Nails 6 Or More","code_information":[{"code":"810014","type":"CDM"},{"code":"361","type":"RC"},{"code":"11721","type":"HCPCS"}],"standard_charges":[{"gross_charge":392.0,"discounted_cash":215.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Debride Subq Tissue 1St 20 Cm Or Less","code_information":[{"code":"810017","type":"CDM"},{"code":"361","type":"RC"},{"code":"11042","type":"HCPCS"}],"standard_charges":[{"gross_charge":1503.0,"discounted_cash":826.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Device Flutter Valve Acapella","code_information":[{"code":"8100172","type":"CDM"},{"code":"270","type":"RC"}],"standard_charges":[{"gross_charge":158.05,"discounted_cash":86.93,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."},{"gross_charge":158.2,"discounted_cash":87.01,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."},{"gross_charge":158.02,"discounted_cash":86.91,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Hc Debride Musc Fascia 1St 20 Cm Or Less","code_information":[{"code":"810018","type":"CDM"},{"code":"361","type":"RC"},{"code":"11043","type":"HCPCS"}],"standard_charges":[{"gross_charge":1505.0,"discounted_cash":827.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Debride Bone 1St 20 Cm Or Less","code_information":[{"code":"810019","type":"CDM"},{"code":"361","type":"RC"},{"code":"11044","type":"HCPCS"}],"standard_charges":[{"gross_charge":3569.0,"discounted_cash":1962.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Esophageal Motility Study","code_information":[{"code":"810027","type":"CDM"},{"code":"750","type":"RC"},{"code":"91010","type":"HCPCS"}],"standard_charges":[{"gross_charge":2344.0,"discounted_cash":1289.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Unlisted Procedure Nervous System","code_information":[{"code":"8100280","type":"CDM"},{"code":"450","type":"RC"},{"code":"64999","type":"HCPCS"}],"standard_charges":[{"gross_charge":822.0,"discounted_cash":452.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Noncdm Charge Record","code_information":[{"code":"810029","type":"CDM"},{"code":"361","type":"RC"},{"code":"11400","type":"HCPCS"}],"standard_charges":[{"gross_charge":326.0,"discounted_cash":179.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Hc I&D Hematoma Seroma Fluid","code_information":[{"code":"810038","type":"CDM"},{"code":"361","type":"RC"},{"code":"10140","type":"HCPCS"}],"standard_charges":[{"gross_charge":5368.0,"discounted_cash":2952.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Iv Inf Hydration Init 31 Min To 1Hr","code_information":[{"code":"810045","type":"CDM"},{"code":"260","type":"RC"},{"code":"96360","type":"HCPCS"}],"standard_charges":[{"gross_charge":464.0,"discounted_cash":255.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Iv Inf Hydration Ea Addl Hr","code_information":[{"code":"810046","type":"CDM"},{"code":"260","type":"RC"},{"code":"96361","type":"HCPCS"}],"standard_charges":[{"gross_charge":228.0,"discounted_cash":125.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Iv Inf Ther/Proph/Diag 1St Hr","code_information":[{"code":"810047","type":"CDM"},{"code":"260","type":"RC"},{"code":"96365","type":"HCPCS"}],"standard_charges":[{"gross_charge":477.0,"discounted_cash":262.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Iv Inf Ther/Proph/Diag Ea Addl Hr","code_information":[{"code":"810048","type":"CDM"},{"code":"260","type":"RC"},{"code":"96366","type":"HCPCS"}],"standard_charges":[{"gross_charge":240.0,"discounted_cash":132.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Drain Pleura W Cath Wo Imaging","code_information":[{"code":"8100490","type":"CDM"},{"code":"450","type":"RC"},{"code":"32556","type":"HCPCS"}],"standard_charges":[{"gross_charge":2613.0,"discounted_cash":1437.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Unlisted Procedure Lungs And Pleura","code_information":[{"code":"8100584","type":"CDM"},{"code":"360","type":"RC"},{"code":"32999","type":"HCPCS"}],"standard_charges":[{"gross_charge":955.0,"discounted_cash":525.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Office Outpt Visit Est Level 4","code_information":[{"code":"810059","type":"CDM"},{"code":"510","type":"RC"},{"code":"99214","type":"HCPCS"}],"standard_charges":[{"gross_charge":383.0,"discounted_cash":210.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"},{"gross_charge":146.0,"discounted_cash":80.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Op Bhs Fsc 3252"}]},{"description":"Hc Office Outpt Visit Est Level 5","code_information":[{"code":"810060","type":"CDM"},{"code":"761","type":"RC"},{"code":"99215","type":"HCPCS"}],"standard_charges":[{"gross_charge":411.0,"discounted_cash":226.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"},{"gross_charge":164.0,"discounted_cash":90.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Op Bhs Fsc 3252"}]},{"description":"Hc Faclty Op New Level 2","code_information":[{"code":"810062","type":"CDM"},{"code":"761","type":"RC"},{"code":"99202","type":"HCPCS"}],"standard_charges":[{"gross_charge":383.0,"discounted_cash":210.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"},{"gross_charge":97.0,"discounted_cash":53.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Op Bhs Fsc 3252"}]},{"description":"Hc Faclty Op New Level 3","code_information":[{"code":"810063","type":"CDM"},{"code":"761","type":"RC"},{"code":"99203","type":"HCPCS"}],"standard_charges":[{"gross_charge":404.0,"discounted_cash":222.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"},{"gross_charge":119.0,"discounted_cash":65.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Op Bhs Fsc 3252"}]},{"description":"Hc Remv Nail Plate Part Or Cmplt Sngl","code_information":[{"code":"810071","type":"CDM"},{"code":"361","type":"RC"},{"code":"11730","type":"HCPCS"}],"standard_charges":[{"gross_charge":435.0,"discounted_cash":239.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Lab O2 Saturation Poct (Ip) Beaker","code_information":[{"code":"8100711","type":"CDM"},{"code":"301","type":"RC"},{"code":"82810","type":"HCPCS"}],"standard_charges":[{"gross_charge":99.0,"discounted_cash":54.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Noncdm Charge Record","code_information":[{"code":"8100714","type":"CDM"},{"code":"361","type":"RC"},{"code":"11981","type":"HCPCS"}],"standard_charges":[{"gross_charge":402.0,"discounted_cash":221.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Hc Rpr Sclp/Trnk/Extrm Intrmd 2.6-7.5 Cm","code_information":[{"code":"810073","type":"CDM"},{"code":"361","type":"RC"},{"code":"12032","type":"HCPCS"}],"standard_charges":[{"gross_charge":1165.0,"discounted_cash":640.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Remove Foreign Body Thigh/Knee","code_information":[{"code":"8100798","type":"CDM"},{"code":"450","type":"RC"},{"code":"27372","type":"HCPCS"}],"standard_charges":[{"gross_charge":9619.0,"discounted_cash":5290.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Trim Hyperkeratotic Skin Lesion 2-4","code_information":[{"code":"810080","type":"CDM"},{"code":"361","type":"RC"},{"code":"11056","type":"HCPCS"}],"standard_charges":[{"gross_charge":529.0,"discounted_cash":290.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Bx Breast Perc 1St Lesn Stereotct","code_information":[{"code":"8100802","type":"CDM"},{"code":"361","type":"RC"},{"code":"19081","type":"HCPCS"}],"standard_charges":[{"gross_charge":4387.0,"discounted_cash":2412.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Bx Breast Perc Ea Addl Lsn Sterotct","code_information":[{"code":"8100803","type":"CDM"},{"code":"361","type":"RC"},{"code":"19082","type":"HCPCS"}],"standard_charges":[{"gross_charge":431.0,"discounted_cash":237.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Bx Breast Perc 1St Lesn Us","code_information":[{"code":"8100804","type":"CDM"},{"code":"361","type":"RC"},{"code":"19083","type":"HCPCS"}],"standard_charges":[{"gross_charge":4387.0,"discounted_cash":2412.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Bx Breast Perc Ea Addl Lesn Us","code_information":[{"code":"8100805","type":"CDM"},{"code":"361","type":"RC"},{"code":"19084","type":"HCPCS"}],"standard_charges":[{"gross_charge":431.0,"discounted_cash":237.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Bx Breast Perc 1St Lesn Mri","code_information":[{"code":"8100806","type":"CDM"},{"code":"361","type":"RC"},{"code":"19085","type":"HCPCS"}],"standard_charges":[{"gross_charge":4387.0,"discounted_cash":2412.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Bx Breast Perc Ea Addl Lesn Mri","code_information":[{"code":"8100807","type":"CDM"},{"code":"361","type":"RC"},{"code":"19086","type":"HCPCS"}],"standard_charges":[{"gross_charge":431.0,"discounted_cash":237.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Plcmt Breast Local Perc 1St Lsn Mamm","code_information":[{"code":"8100808","type":"CDM"},{"code":"361","type":"RC"},{"code":"19281","type":"HCPCS"}],"standard_charges":[{"gross_charge":1188.0,"discounted_cash":653.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Plcmt Breast Local Perc Ea Addl Lsn Mamm","code_information":[{"code":"8100809","type":"CDM"},{"code":"361","type":"RC"},{"code":"19282","type":"HCPCS"}],"standard_charges":[{"gross_charge":495.0,"discounted_cash":272.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Trim Hyperkeratotic Skin Lesion Sngl","code_information":[{"code":"810081","type":"CDM"},{"code":"361","type":"RC"},{"code":"11055","type":"HCPCS"}],"standard_charges":[{"gross_charge":484.0,"discounted_cash":266.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Plcmt Breast Local Perc 1St Lsn Stereo","code_information":[{"code":"8100810","type":"CDM"},{"code":"361","type":"RC"},{"code":"19283","type":"HCPCS"}],"standard_charges":[{"gross_charge":1188.0,"discounted_cash":653.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Plcmt Breast Local Perc Addl Lsn Stereo","code_information":[{"code":"8100811","type":"CDM"},{"code":"361","type":"RC"},{"code":"19284","type":"HCPCS"}],"standard_charges":[{"gross_charge":524.0,"discounted_cash":288.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Plcmt Breast Local Perc 1St Lsn Us","code_information":[{"code":"8100812","type":"CDM"},{"code":"361","type":"RC"},{"code":"19285","type":"HCPCS"}],"standard_charges":[{"gross_charge":1188.0,"discounted_cash":653.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Plcmt Breast Local Perc Ea Addl Lsn Us","code_information":[{"code":"8100813","type":"CDM"},{"code":"361","type":"RC"},{"code":"19286","type":"HCPCS"}],"standard_charges":[{"gross_charge":522.0,"discounted_cash":287.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Plcmt Breast Local Perc 1St Lsn Mri","code_information":[{"code":"8100814","type":"CDM"},{"code":"361","type":"RC"},{"code":"19287","type":"HCPCS"}],"standard_charges":[{"gross_charge":1188.0,"discounted_cash":653.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Plcmt Breast Local Perc Ea Addl Lsn Mri","code_information":[{"code":"8100815","type":"CDM"},{"code":"361","type":"RC"},{"code":"19288","type":"HCPCS"}],"standard_charges":[{"gross_charge":522.0,"discounted_cash":287.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Plcmt Vasc Stent Trancath Init Art Upper","code_information":[{"code":"8100817","type":"CDM"},{"code":"360","type":"RC"},{"code":"37236","type":"HCPCS"}],"standard_charges":[{"gross_charge":25235.0,"discounted_cash":13879.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Plcmt Vasc Stent Trancath Addl Art Upper","code_information":[{"code":"8100818","type":"CDM"},{"code":"360","type":"RC"},{"code":"37237","type":"HCPCS"}],"standard_charges":[{"gross_charge":13787.0,"discounted_cash":7582.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Plcmt Vasc Stent Transcath Initial Vein","code_information":[{"code":"8100819","type":"CDM"},{"code":"360","type":"RC"},{"code":"37238","type":"HCPCS"}],"standard_charges":[{"gross_charge":24004.0,"discounted_cash":13202.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Plcmt Vasc Stent Transcath Ea Add Vein","code_information":[{"code":"8100820","type":"CDM"},{"code":"360","type":"RC"},{"code":"37239","type":"HCPCS"}],"standard_charges":[{"gross_charge":12045.0,"discounted_cash":6624.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Emboliz Vein  W Image Non Hemorrhage","code_information":[{"code":"8100821","type":"CDM"},{"code":"360","type":"RC"},{"code":"37241","type":"HCPCS"}],"standard_charges":[{"gross_charge":16955.0,"discounted_cash":9325.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Emboliz Artery W Image Non Hemorrhage","code_information":[{"code":"8100822","type":"CDM"},{"code":"360","type":"RC"},{"code":"37242","type":"HCPCS"}],"standard_charges":[{"gross_charge":14603.0,"discounted_cash":8031.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Emboliz Vascular W Image Tumor Ischemia","code_information":[{"code":"8100823","type":"CDM"},{"code":"360","type":"RC"},{"code":"37243","type":"HCPCS"}],"standard_charges":[{"gross_charge":16711.0,"discounted_cash":9191.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Emboliz Art Or Vein Hemorrhage W Image","code_information":[{"code":"8100824","type":"CDM"},{"code":"360","type":"RC"},{"code":"37244","type":"HCPCS"}],"standard_charges":[{"gross_charge":17378.0,"discounted_cash":9557.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Img Guide Drain W Cath Visceral Perc","code_information":[{"code":"8100827","type":"CDM"},{"code":"361","type":"RC"},{"code":"49405","type":"HCPCS"}],"standard_charges":[{"gross_charge":5246.0,"discounted_cash":2885.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Img Guide Drain W Cath Periton Perc","code_information":[{"code":"8100828","type":"CDM"},{"code":"361","type":"RC"},{"code":"49406","type":"HCPCS"}],"standard_charges":[{"gross_charge":5209.0,"discounted_cash":2864.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Chemodenerv Musc Neck Unilateral","code_information":[{"code":"8100829","type":"CDM"},{"code":"361","type":"RC"},{"code":"64616","type":"HCPCS"}],"standard_charges":[{"gross_charge":1743.0,"discounted_cash":958.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Chemodenerv One Extrem 1-4 Muscles","code_information":[{"code":"8100830","type":"CDM"},{"code":"361","type":"RC"},{"code":"64642","type":"HCPCS"}],"standard_charges":[{"gross_charge":1979.0,"discounted_cash":1088.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Chemodenerv Ea Addl Extrem >=5 Musc","code_information":[{"code":"8100833","type":"CDM"},{"code":"361","type":"RC"},{"code":"64645","type":"HCPCS"}],"standard_charges":[{"gross_charge":2639.0,"discounted_cash":1451.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Chemodenerv Trunk  1-5 Muscles","code_information":[{"code":"8100834","type":"CDM"},{"code":"361","type":"RC"},{"code":"64646","type":"HCPCS"}],"standard_charges":[{"gross_charge":1979.0,"discounted_cash":1088.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Chemodenerv Trunk >=6 Muscles","code_information":[{"code":"8100835","type":"CDM"},{"code":"361","type":"RC"},{"code":"64647","type":"HCPCS"}],"standard_charges":[{"gross_charge":2505.0,"discounted_cash":1377.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Eval Speech Fluency 15 Min","code_information":[{"code":"8100837","type":"CDM"},{"code":"444","type":"RC"},{"code":"92521","type":"HCPCS"}],"standard_charges":[{"gross_charge":582.0,"discounted_cash":320.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Eval Speech Fluency 30 Min","code_information":[{"code":"8100838","type":"CDM"},{"code":"444","type":"RC"},{"code":"92521","type":"HCPCS"}],"standard_charges":[{"gross_charge":582.0,"discounted_cash":320.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Eval Speech Fluency 45 Min","code_information":[{"code":"8100839","type":"CDM"},{"code":"444","type":"RC"},{"code":"92521","type":"HCPCS"}],"standard_charges":[{"gross_charge":582.0,"discounted_cash":320.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Eval Speech Fluency 60 Min","code_information":[{"code":"8100840","type":"CDM"},{"code":"444","type":"RC"},{"code":"92521","type":"HCPCS"}],"standard_charges":[{"gross_charge":582.0,"discounted_cash":320.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Eval Speech Sound Production 15 Min","code_information":[{"code":"8100842","type":"CDM"},{"code":"444","type":"RC"},{"code":"92522","type":"HCPCS"}],"standard_charges":[{"gross_charge":448.0,"discounted_cash":246.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Eval Speech Sound Production 30 Min","code_information":[{"code":"8100843","type":"CDM"},{"code":"444","type":"RC"},{"code":"92522","type":"HCPCS"}],"standard_charges":[{"gross_charge":538.0,"discounted_cash":295.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Eval Speech Sound Production 45 Min","code_information":[{"code":"8100844","type":"CDM"},{"code":"444","type":"RC"},{"code":"92522","type":"HCPCS"}],"standard_charges":[{"gross_charge":627.0,"discounted_cash":344.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Eval Speech Sound Production 60 Min","code_information":[{"code":"8100845","type":"CDM"},{"code":"444","type":"RC"},{"code":"92522","type":"HCPCS"}],"standard_charges":[{"gross_charge":717.0,"discounted_cash":394.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Eval Speech Sound Prod W Lang 15 Min","code_information":[{"code":"8100847","type":"CDM"},{"code":"444","type":"RC"},{"code":"92523","type":"HCPCS"}],"standard_charges":[{"gross_charge":1036.0,"discounted_cash":569.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Eval Speech Sound Prod W Lang 30 Min","code_information":[{"code":"8100848","type":"CDM"},{"code":"444","type":"RC"},{"code":"92523","type":"HCPCS"}],"standard_charges":[{"gross_charge":1036.0,"discounted_cash":569.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Eval Speech Sound Prod W Lang 45 Min","code_information":[{"code":"8100849","type":"CDM"},{"code":"444","type":"RC"},{"code":"92523","type":"HCPCS"}],"standard_charges":[{"gross_charge":1036.0,"discounted_cash":569.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Eval Speech Sound Prod W Lang 60 Min","code_information":[{"code":"8100850","type":"CDM"},{"code":"444","type":"RC"},{"code":"92523","type":"HCPCS"}],"standard_charges":[{"gross_charge":1036.0,"discounted_cash":569.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Eval Speech Sound Prod W Lang 75 Min","code_information":[{"code":"8100851","type":"CDM"},{"code":"444","type":"RC"},{"code":"92523","type":"HCPCS"}],"standard_charges":[{"gross_charge":1036.0,"discounted_cash":569.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Eval Speech Sound Prod W Lang 90 Min","code_information":[{"code":"8100852","type":"CDM"},{"code":"444","type":"RC"},{"code":"92523","type":"HCPCS"}],"standard_charges":[{"gross_charge":1036.0,"discounted_cash":569.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ans General","code_information":[{"code":"810086","type":"CDM"},{"code":"370","type":"RC"}],"standard_charges":[{"gross_charge":3596.0,"discounted_cash":1977.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Behav And Qual Analysis For Voice 15 Min","code_information":[{"code":"8100860","type":"CDM"},{"code":"444","type":"RC"},{"code":"92524","type":"HCPCS"}],"standard_charges":[{"gross_charge":518.0,"discounted_cash":284.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Behav And Qual Analysis For Voice 30 Min","code_information":[{"code":"8100861","type":"CDM"},{"code":"444","type":"RC"},{"code":"92524","type":"HCPCS"}],"standard_charges":[{"gross_charge":518.0,"discounted_cash":284.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Behav And Qual Analysis For Voice 45 Min","code_information":[{"code":"8100862","type":"CDM"},{"code":"444","type":"RC"},{"code":"92524","type":"HCPCS"}],"standard_charges":[{"gross_charge":518.0,"discounted_cash":284.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Behav And Qual Analysis For Voice 60 Min","code_information":[{"code":"8100863","type":"CDM"},{"code":"444","type":"RC"},{"code":"92524","type":"HCPCS"}],"standard_charges":[{"gross_charge":518.0,"discounted_cash":284.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Img Guide Drain W Cath Sft Tiss Perc","code_information":[{"code":"8100866","type":"CDM"},{"code":"361","type":"RC"},{"code":"10030","type":"HCPCS"}],"standard_charges":[{"gross_charge":6266.0,"discounted_cash":3446.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Img Guide Drain W Cath Perit Vag Rectal","code_information":[{"code":"8100867","type":"CDM"},{"code":"361","type":"RC"},{"code":"49407","type":"HCPCS"}],"standard_charges":[{"gross_charge":4599.0,"discounted_cash":2529.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Resp Motion Mgmt Simulation","code_information":[{"code":"8100869","type":"CDM"},{"code":"333","type":"RC"},{"code":"77293","type":"HCPCS"}],"standard_charges":[{"gross_charge":2944.0,"discounted_cash":1619.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Oscillation Chest Wall Mech Per Session","code_information":[{"code":"8100872","type":"CDM"},{"code":"410","type":"RC"},{"code":"94669","type":"HCPCS"}],"standard_charges":[{"gross_charge":193.0,"discounted_cash":106.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc App Skin Sub Low T/A/L <100Cm 1St 25Cm","code_information":[{"code":"8100875","type":"CDM"},{"code":"361","type":"RC"},{"code":"C5271","type":"HCPCS"}],"standard_charges":[{"gross_charge":2622.0,"discounted_cash":1442.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc App Skin Sub Low T/A/L <100Cm Addl 25Cm","code_information":[{"code":"8100876","type":"CDM"},{"code":"361","type":"RC"},{"code":"C5272","type":"HCPCS"}],"standard_charges":[{"gross_charge":562.0,"discounted_cash":309.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc App Skin Sub Low T/A/L >100Cm 1St 100Cm","code_information":[{"code":"8100877","type":"CDM"},{"code":"361","type":"RC"},{"code":"C5273","type":"HCPCS"}],"standard_charges":[{"gross_charge":5429.0,"discounted_cash":2985.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc App Skin Sub Low T/A/L >100Cm Add 100Cm","code_information":[{"code":"8100878","type":"CDM"},{"code":"361","type":"RC"},{"code":"C5274","type":"HCPCS"}],"standard_charges":[{"gross_charge":1808.0,"discounted_cash":994.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc App Skin Sub Low F/S/H <100 Cm 1St 25","code_information":[{"code":"8100879","type":"CDM"},{"code":"361","type":"RC"},{"code":"C5275","type":"HCPCS"}],"standard_charges":[{"gross_charge":2496.0,"discounted_cash":1372.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Anesthesia Mac","code_information":[{"code":"810088","type":"CDM"},{"code":"370","type":"RC"}],"standard_charges":[{"gross_charge":3330.0,"discounted_cash":1831.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc App Skin Sub Low F/S/H <100Cm Add 25Cm","code_information":[{"code":"8100880","type":"CDM"},{"code":"361","type":"RC"},{"code":"C5276","type":"HCPCS"}],"standard_charges":[{"gross_charge":587.0,"discounted_cash":322.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc App Skin Sub Low F/S/H >100Cm 1St 100Cm","code_information":[{"code":"8100881","type":"CDM"},{"code":"361","type":"RC"},{"code":"C5277","type":"HCPCS"}],"standard_charges":[{"gross_charge":5482.0,"discounted_cash":3015.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Hosp Op Clinic Visit Assessment","code_information":[{"code":"8100883","type":"CDM"},{"code":"761","type":"RC"},{"code":"G0463","type":"HCPCS"}],"standard_charges":[{"gross_charge":315.0,"discounted_cash":173.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Chemodenerv Musc Neck Bilateral","code_information":[{"code":"8100884","type":"CDM"},{"code":"361","type":"RC"},{"code":"64616","type":"HCPCS"}],"standard_charges":[{"gross_charge":3483.0,"discounted_cash":1915.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Srs Cranial 1 Sess Cmplt Linear Accel","code_information":[{"code":"8100990","type":"CDM"},{"code":"333","type":"RC"},{"code":"77372","type":"HCPCS"}],"standard_charges":[{"gross_charge":14600.0,"discounted_cash":8030.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Sbrt Per Fraction <= 5 Fractions W Img","code_information":[{"code":"8100991","type":"CDM"},{"code":"333","type":"RC"},{"code":"77373","type":"HCPCS"}],"standard_charges":[{"gross_charge":10717.0,"discounted_cash":5894.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Recovery Charge Phase 2","code_information":[{"code":"8100993","type":"CDM"},{"code":"710","type":"RC"}],"standard_charges":[{"gross_charge":4.35,"discounted_cash":2.39,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Dplr Color Flow Velocity Map","code_information":[{"code":"810108","type":"CDM"},{"code":"483","type":"RC"},{"code":"93325","type":"HCPCS"}],"standard_charges":[{"gross_charge":829.0,"discounted_cash":455.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Dplr Heart Lmtd","code_information":[{"code":"810110","type":"CDM"},{"code":"483","type":"RC"},{"code":"93321","type":"HCPCS"}],"standard_charges":[{"gross_charge":326.0,"discounted_cash":179.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ecg Monitor Up To 48 Hrs Recording","code_information":[{"code":"810112","type":"CDM"},{"code":"731","type":"RC"},{"code":"93225","type":"HCPCS"}],"standard_charges":[{"gross_charge":840.0,"discounted_cash":462.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ecg Monitor Up To 48Hrs Scan W Report","code_information":[{"code":"810113","type":"CDM"},{"code":"731","type":"RC"},{"code":"93226","type":"HCPCS"}],"standard_charges":[{"gross_charge":2185.0,"discounted_cash":1201.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Tc99 Tilmanocept Diag 0.5Mci","code_information":[{"code":"8101133","type":"CDM"},{"code":"343","type":"RC"},{"code":"A9520","type":"HCPCS"}],"standard_charges":[{"gross_charge":558.0,"discounted_cash":306.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Noncdm Charge Record","code_information":[{"code":"8101135","type":"CDM"},{"code":"361","type":"RC"},{"code":"11983","type":"HCPCS"}],"standard_charges":[{"gross_charge":686.4,"discounted_cash":377.52,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Hc Tee Complete Wo Contrast","code_information":[{"code":"810120","type":"CDM"},{"code":"483","type":"RC"},{"code":"93312","type":"HCPCS"}],"standard_charges":[{"gross_charge":2106.0,"discounted_cash":1158.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Tte Follow Up Or Limited Wo Contrast","code_information":[{"code":"810123","type":"CDM"},{"code":"483","type":"RC"},{"code":"93308","type":"HCPCS"}],"standard_charges":[{"gross_charge":920.0,"discounted_cash":506.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Noncdm Charge Record","code_information":[{"code":"8101272","type":"CDM"},{"code":"940","type":"RC"},{"code":"99199","type":"HCPCS"}],"standard_charges":[{"gross_charge":373.0,"discounted_cash":205.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Noncdm Charge Record","code_information":[{"code":"810131","type":"CDM"},{"code":"483","type":"RC"},{"code":"93303","type":"HCPCS"}],"standard_charges":[{"gross_charge":2180.0,"discounted_cash":1199.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Hc Lab Glucose Poct Pbb Bill","code_information":[{"code":"8101319","type":"CDM"},{"code":"301","type":"RC"},{"code":"82962","type":"HCPCS"}],"standard_charges":[{"gross_charge":46.0,"discounted_cash":25.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Echo Tte Cong Anom Cmplt","code_information":[{"code":"810132","type":"CDM"},{"code":"483","type":"RC"},{"code":"93303","type":"HCPCS"}],"standard_charges":[{"gross_charge":2180.0,"discounted_cash":1199.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Echo Transthoracic Cong Anom Lmtd","code_information":[{"code":"810133","type":"CDM"},{"code":"483","type":"RC"},{"code":"93304","type":"HCPCS"}],"standard_charges":[{"gross_charge":1569.0,"discounted_cash":862.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ekg 12 Lead","code_information":[{"code":"810136","type":"CDM"},{"code":"730","type":"RC"},{"code":"93005","type":"HCPCS"}],"standard_charges":[{"gross_charge":312.0,"discounted_cash":171.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Eval Device Program Subq Card Rhythm Mon","code_information":[{"code":"810138","type":"CDM"},{"code":"480","type":"RC"},{"code":"93285","type":"HCPCS"}],"standard_charges":[{"gross_charge":166.0,"discounted_cash":91.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Event Recording Ekg Remote Up To 30 Days","code_information":[{"code":"810139","type":"CDM"},{"code":"731","type":"RC"},{"code":"93270","type":"HCPCS"}],"standard_charges":[{"gross_charge":635.0,"discounted_cash":349.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Dilate Esophagus Sound Or Bougie","code_information":[{"code":"8101471","type":"CDM"},{"code":"361","type":"RC"},{"code":"43450","type":"HCPCS"}],"standard_charges":[{"gross_charge":4152.0,"discounted_cash":2283.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Tx Disloc Metatarsophal Closed W Anes","code_information":[{"code":"8101475","type":"CDM"},{"code":"450","type":"RC"},{"code":"28635","type":"HCPCS"}],"standard_charges":[{"gross_charge":6079.0,"discounted_cash":3343.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Suture Wound Eyelid Full Thickness","code_information":[{"code":"8101476","type":"CDM"},{"code":"450","type":"RC"},{"code":"67935","type":"HCPCS"}],"standard_charges":[{"gross_charge":7040.0,"discounted_cash":3872.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Pacer Analysis Phone","code_information":[{"code":"810148","type":"CDM"},{"code":"480","type":"RC"},{"code":"93293","type":"HCPCS"}],"standard_charges":[{"gross_charge":154.0,"discounted_cash":84.7,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Lab Differential Manual Pbb Bill","code_information":[{"code":"8101519","type":"CDM"},{"code":"305","type":"RC"},{"code":"85007","type":"HCPCS"}],"standard_charges":[{"gross_charge":13.0,"discounted_cash":7.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Tx Hip Disloc Spontaneous W Anes","code_information":[{"code":"8101573","type":"CDM"},{"code":"450","type":"RC"},{"code":"27257","type":"HCPCS"}],"standard_charges":[{"gross_charge":5731.0,"discounted_cash":3152.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Drainage Absess Skenes Gland","code_information":[{"code":"8101588","type":"CDM"},{"code":"450","type":"RC"},{"code":"53060","type":"HCPCS"}],"standard_charges":[{"gross_charge":5380.0,"discounted_cash":2959.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Tilt Table Eval","code_information":[{"code":"810159","type":"CDM"},{"code":"480","type":"RC"},{"code":"93660","type":"HCPCS"}],"standard_charges":[{"gross_charge":3248.0,"discounted_cash":1786.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Tx Disloc Ip Jt Single Open","code_information":[{"code":"8101590","type":"CDM"},{"code":"450","type":"RC"},{"code":"26785","type":"HCPCS"}],"standard_charges":[{"gross_charge":12359.0,"discounted_cash":6797.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Noncdm Charge Record","code_information":[{"code":"8101664","type":"CDM"},{"code":"361","type":"RC"},{"code":"G0268","type":"HCPCS"}],"standard_charges":[{"gross_charge":254.0,"discounted_cash":139.7,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Hc Polysomn 4 Or More Less Than 6 Hrs","code_information":[{"code":"8101676","type":"CDM"},{"code":"920","type":"RC"},{"code":"95810","type":"HCPCS"}],"standard_charges":[{"gross_charge":5844.0,"discounted_cash":3214.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Angio Extrem Unilat S&I","code_information":[{"code":"810169","type":"CDM"},{"code":"323","type":"RC"},{"code":"75710","type":"HCPCS"}],"standard_charges":[{"gross_charge":11387.0,"discounted_cash":6262.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Trimming Of Dystrophic Nail Any Number","code_information":[{"code":"8101695","type":"CDM"},{"code":"361","type":"RC"},{"code":"G0127","type":"HCPCS"}],"standard_charges":[{"gross_charge":101.0,"discounted_cash":55.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Angio Iliac W/ Card Cath","code_information":[{"code":"810170","type":"CDM"},{"code":"320","type":"RC"},{"code":"G0278","type":"HCPCS"}],"standard_charges":[{"gross_charge":943.0,"discounted_cash":518.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Angio Pelv Select S&I","code_information":[{"code":"810173","type":"CDM"},{"code":"323","type":"RC"},{"code":"75736","type":"HCPCS"}],"standard_charges":[{"gross_charge":3233.0,"discounted_cash":1778.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Implant Pressure Sensor W Angio","code_information":[{"code":"8101740","type":"CDM"},{"code":"481","type":"RC"},{"code":"33289","type":"HCPCS"}],"standard_charges":[{"gross_charge":60335.0,"discounted_cash":33184.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Dexa Assessment Fracture Vertebral","code_information":[{"code":"8101765","type":"CDM"},{"code":"320","type":"RC"},{"code":"77086","type":"HCPCS"}],"standard_charges":[{"gross_charge":313.0,"discounted_cash":172.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Teletherapy Isodose Plan Simple","code_information":[{"code":"8101766","type":"CDM"},{"code":"333","type":"RC"},{"code":"77306","type":"HCPCS"}],"standard_charges":[{"gross_charge":2891.0,"discounted_cash":1590.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Teletherapy Isodose Plan Complex","code_information":[{"code":"8101767","type":"CDM"},{"code":"333","type":"RC"},{"code":"77307","type":"HCPCS"}],"standard_charges":[{"gross_charge":3886.0,"discounted_cash":2137.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Imrt Delivery W Guidance Simple","code_information":[{"code":"8101771","type":"CDM"},{"code":"333","type":"RC"},{"code":"77385","type":"HCPCS"}],"standard_charges":[{"gross_charge":4456.0,"discounted_cash":2450.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Imrt Delivery W Guidance Complex","code_information":[{"code":"8101772","type":"CDM"},{"code":"333","type":"RC"},{"code":"77386","type":"HCPCS"}],"standard_charges":[{"gross_charge":4456.0,"discounted_cash":2450.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Guide For Localization Rad Tx Delivery","code_information":[{"code":"8101773","type":"CDM"},{"code":"333","type":"RC"},{"code":"77387","type":"HCPCS"}],"standard_charges":[{"gross_charge":788.0,"discounted_cash":433.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Rpr Mitral Vlv Transcath Initial Prosth","code_information":[{"code":"8101774","type":"CDM"},{"code":"360","type":"RC"},{"code":"33418","type":"HCPCS"}],"standard_charges":[{"gross_charge":19558.0,"discounted_cash":10756.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Rpr Mitral Vlv Transcath Addl Prosth","code_information":[{"code":"8101775","type":"CDM"},{"code":"360","type":"RC"},{"code":"33419","type":"HCPCS"}],"standard_charges":[{"gross_charge":5660.0,"discounted_cash":3113.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Transcath Stent Thoracic Cca Innominate","code_information":[{"code":"8101776","type":"CDM"},{"code":"360","type":"RC"},{"code":"37218","type":"HCPCS"}],"standard_charges":[{"gross_charge":13138.0,"discounted_cash":7225.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Arthrocentesis Joint Small With Us","code_information":[{"code":"8101777","type":"CDM"},{"code":"361","type":"RC"},{"code":"20604","type":"HCPCS"}],"standard_charges":[{"gross_charge":2087.0,"discounted_cash":1147.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Arthrocentesis Joint Intermed With Us","code_information":[{"code":"8101778","type":"CDM"},{"code":"361","type":"RC"},{"code":"20606","type":"HCPCS"}],"standard_charges":[{"gross_charge":2479.0,"discounted_cash":1363.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Arthrocentesis Joint Major With Us","code_information":[{"code":"8101779","type":"CDM"},{"code":"361","type":"RC"},{"code":"20611","type":"HCPCS"}],"standard_charges":[{"gross_charge":2492.0,"discounted_cash":1370.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Perc Vertebroplsty 1 Bdy Cervicoth W Img","code_information":[{"code":"8101780","type":"CDM"},{"code":"361","type":"RC"},{"code":"22510","type":"HCPCS"}],"standard_charges":[{"gross_charge":8252.0,"discounted_cash":4538.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Perc Vertebroplsty 1 Bdy Lumbosac W Img","code_information":[{"code":"8101781","type":"CDM"},{"code":"361","type":"RC"},{"code":"22511","type":"HCPCS"}],"standard_charges":[{"gross_charge":8252.0,"discounted_cash":4538.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Perc Vertebroplsty Ea Add Lvl C Ls W Img","code_information":[{"code":"8101782","type":"CDM"},{"code":"361","type":"RC"},{"code":"22512","type":"HCPCS"}],"standard_charges":[{"gross_charge":8212.0,"discounted_cash":4516.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Perc Vert Aug Mech 1 Bdy Thorac W Img","code_information":[{"code":"8101783","type":"CDM"},{"code":"361","type":"RC"},{"code":"22513","type":"HCPCS"}],"standard_charges":[{"gross_charge":12736.0,"discounted_cash":7004.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Perc Vert Aug Mech 1 Bdy Lumbar W Img","code_information":[{"code":"8101784","type":"CDM"},{"code":"361","type":"RC"},{"code":"22514","type":"HCPCS"}],"standard_charges":[{"gross_charge":12978.0,"discounted_cash":7137.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Perc Vert Aug Mech Ea Add Lvl T L W Img","code_information":[{"code":"8101785","type":"CDM"},{"code":"361","type":"RC"},{"code":"22515","type":"HCPCS"}],"standard_charges":[{"gross_charge":12346.0,"discounted_cash":6790.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Perc Cryoablation Tumor Liver","code_information":[{"code":"8101786","type":"CDM"},{"code":"361","type":"RC"},{"code":"47383","type":"HCPCS"}],"standard_charges":[{"gross_charge":17325.0,"discounted_cash":9528.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Myelogram Cervical Via Lumbar Injection","code_information":[{"code":"8101787","type":"CDM"},{"code":"361","type":"RC"},{"code":"62302","type":"HCPCS"}],"standard_charges":[{"gross_charge":3836.0,"discounted_cash":2109.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Myelogram Thoracic Via Lumbar Injection","code_information":[{"code":"8101788","type":"CDM"},{"code":"361","type":"RC"},{"code":"62303","type":"HCPCS"}],"standard_charges":[{"gross_charge":4131.0,"discounted_cash":2272.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Myelogram Lumbosac Via Lumbar Injection","code_information":[{"code":"8101789","type":"CDM"},{"code":"361","type":"RC"},{"code":"62304","type":"HCPCS"}],"standard_charges":[{"gross_charge":4277.0,"discounted_cash":2352.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Myelogram 2 Or More Regn Via Lumbar Inj","code_information":[{"code":"8101790","type":"CDM"},{"code":"361","type":"RC"},{"code":"62305","type":"HCPCS"}],"standard_charges":[{"gross_charge":5553.0,"discounted_cash":3054.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Tomosynthesis Digital Breast Dx Unilat","code_information":[{"code":"8101791","type":"CDM"},{"code":"401","type":"RC"},{"code":"77061","type":"HCPCS"}],"standard_charges":[{"gross_charge":35.0,"discounted_cash":19.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Tomosynthesis Digital Breast Dx Bilat","code_information":[{"code":"8101792","type":"CDM"},{"code":"401","type":"RC"},{"code":"77062","type":"HCPCS"}],"standard_charges":[{"gross_charge":35.0,"discounted_cash":19.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Us Breast Unilateral Complete","code_information":[{"code":"8101793","type":"CDM"},{"code":"402","type":"RC"},{"code":"76641","type":"HCPCS"}],"standard_charges":[{"gross_charge":794.0,"discounted_cash":436.7,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Us Breast Unilateral Limited","code_information":[{"code":"8101794","type":"CDM"},{"code":"402","type":"RC"},{"code":"76642","type":"HCPCS"}],"standard_charges":[{"gross_charge":744.0,"discounted_cash":409.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Tomosynthesis Digital Breast Screen Bilat","code_information":[{"code":"8101795","type":"CDM"},{"code":"403","type":"RC"},{"code":"77063","type":"HCPCS"}],"standard_charges":[{"gross_charge":35.0,"discounted_cash":19.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Hyperbaric Oxygen Full Body Per 30 Min","code_information":[{"code":"8101796","type":"CDM"},{"code":"413","type":"RC"},{"code":"G0277","type":"HCPCS"}],"standard_charges":[{"gross_charge":665.0,"discounted_cash":365.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Insert Replc Subq Implant Defib System","code_information":[{"code":"8101797","type":"CDM"},{"code":"481","type":"RC"},{"code":"33270","type":"HCPCS"}],"standard_charges":[{"gross_charge":37940.0,"discounted_cash":20867.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Insert Electrode Subq Implant Defib","code_information":[{"code":"8101798","type":"CDM"},{"code":"481","type":"RC"},{"code":"33271","type":"HCPCS"}],"standard_charges":[{"gross_charge":13350.0,"discounted_cash":7342.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Remove Electrode Subq Implant Defib","code_information":[{"code":"8101799","type":"CDM"},{"code":"481","type":"RC"},{"code":"33272","type":"HCPCS"}],"standard_charges":[{"gross_charge":4899.0,"discounted_cash":2694.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Echo Transesophageal W Intervention","code_information":[{"code":"8101803","type":"CDM"},{"code":"481","type":"RC"},{"code":"93355","type":"HCPCS"}],"standard_charges":[{"gross_charge":2552.0,"discounted_cash":1403.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ep Eval Subq Implantable Defib","code_information":[{"code":"8101804","type":"CDM"},{"code":"481","type":"RC"},{"code":"93644","type":"HCPCS"}],"standard_charges":[{"gross_charge":2825.0,"discounted_cash":1553.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ecmo Initiation Venous","code_information":[{"code":"8101810","type":"CDM"},{"code":"360","type":"RC"},{"code":"33946","type":"HCPCS"}],"standard_charges":[{"gross_charge":2786.0,"discounted_cash":1532.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ecmo Initiation Arterial","code_information":[{"code":"8101811","type":"CDM"},{"code":"360","type":"RC"},{"code":"33947","type":"HCPCS"}],"standard_charges":[{"gross_charge":3143.0,"discounted_cash":1728.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ecmo Daily Management Venous","code_information":[{"code":"8101812","type":"CDM"},{"code":"360","type":"RC"},{"code":"33948","type":"HCPCS"}],"standard_charges":[{"gross_charge":1861.0,"discounted_cash":1023.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ecmo Daily Management Arterial","code_information":[{"code":"8101813","type":"CDM"},{"code":"360","type":"RC"},{"code":"33949","type":"HCPCS"}],"standard_charges":[{"gross_charge":1861.0,"discounted_cash":1023.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Neg Press Tx Non Dme Equip 50Cm Or Less","code_information":[{"code":"8101814","type":"CDM"},{"code":"761","type":"RC"},{"code":"97607","type":"HCPCS"}],"standard_charges":[{"gross_charge":542.0,"discounted_cash":298.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Neg Press Tx Non Dme Equip More Thn 50Cm","code_information":[{"code":"8101815","type":"CDM"},{"code":"761","type":"RC"},{"code":"97608","type":"HCPCS"}],"standard_charges":[{"gross_charge":542.0,"discounted_cash":298.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Aortogram Abd Serial S&I","code_information":[{"code":"810182","type":"CDM"},{"code":"323","type":"RC"},{"code":"75625","type":"HCPCS"}],"standard_charges":[{"gross_charge":4594.0,"discounted_cash":2526.7,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Tap Block Unilateral By Injection","code_information":[{"code":"8101824","type":"CDM"},{"code":"361","type":"RC"},{"code":"64486","type":"HCPCS"}],"standard_charges":[{"gross_charge":1418.0,"discounted_cash":779.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Tap Block Bilateral By Injection","code_information":[{"code":"8101825","type":"CDM"},{"code":"361","type":"RC"},{"code":"64488","type":"HCPCS"}],"standard_charges":[{"gross_charge":2570.0,"discounted_cash":1413.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Elastography Liver Shear Wave Wo Img","code_information":[{"code":"8101832","type":"CDM"},{"code":"750","type":"RC"},{"code":"91200","type":"HCPCS"}],"standard_charges":[{"gross_charge":586.0,"discounted_cash":322.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ablate Tumor Pulm Cryo Perc Uni W Guide","code_information":[{"code":"8101837","type":"CDM"},{"code":"361","type":"RC"},{"code":"32994","type":"HCPCS"}],"standard_charges":[{"gross_charge":11425.0,"discounted_cash":6283.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Tx Fx Acteabulum W/O Manip","code_information":[{"code":"8101838","type":"CDM"},{"code":"450","type":"RC"},{"code":"27222","type":"HCPCS"}],"standard_charges":[{"gross_charge":686.0,"discounted_cash":377.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Atherectmy Perc Ea Add Brnch Maj Cor Art","code_information":[{"code":"810184","type":"CDM"},{"code":"481","type":"RC"},{"code":"92925","type":"HCPCS"}],"standard_charges":[{"gross_charge":21518.0,"discounted_cash":11834.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Atherectmy Perc W Ang Sngl Maj Coron Art","code_information":[{"code":"810185","type":"CDM"},{"code":"481","type":"RC"},{"code":"92924","type":"HCPCS"}],"standard_charges":[{"gross_charge":21724.0,"discounted_cash":11948.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Autotransfusion","code_information":[{"code":"810188","type":"CDM"},{"code":"360","type":"RC"}],"standard_charges":[{"gross_charge":4427.0,"discounted_cash":2434.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Closed Rx Inter/Subtroch Fx Manip","code_information":[{"code":"8101926","type":"CDM"},{"code":"450","type":"RC"},{"code":"27240","type":"HCPCS"}],"standard_charges":[{"gross_charge":4549.0,"discounted_cash":2501.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Noncdm Charge Record","code_information":[{"code":"8101939","type":"CDM"},{"code":"361","type":"RC"},{"code":"52332","type":"HCPCS"}],"standard_charges":[{"gross_charge":1516.8,"discounted_cash":834.24,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Hc Cardiopulmonary Resuscitation","code_information":[{"code":"810194","type":"CDM"},{"code":"410","type":"RC"},{"code":"92950","type":"HCPCS"}],"standard_charges":[{"gross_charge":963.0,"discounted_cash":529.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Resting Hand Splint","code_information":[{"code":"8101945","type":"CDM"},{"code":"274","type":"RC"},{"code":"L3807","type":"HCPCS"}],"standard_charges":[{"gross_charge":339.47,"discounted_cash":186.71,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Cardioversion Elective External","code_information":[{"code":"810196","type":"CDM"},{"code":"480","type":"RC"},{"code":"92960","type":"HCPCS"}],"standard_charges":[{"gross_charge":2305.0,"discounted_cash":1267.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Tenotomy Hip Flexor Open","code_information":[{"code":"8101989","type":"CDM"},{"code":"360","type":"RC"},{"code":"27005","type":"HCPCS"}],"standard_charges":[{"gross_charge":10287.0,"discounted_cash":5657.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Eval Speech Fluency 75 Min","code_information":[{"code":"8102040","type":"CDM"},{"code":"444","type":"RC"},{"code":"92521","type":"HCPCS"}],"standard_charges":[{"gross_charge":582.0,"discounted_cash":320.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Eval Speech Fluency 90 Min","code_information":[{"code":"8102041","type":"CDM"},{"code":"444","type":"RC"},{"code":"92521","type":"HCPCS"}],"standard_charges":[{"gross_charge":582.0,"discounted_cash":320.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Eval Speech Sound Production 75 Min","code_information":[{"code":"8102042","type":"CDM"},{"code":"444","type":"RC"},{"code":"92522","type":"HCPCS"}],"standard_charges":[{"gross_charge":806.0,"discounted_cash":443.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Eval Speech Sound Production 90 Min","code_information":[{"code":"8102043","type":"CDM"},{"code":"444","type":"RC"},{"code":"92522","type":"HCPCS"}],"standard_charges":[{"gross_charge":895.0,"discounted_cash":492.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Cath Thrombectomy Embolectomy","code_information":[{"code":"810207","type":"CDM"},{"code":"272","type":"RC"},{"code":"C1757","type":"HCPCS"}],"standard_charges":[{"gross_charge":4742.37,"discounted_cash":2608.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Noncdm Charge Record","code_information":[{"code":"8102075","type":"CDM"},{"code":"490","type":"RC"},{"code":"52234","type":"HCPCS"}],"standard_charges":[{"gross_charge":1957.2,"discounted_cash":1076.46,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Hc Wheelchair Mgmnt Training Ea 15Min Pt","code_information":[{"code":"8102093","type":"CDM"},{"code":"420","type":"RC"},{"code":"97542","type":"HCPCS"}],"standard_charges":[{"gross_charge":89.0,"discounted_cash":48.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Tomosynthesis Digital Breast Scrn Unilat","code_information":[{"code":"8102094","type":"CDM"},{"code":"403","type":"RC"},{"code":"77063","type":"HCPCS"}],"standard_charges":[{"gross_charge":35.0,"discounted_cash":19.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Noncdm Charge Record","code_information":[{"code":"8102108","type":"CDM"},{"code":"490","type":"RC"},{"code":"52005","type":"HCPCS"}],"standard_charges":[{"gross_charge":1041.0,"discounted_cash":572.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Hc Inj Intralesional More Than 7 Lesions","code_information":[{"code":"8102124","type":"CDM"},{"code":"361","type":"RC"},{"code":"11901","type":"HCPCS"}],"standard_charges":[{"gross_charge":739.0,"discounted_cash":406.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Arthrocentesis Joint Intermed With Us","code_information":[{"code":"8102150","type":"CDM"},{"code":"450","type":"RC"},{"code":"20606","type":"HCPCS"}],"standard_charges":[{"gross_charge":2851.0,"discounted_cash":1568.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Lab Comprehensive Metabolic Pbb Bill","code_information":[{"code":"8102218","type":"CDM"},{"code":"301","type":"RC"},{"code":"80053","type":"HCPCS"}],"standard_charges":[{"gross_charge":241.0,"discounted_cash":132.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Mri Whole Body Survey","code_information":[{"code":"8102271","type":"CDM"},{"code":"610","type":"RC"},{"code":"76498","type":"HCPCS"}],"standard_charges":[{"gross_charge":299.0,"discounted_cash":164.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Duplex Carotid Bilat","code_information":[{"code":"810233","type":"CDM"},{"code":"921","type":"RC"},{"code":"93880","type":"HCPCS"}],"standard_charges":[{"gross_charge":1751.0,"discounted_cash":963.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Oxygen Per Day","code_information":[{"code":"8102335","type":"CDM"},{"code":"272","type":"RC"}],"standard_charges":[{"gross_charge":210.75,"discounted_cash":115.91,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."},{"gross_charge":191.55,"discounted_cash":105.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."},{"gross_charge":186.49,"discounted_cash":102.57,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Noncdm Charge Record","code_information":[{"code":"8102351","type":"CDM"},{"code":"361","type":"RC"},{"code":"10035","type":"HCPCS"}],"standard_charges":[{"gross_charge":1883.0,"discounted_cash":1035.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Hc Intravascular Us Noncoronary Initial","code_information":[{"code":"8102353","type":"CDM"},{"code":"481","type":"RC"},{"code":"37252","type":"HCPCS"}],"standard_charges":[{"gross_charge":5805.0,"discounted_cash":3192.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Intravascular Us Noncoronary Each Addtl","code_information":[{"code":"8102354","type":"CDM"},{"code":"481","type":"RC"},{"code":"37253","type":"HCPCS"}],"standard_charges":[{"gross_charge":5805.0,"discounted_cash":3192.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Inj For Cholangiogram Existing Access","code_information":[{"code":"8102355","type":"CDM"},{"code":"361","type":"RC"},{"code":"47531","type":"HCPCS"}],"standard_charges":[{"gross_charge":4412.0,"discounted_cash":2426.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Plmt Cath Bilary Drainage External","code_information":[{"code":"8102357","type":"CDM"},{"code":"361","type":"RC"},{"code":"47533","type":"HCPCS"}],"standard_charges":[{"gross_charge":6073.0,"discounted_cash":3340.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Plmt Cath Bilary Drainage Int And Ext","code_information":[{"code":"8102358","type":"CDM"},{"code":"361","type":"RC"},{"code":"47534","type":"HCPCS"}],"standard_charges":[{"gross_charge":6548.0,"discounted_cash":3601.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Exchange Cath Biliary Drainage","code_information":[{"code":"8102360","type":"CDM"},{"code":"361","type":"RC"},{"code":"47536","type":"HCPCS"}],"standard_charges":[{"gross_charge":974.0,"discounted_cash":535.7,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Remove Cath Biliary Drainage W Fluoro","code_information":[{"code":"8102361","type":"CDM"},{"code":"361","type":"RC"},{"code":"47537","type":"HCPCS"}],"standard_charges":[{"gross_charge":2405.0,"discounted_cash":1322.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Removal Calculi Biliary Duct Or Gallbld","code_information":[{"code":"8102367","type":"CDM"},{"code":"361","type":"RC"},{"code":"47544","type":"HCPCS"}],"standard_charges":[{"gross_charge":6652.0,"discounted_cash":3658.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Sclerotherapy Fluid Collection","code_information":[{"code":"8102368","type":"CDM"},{"code":"361","type":"RC"},{"code":"49185","type":"HCPCS"}],"standard_charges":[{"gross_charge":1362.0,"discounted_cash":749.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Inj Nephrostogrm Ureterogrm New","code_information":[{"code":"8102369","type":"CDM"},{"code":"361","type":"RC"},{"code":"50430","type":"HCPCS"}],"standard_charges":[{"gross_charge":1820.0,"discounted_cash":1001.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ep Ablate Av Node","code_information":[{"code":"810237","type":"CDM"},{"code":"480","type":"RC"},{"code":"93650","type":"HCPCS"}],"standard_charges":[{"gross_charge":13489.0,"discounted_cash":7418.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Inj Nephrostogrm Ureterogrm Existing","code_information":[{"code":"8102370","type":"CDM"},{"code":"361","type":"RC"},{"code":"50431","type":"HCPCS"}],"standard_charges":[{"gross_charge":1694.0,"discounted_cash":931.7,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Plcmt Cath Nephrostomy Percutaneous","code_information":[{"code":"8102371","type":"CDM"},{"code":"361","type":"RC"},{"code":"50432","type":"HCPCS"}],"standard_charges":[{"gross_charge":2801.0,"discounted_cash":1540.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Plcmt Cath Nephroureteral New","code_information":[{"code":"8102372","type":"CDM"},{"code":"361","type":"RC"},{"code":"50433","type":"HCPCS"}],"standard_charges":[{"gross_charge":2806.0,"discounted_cash":1543.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Convert Nephrostmy To Nephrouret Cath Ex","code_information":[{"code":"8102373","type":"CDM"},{"code":"361","type":"RC"},{"code":"50434","type":"HCPCS"}],"standard_charges":[{"gross_charge":3278.0,"discounted_cash":1802.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Exchange Cath Nephrostomy Percutaneous","code_information":[{"code":"8102374","type":"CDM"},{"code":"361","type":"RC"},{"code":"50435","type":"HCPCS"}],"standard_charges":[{"gross_charge":4345.0,"discounted_cash":2389.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Plcmt Stent Ureteral Existing Tract","code_information":[{"code":"8102375","type":"CDM"},{"code":"361","type":"RC"},{"code":"50693","type":"HCPCS"}],"standard_charges":[{"gross_charge":6258.0,"discounted_cash":3441.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Plcmt Stent Ureteral New Wo Neph Cath","code_information":[{"code":"8102376","type":"CDM"},{"code":"361","type":"RC"},{"code":"50694","type":"HCPCS"}],"standard_charges":[{"gross_charge":6258.0,"discounted_cash":3441.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Dilation Ureteral Stricture Balloon","code_information":[{"code":"8102378","type":"CDM"},{"code":"361","type":"RC"},{"code":"50706","type":"HCPCS"}],"standard_charges":[{"gross_charge":2308.0,"discounted_cash":1269.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Mech Thromb Inf Percut Art Intracranial","code_information":[{"code":"8102379","type":"CDM"},{"code":"360","type":"RC"},{"code":"61645","type":"HCPCS"}],"standard_charges":[{"gross_charge":6326.0,"discounted_cash":3479.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Prolong Admn Rx Endovasc Intracran Init","code_information":[{"code":"8102380","type":"CDM"},{"code":"361","type":"RC"},{"code":"61650","type":"HCPCS"}],"standard_charges":[{"gross_charge":4232.0,"discounted_cash":2327.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Paravert Block Thoracic Single Inj","code_information":[{"code":"8102382","type":"CDM"},{"code":"361","type":"RC"},{"code":"64461","type":"HCPCS"}],"standard_charges":[{"gross_charge":2140.0,"discounted_cash":1177.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Paravert Block Thoracic Subsequent Inj","code_information":[{"code":"8102383","type":"CDM"},{"code":"361","type":"RC"},{"code":"64462","type":"HCPCS"}],"standard_charges":[{"gross_charge":1087.0,"discounted_cash":597.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Paravert Block Thoracic Continuous Inf","code_information":[{"code":"8102384","type":"CDM"},{"code":"361","type":"RC"},{"code":"64463","type":"HCPCS"}],"standard_charges":[{"gross_charge":2140.0,"discounted_cash":1177.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Remove Cerumen Impacted W Lavage Uni","code_information":[{"code":"8102385","type":"CDM"},{"code":"450","type":"RC"},{"code":"69209","type":"HCPCS"}],"standard_charges":[{"gross_charge":261.0,"discounted_cash":143.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Noncdm Charge Record","code_information":[{"code":"8102387","type":"CDM"},{"code":"361","type":"RC"},{"code":"69209","type":"HCPCS"}],"standard_charges":[{"gross_charge":213.78,"discounted_cash":117.58,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Hc Xray Spine Entire 1 View","code_information":[{"code":"8102389","type":"CDM"},{"code":"320","type":"RC"},{"code":"72081","type":"HCPCS"}],"standard_charges":[{"gross_charge":553.0,"discounted_cash":304.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Xray Spine Entire 2 Or 3 Views","code_information":[{"code":"8102390","type":"CDM"},{"code":"320","type":"RC"},{"code":"72082","type":"HCPCS"}],"standard_charges":[{"gross_charge":553.0,"discounted_cash":304.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Xray Hip Unilat 1 View","code_information":[{"code":"8102393","type":"CDM"},{"code":"320","type":"RC"},{"code":"73501","type":"HCPCS"}],"standard_charges":[{"gross_charge":553.0,"discounted_cash":304.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Xray Hip Unilat 2-3 Views","code_information":[{"code":"8102394","type":"CDM"},{"code":"320","type":"RC"},{"code":"73502","type":"HCPCS"}],"standard_charges":[{"gross_charge":553.0,"discounted_cash":304.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Xray Hips Bilat W Pelvis 2 Views","code_information":[{"code":"8102396","type":"CDM"},{"code":"320","type":"RC"},{"code":"73521","type":"HCPCS"}],"standard_charges":[{"gross_charge":495.0,"discounted_cash":272.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Xray Hips Bilat W Pelvis 3-4 Views","code_information":[{"code":"8102397","type":"CDM"},{"code":"320","type":"RC"},{"code":"73522","type":"HCPCS"}],"standard_charges":[{"gross_charge":553.0,"discounted_cash":304.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Xray Hips Bilateral W Pelv Min 5 Vw","code_information":[{"code":"8102398","type":"CDM"},{"code":"320","type":"RC"},{"code":"73523","type":"HCPCS"}],"standard_charges":[{"gross_charge":611.0,"discounted_cash":336.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ep Bundle Of His Recrd","code_information":[{"code":"810240","type":"CDM"},{"code":"480","type":"RC"},{"code":"93600","type":"HCPCS"}],"standard_charges":[{"gross_charge":13334.0,"discounted_cash":7333.7,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Xray Femur Minimum 2 Views","code_information":[{"code":"8102400","type":"CDM"},{"code":"320","type":"RC"},{"code":"73552","type":"HCPCS"}],"standard_charges":[{"gross_charge":553.0,"discounted_cash":304.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ep Echo Intracard","code_information":[{"code":"810241","type":"CDM"},{"code":"480","type":"RC"},{"code":"93662","type":"HCPCS"}],"standard_charges":[{"gross_charge":9765.0,"discounted_cash":5370.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ep Eval Icd Implant Follow Up","code_information":[{"code":"810242","type":"CDM"},{"code":"480","type":"RC"},{"code":"93642","type":"HCPCS"}],"standard_charges":[{"gross_charge":2836.0,"discounted_cash":1559.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Imaging Myocardial Strain","code_information":[{"code":"8102425","type":"CDM"},{"code":"480","type":"RC"},{"code":"93356","type":"HCPCS"}],"standard_charges":[{"gross_charge":418.0,"discounted_cash":229.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ep Eval Icd Lead Test During Implant","code_information":[{"code":"810243","type":"CDM"},{"code":"480","type":"RC"},{"code":"93640","type":"HCPCS"}],"standard_charges":[{"gross_charge":1369.0,"discounted_cash":752.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Plcmt Cath Nephrostomy Percutaneous Bil","code_information":[{"code":"8102438","type":"CDM"},{"code":"361","type":"RC"},{"code":"50432","type":"HCPCS"}],"standard_charges":[{"gross_charge":5602.0,"discounted_cash":3081.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ep Eval Icd Lead/Gen Test During Impl","code_information":[{"code":"810244","type":"CDM"},{"code":"480","type":"RC"},{"code":"93641","type":"HCPCS"}],"standard_charges":[{"gross_charge":1749.0,"discounted_cash":961.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Exch Cath Nephrostomy Percutaneous Bil","code_information":[{"code":"8102440","type":"CDM"},{"code":"361","type":"RC"},{"code":"50435","type":"HCPCS"}],"standard_charges":[{"gross_charge":8690.0,"discounted_cash":4779.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ep Eval W/ Induction Left Atrial Or Cs","code_information":[{"code":"810245","type":"CDM"},{"code":"480","type":"RC"},{"code":"93621","type":"HCPCS"}],"standard_charges":[{"gross_charge":6582.0,"discounted_cash":3620.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Noncdm Charge Record","code_information":[{"code":"8102458","type":"CDM"},{"code":"510","type":"RC"},{"code":"99497","type":"HCPCS"}],"standard_charges":[{"gross_charge":240.0,"discounted_cash":132.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Hc Ed Inject Ans Plantar Digtl Nerve","code_information":[{"code":"8102459","type":"CDM"},{"code":"450","type":"RC"},{"code":"64455","type":"HCPCS"}],"standard_charges":[{"gross_charge":1093.0,"discounted_cash":601.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ep Eval W/ Induction Right A/V","code_information":[{"code":"810246","type":"CDM"},{"code":"480","type":"RC"},{"code":"93620","type":"HCPCS"}],"standard_charges":[{"gross_charge":16486.0,"discounted_cash":9067.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ep Eval W/O Induction Right A/V","code_information":[{"code":"810247","type":"CDM"},{"code":"480","type":"RC"},{"code":"93619","type":"HCPCS"}],"standard_charges":[{"gross_charge":16486.0,"discounted_cash":9067.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ep Intracard 3D Mapping","code_information":[{"code":"810248","type":"CDM"},{"code":"480","type":"RC"},{"code":"93613","type":"HCPCS"}],"standard_charges":[{"gross_charge":5671.0,"discounted_cash":3119.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Fibrinolysis Via Chest Tube Initial Day","code_information":[{"code":"8102495","type":"CDM"},{"code":"361","type":"RC"},{"code":"32561","type":"HCPCS"}],"standard_charges":[{"gross_charge":1295.0,"discounted_cash":712.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ep Right Vent Recrd","code_information":[{"code":"810252","type":"CDM"},{"code":"480","type":"RC"},{"code":"93603","type":"HCPCS"}],"standard_charges":[{"gross_charge":2284.0,"discounted_cash":1256.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ep Stim After Iv Drug Inf","code_information":[{"code":"810253","type":"CDM"},{"code":"480","type":"RC"},{"code":"93623","type":"HCPCS"}],"standard_charges":[{"gross_charge":5671.0,"discounted_cash":3119.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Noncdm Charge Record","code_information":[{"code":"8102540","type":"CDM"},{"code":"440","type":"RC"},{"code":"92611","type":"HCPCS"}],"standard_charges":[{"gross_charge":361.0,"discounted_cash":198.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Hc Ep Tachycardia Mapping","code_information":[{"code":"810255","type":"CDM"},{"code":"480","type":"RC"},{"code":"93609","type":"HCPCS"}],"standard_charges":[{"gross_charge":8830.0,"discounted_cash":4856.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Sleep Study Attended Reduced","code_information":[{"code":"8102559","type":"CDM"},{"code":"920","type":"RC"},{"code":"95807","type":"HCPCS"}],"standard_charges":[{"gross_charge":5873.0,"discounted_cash":3230.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Remvl Non Bio Drug Implant","code_information":[{"code":"8102577","type":"CDM"},{"code":"450","type":"RC"},{"code":"11982","type":"HCPCS"}],"standard_charges":[{"gross_charge":735.0,"discounted_cash":404.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Rpr Open Perc Ruptured Achilles","code_information":[{"code":"8102595","type":"CDM"},{"code":"450","type":"RC"},{"code":"27650","type":"HCPCS"}],"standard_charges":[{"gross_charge":24418.0,"discounted_cash":13429.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Guide Wire","code_information":[{"code":"810260","type":"CDM"},{"code":"272","type":"RC"},{"code":"C1769","type":"HCPCS"}],"standard_charges":[{"gross_charge":17.6,"discounted_cash":9.68,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"},{"gross_charge":17.27,"discounted_cash":9.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."},{"gross_charge":306.38,"discounted_cash":168.51,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Hc Ed Arthrocentesis Joint Major With Us","code_information":[{"code":"8102600","type":"CDM"},{"code":"450","type":"RC"},{"code":"20611","type":"HCPCS"}],"standard_charges":[{"gross_charge":2866.0,"discounted_cash":1576.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Sleep Study Unattended W Sleep Time","code_information":[{"code":"8102633","type":"CDM"},{"code":"740","type":"RC"},{"code":"95800","type":"HCPCS"}],"standard_charges":[{"gross_charge":1116.0,"discounted_cash":613.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Heart Flow Reserve Measure Init Vessel","code_information":[{"code":"810267","type":"CDM"},{"code":"481","type":"RC"},{"code":"93571","type":"HCPCS"}],"standard_charges":[{"gross_charge":4795.0,"discounted_cash":2637.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Inj Epidural Cervical Thor Wo Img","code_information":[{"code":"8102670","type":"CDM"},{"code":"361","type":"RC"},{"code":"62320","type":"HCPCS"}],"standard_charges":[{"gross_charge":1996.0,"discounted_cash":1097.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Inj Epidural Cervical Thor W Img","code_information":[{"code":"8102671","type":"CDM"},{"code":"361","type":"RC"},{"code":"62321","type":"HCPCS"}],"standard_charges":[{"gross_charge":3085.0,"discounted_cash":1696.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Inj Epidural Lumbar Sacral Wo Img","code_information":[{"code":"8102672","type":"CDM"},{"code":"361","type":"RC"},{"code":"62322","type":"HCPCS"}],"standard_charges":[{"gross_charge":1950.0,"discounted_cash":1072.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Inj Epidural Lumbar Sacral W Img","code_information":[{"code":"8102673","type":"CDM"},{"code":"361","type":"RC"},{"code":"62323","type":"HCPCS"}],"standard_charges":[{"gross_charge":3107.0,"discounted_cash":1708.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Inf Cont Epidural Cervical Thor Wo Img","code_information":[{"code":"8102674","type":"CDM"},{"code":"361","type":"RC"},{"code":"62324","type":"HCPCS"}],"standard_charges":[{"gross_charge":2051.0,"discounted_cash":1128.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Inf Cont Epidural Cervical Thor W Img","code_information":[{"code":"8102675","type":"CDM"},{"code":"361","type":"RC"},{"code":"62325","type":"HCPCS"}],"standard_charges":[{"gross_charge":2964.0,"discounted_cash":1630.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Inf Cont Epidural Lumb Sacral Wo Img","code_information":[{"code":"8102676","type":"CDM"},{"code":"361","type":"RC"},{"code":"62326","type":"HCPCS"}],"standard_charges":[{"gross_charge":2051.0,"discounted_cash":1128.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Inf Cont Epidural Lumb Sacral W Img","code_information":[{"code":"8102677","type":"CDM"},{"code":"361","type":"RC"},{"code":"62327","type":"HCPCS"}],"standard_charges":[{"gross_charge":3076.0,"discounted_cash":1691.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Mamm Dx Unilateral Includes Cad/Ai","code_information":[{"code":"8102678","type":"CDM"},{"code":"401","type":"RC"},{"code":"77065","type":"HCPCS"}],"standard_charges":[{"gross_charge":363.0,"discounted_cash":199.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Mamm Dx Bilateral Includes Cad/Ai","code_information":[{"code":"8102679","type":"CDM"},{"code":"401","type":"RC"},{"code":"77066","type":"HCPCS"}],"standard_charges":[{"gross_charge":726.0,"discounted_cash":399.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Heart Flow Rsrv Measure Ea Addl Vessel","code_information":[{"code":"810268","type":"CDM"},{"code":"481","type":"RC"},{"code":"93572","type":"HCPCS"}],"standard_charges":[{"gross_charge":2576.0,"discounted_cash":1416.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Mamm Screen Bilat Includes Cad/Ai","code_information":[{"code":"8102680","type":"CDM"},{"code":"403","type":"RC"},{"code":"77067","type":"HCPCS"}],"standard_charges":[{"gross_charge":395.0,"discounted_cash":217.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Mod Sed Same Phys <5 Yrs Init 15 Min","code_information":[{"code":"8102681","type":"CDM"},{"code":"370","type":"RC"},{"code":"99151","type":"HCPCS"}],"standard_charges":[{"gross_charge":173.0,"discounted_cash":95.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Mod Sed Same Phys 5>=Yrs Init 15 Min","code_information":[{"code":"8102682","type":"CDM"},{"code":"370","type":"RC"},{"code":"99152","type":"HCPCS"}],"standard_charges":[{"gross_charge":173.0,"discounted_cash":95.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Mod Sed Same Phys Ea Addl 15 Min","code_information":[{"code":"8102683","type":"CDM"},{"code":"370","type":"RC"},{"code":"99153","type":"HCPCS"}],"standard_charges":[{"gross_charge":125.0,"discounted_cash":68.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Mod Sed Oth Phys <5 Yrs Init 15 Min","code_information":[{"code":"8102684","type":"CDM"},{"code":"370","type":"RC"},{"code":"99155","type":"HCPCS"}],"standard_charges":[{"gross_charge":173.0,"discounted_cash":95.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Mod Sed Oth Phys 5>=Yrs Init 15 Min","code_information":[{"code":"8102685","type":"CDM"},{"code":"370","type":"RC"},{"code":"99156","type":"HCPCS"}],"standard_charges":[{"gross_charge":173.0,"discounted_cash":95.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Mod Sed Other Phys Ea Addl 15 Min","code_information":[{"code":"8102686","type":"CDM"},{"code":"370","type":"RC"},{"code":"99157","type":"HCPCS"}],"standard_charges":[{"gross_charge":129.0,"discounted_cash":70.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Intro Cath W Angio Dialysis Periph","code_information":[{"code":"8102689","type":"CDM"},{"code":"361","type":"RC"},{"code":"36901","type":"HCPCS"}],"standard_charges":[{"gross_charge":1222.0,"discounted_cash":672.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Intro Cath W Ball Angiop Dialysis Periph","code_information":[{"code":"8102690","type":"CDM"},{"code":"361","type":"RC"},{"code":"36902","type":"HCPCS"}],"standard_charges":[{"gross_charge":11395.0,"discounted_cash":6267.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Intro Cath W Stent Dialysis Periph","code_information":[{"code":"8102691","type":"CDM"},{"code":"361","type":"RC"},{"code":"36903","type":"HCPCS"}],"standard_charges":[{"gross_charge":19837.0,"discounted_cash":10910.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Thrombectomy Dialysis Circ Percut","code_information":[{"code":"8102692","type":"CDM"},{"code":"361","type":"RC"},{"code":"36904","type":"HCPCS"}],"standard_charges":[{"gross_charge":8495.0,"discounted_cash":4672.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Thrombect W Ball Angio Dialysis Periph","code_information":[{"code":"8102693","type":"CDM"},{"code":"361","type":"RC"},{"code":"36905","type":"HCPCS"}],"standard_charges":[{"gross_charge":17168.0,"discounted_cash":9442.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Thrombectomy W Stent Dialysis Periph","code_information":[{"code":"8102694","type":"CDM"},{"code":"361","type":"RC"},{"code":"36906","type":"HCPCS"}],"standard_charges":[{"gross_charge":29926.0,"discounted_cash":16459.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Angioplasty Balloon Dialysis Central","code_information":[{"code":"8102695","type":"CDM"},{"code":"361","type":"RC"},{"code":"36907","type":"HCPCS"}],"standard_charges":[{"gross_charge":593.0,"discounted_cash":326.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Plcmt Stent Dialysis Central","code_information":[{"code":"8102696","type":"CDM"},{"code":"361","type":"RC"},{"code":"36908","type":"HCPCS"}],"standard_charges":[{"gross_charge":9646.0,"discounted_cash":5305.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Emboliz Occlus Dialysis Endovascular","code_information":[{"code":"8102697","type":"CDM"},{"code":"361","type":"RC"},{"code":"36909","type":"HCPCS"}],"standard_charges":[{"gross_charge":1448.0,"discounted_cash":796.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Angioplasty Balloon Translum Init Art","code_information":[{"code":"8102698","type":"CDM"},{"code":"361","type":"RC"},{"code":"37246","type":"HCPCS"}],"standard_charges":[{"gross_charge":14638.0,"discounted_cash":8050.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Angioplasty Balloon Translum Ea Add Art","code_information":[{"code":"8102699","type":"CDM"},{"code":"361","type":"RC"},{"code":"37247","type":"HCPCS"}],"standard_charges":[{"gross_charge":7250.0,"discounted_cash":3987.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Angioplasty Balloon Translum Init Vein","code_information":[{"code":"8102700","type":"CDM"},{"code":"361","type":"RC"},{"code":"37248","type":"HCPCS"}],"standard_charges":[{"gross_charge":14429.0,"discounted_cash":7935.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Applic On Body Inject For Timed Subq Inj","code_information":[{"code":"8102702","type":"CDM"},{"code":"260","type":"RC"},{"code":"96377","type":"HCPCS"}],"standard_charges":[{"gross_charge":185.0,"discounted_cash":101.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Athletic Trn Eval Low Complexity","code_information":[{"code":"8102715","type":"CDM"},{"code":"951","type":"RC"},{"code":"97169","type":"HCPCS"}],"standard_charges":[{"gross_charge":307.0,"discounted_cash":168.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Athletic Trn Eval Mod Complexity","code_information":[{"code":"8102716","type":"CDM"},{"code":"951","type":"RC"},{"code":"97170","type":"HCPCS"}],"standard_charges":[{"gross_charge":361.0,"discounted_cash":198.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Athletic Trn Eval High Complexity","code_information":[{"code":"8102717","type":"CDM"},{"code":"951","type":"RC"},{"code":"97171","type":"HCPCS"}],"standard_charges":[{"gross_charge":409.0,"discounted_cash":224.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Athletic Trn Reeval Plan Low Complexity","code_information":[{"code":"8102718","type":"CDM"},{"code":"951","type":"RC"},{"code":"97172","type":"HCPCS"}],"standard_charges":[{"gross_charge":198.0,"discounted_cash":108.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Insert Electrodes Two Transvenous","code_information":[{"code":"810274","type":"CDM"},{"code":"481","type":"RC"},{"code":"33217","type":"HCPCS"}],"standard_charges":[{"gross_charge":12938.0,"discounted_cash":7115.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Insert Electrode Sngl Transvenous","code_information":[{"code":"810275","type":"CDM"},{"code":"481","type":"RC"},{"code":"33216","type":"HCPCS"}],"standard_charges":[{"gross_charge":11330.0,"discounted_cash":6231.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Pt Eval Low Complexity 1 Rvu","code_information":[{"code":"8102757","type":"CDM"},{"code":"424","type":"RC"},{"code":"97161","type":"HCPCS"}],"standard_charges":[{"gross_charge":205.0,"discounted_cash":112.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Pt Eval Low Complexity 2 Rvu","code_information":[{"code":"8102758","type":"CDM"},{"code":"424","type":"RC"},{"code":"97161","type":"HCPCS"}],"standard_charges":[{"gross_charge":205.0,"discounted_cash":112.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Pt Eval Low Complexity 3 Rvu","code_information":[{"code":"8102759","type":"CDM"},{"code":"424","type":"RC"},{"code":"97161","type":"HCPCS"}],"standard_charges":[{"gross_charge":205.0,"discounted_cash":112.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Pt Eval Low Complexity 4 Rvu","code_information":[{"code":"8102760","type":"CDM"},{"code":"424","type":"RC"},{"code":"97161","type":"HCPCS"}],"standard_charges":[{"gross_charge":205.0,"discounted_cash":112.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Pt Eval Low Complexity 5 Rvu","code_information":[{"code":"8102761","type":"CDM"},{"code":"424","type":"RC"},{"code":"97161","type":"HCPCS"}],"standard_charges":[{"gross_charge":205.0,"discounted_cash":112.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Pt Eval Low Complexity 6 Rvu","code_information":[{"code":"8102762","type":"CDM"},{"code":"424","type":"RC"},{"code":"97161","type":"HCPCS"}],"standard_charges":[{"gross_charge":205.0,"discounted_cash":112.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Pt Eval Mod Complexity 2 Rvu","code_information":[{"code":"8102763","type":"CDM"},{"code":"424","type":"RC"},{"code":"97162","type":"HCPCS"}],"standard_charges":[{"gross_charge":244.0,"discounted_cash":134.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Pt Eval Mod Complexity 3 Rvu","code_information":[{"code":"8102764","type":"CDM"},{"code":"424","type":"RC"},{"code":"97162","type":"HCPCS"}],"standard_charges":[{"gross_charge":244.0,"discounted_cash":134.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Pt Eval Mod Complexity 4 Rvu","code_information":[{"code":"8102765","type":"CDM"},{"code":"424","type":"RC"},{"code":"97162","type":"HCPCS"}],"standard_charges":[{"gross_charge":244.0,"discounted_cash":134.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Pt Eval Mod Complexity 5 Rvu","code_information":[{"code":"8102766","type":"CDM"},{"code":"424","type":"RC"},{"code":"97162","type":"HCPCS"}],"standard_charges":[{"gross_charge":244.0,"discounted_cash":134.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Pt Eval Mod Complexity 6 Rvu","code_information":[{"code":"8102767","type":"CDM"},{"code":"424","type":"RC"},{"code":"97162","type":"HCPCS"}],"standard_charges":[{"gross_charge":244.0,"discounted_cash":134.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Pt Eval High Complexity 3 Rvu","code_information":[{"code":"8102768","type":"CDM"},{"code":"424","type":"RC"},{"code":"97163","type":"HCPCS"}],"standard_charges":[{"gross_charge":282.0,"discounted_cash":155.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Pt Eval High Complexity 4 Rvu","code_information":[{"code":"8102769","type":"CDM"},{"code":"424","type":"RC"},{"code":"97163","type":"HCPCS"}],"standard_charges":[{"gross_charge":282.0,"discounted_cash":155.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Insert Intra Aortic Balloon","code_information":[{"code":"810277","type":"CDM"},{"code":"360","type":"RC"},{"code":"33967","type":"HCPCS"}],"standard_charges":[{"gross_charge":4599.0,"discounted_cash":2529.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Pt Eval High Complexity 5 Rvu","code_information":[{"code":"8102770","type":"CDM"},{"code":"424","type":"RC"},{"code":"97163","type":"HCPCS"}],"standard_charges":[{"gross_charge":282.0,"discounted_cash":155.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Pt Eval High Complexity 6 Rvu","code_information":[{"code":"8102771","type":"CDM"},{"code":"424","type":"RC"},{"code":"97163","type":"HCPCS"}],"standard_charges":[{"gross_charge":282.0,"discounted_cash":155.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ot Eval Low Complexity 2 Rvu","code_information":[{"code":"8102772","type":"CDM"},{"code":"434","type":"RC"},{"code":"97165","type":"HCPCS"}],"standard_charges":[{"gross_charge":207.0,"discounted_cash":113.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ot Eval Low Complexity 3 Rvu","code_information":[{"code":"8102773","type":"CDM"},{"code":"434","type":"RC"},{"code":"97165","type":"HCPCS"}],"standard_charges":[{"gross_charge":207.0,"discounted_cash":113.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ot Eval Low Complexity 4 Rvu","code_information":[{"code":"8102774","type":"CDM"},{"code":"434","type":"RC"},{"code":"97165","type":"HCPCS"}],"standard_charges":[{"gross_charge":207.0,"discounted_cash":113.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ot Eval Low Complexity 5 Rvu","code_information":[{"code":"8102775","type":"CDM"},{"code":"434","type":"RC"},{"code":"97165","type":"HCPCS"}],"standard_charges":[{"gross_charge":207.0,"discounted_cash":113.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ot Eval Low Complexity 6 Rvu","code_information":[{"code":"8102776","type":"CDM"},{"code":"434","type":"RC"},{"code":"97165","type":"HCPCS"}],"standard_charges":[{"gross_charge":207.0,"discounted_cash":113.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ot Eval Mod Complexity 3 Rvu","code_information":[{"code":"8102777","type":"CDM"},{"code":"434","type":"RC"},{"code":"97166","type":"HCPCS"}],"standard_charges":[{"gross_charge":245.0,"discounted_cash":134.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ot Eval Mod Complexity 4 Rvu","code_information":[{"code":"8102778","type":"CDM"},{"code":"434","type":"RC"},{"code":"97166","type":"HCPCS"}],"standard_charges":[{"gross_charge":245.0,"discounted_cash":134.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ot Eval Mod Complexity 5 Rvu","code_information":[{"code":"8102779","type":"CDM"},{"code":"434","type":"RC"},{"code":"97166","type":"HCPCS"}],"standard_charges":[{"gross_charge":245.0,"discounted_cash":134.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ot Eval Mod Complexity 6 Rvu","code_information":[{"code":"8102780","type":"CDM"},{"code":"434","type":"RC"},{"code":"97166","type":"HCPCS"}],"standard_charges":[{"gross_charge":245.0,"discounted_cash":134.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ot Eval High Complexity 4 Rvu","code_information":[{"code":"8102781","type":"CDM"},{"code":"434","type":"RC"},{"code":"97167","type":"HCPCS"}],"standard_charges":[{"gross_charge":280.0,"discounted_cash":154.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ot Eval High Complexity 5 Rvu","code_information":[{"code":"8102782","type":"CDM"},{"code":"434","type":"RC"},{"code":"97167","type":"HCPCS"}],"standard_charges":[{"gross_charge":280.0,"discounted_cash":154.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ot Eval High Complexity 6 Rvu","code_information":[{"code":"8102783","type":"CDM"},{"code":"434","type":"RC"},{"code":"97167","type":"HCPCS"}],"standard_charges":[{"gross_charge":280.0,"discounted_cash":154.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Insert Pacing Electrode W/ New Device","code_information":[{"code":"810280","type":"CDM"},{"code":"481","type":"RC"},{"code":"33225","type":"HCPCS"}],"standard_charges":[{"gross_charge":39573.0,"discounted_cash":21765.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Insert Repl Pm Temp Sngl Chmbr","code_information":[{"code":"810281","type":"CDM"},{"code":"481","type":"RC"},{"code":"33210","type":"HCPCS"}],"standard_charges":[{"gross_charge":9220.0,"discounted_cash":5071.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Insert Repl Ppm Transven Atrial","code_information":[{"code":"810282","type":"CDM"},{"code":"481","type":"RC"},{"code":"33206","type":"HCPCS"}],"standard_charges":[{"gross_charge":10697.0,"discounted_cash":5883.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Initiate Chemo Iv Portable Pump For Home","code_information":[{"code":"8102826","type":"CDM"},{"code":"335","type":"RC"},{"code":"G0498","type":"HCPCS"}],"standard_charges":[{"gross_charge":695.0,"discounted_cash":382.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Insert Repl Ppm Transven Atrial & Vent","code_information":[{"code":"810283","type":"CDM"},{"code":"481","type":"RC"},{"code":"33208","type":"HCPCS"}],"standard_charges":[{"gross_charge":10799.0,"discounted_cash":5939.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Pt Eval Mod Complexity 1 Rvu","code_information":[{"code":"8102831","type":"CDM"},{"code":"424","type":"RC"},{"code":"97162","type":"HCPCS"}],"standard_charges":[{"gross_charge":244.0,"discounted_cash":134.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Pt Eval High Complexity 1 Rvu","code_information":[{"code":"8102834","type":"CDM"},{"code":"424","type":"RC"},{"code":"97163","type":"HCPCS"}],"standard_charges":[{"gross_charge":282.0,"discounted_cash":155.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Pt Eval High Complexity 2 Rvu","code_information":[{"code":"8102835","type":"CDM"},{"code":"424","type":"RC"},{"code":"97163","type":"HCPCS"}],"standard_charges":[{"gross_charge":282.0,"discounted_cash":155.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ot Eval Low Complexity 1 Rvu","code_information":[{"code":"8102838","type":"CDM"},{"code":"434","type":"RC"},{"code":"97165","type":"HCPCS"}],"standard_charges":[{"gross_charge":207.0,"discounted_cash":113.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ot Eval Mod Complexity 1 Rvu","code_information":[{"code":"8102839","type":"CDM"},{"code":"434","type":"RC"},{"code":"97166","type":"HCPCS"}],"standard_charges":[{"gross_charge":245.0,"discounted_cash":134.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Insert Repl Ppm Transven Ventricular","code_information":[{"code":"810284","type":"CDM"},{"code":"481","type":"RC"},{"code":"33207","type":"HCPCS"}],"standard_charges":[{"gross_charge":10800.0,"discounted_cash":5940.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ot Eval Mod Complexity 2 Rvu","code_information":[{"code":"8102840","type":"CDM"},{"code":"434","type":"RC"},{"code":"97166","type":"HCPCS"}],"standard_charges":[{"gross_charge":245.0,"discounted_cash":134.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ot Eval High Complexity 1 Rvu","code_information":[{"code":"8102841","type":"CDM"},{"code":"434","type":"RC"},{"code":"97167","type":"HCPCS"}],"standard_charges":[{"gross_charge":280.0,"discounted_cash":154.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ot Eval High Complexity 2 Rvu","code_information":[{"code":"8102842","type":"CDM"},{"code":"434","type":"RC"},{"code":"97167","type":"HCPCS"}],"standard_charges":[{"gross_charge":280.0,"discounted_cash":154.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ot Eval High Complexity 3 Rvu","code_information":[{"code":"8102843","type":"CDM"},{"code":"434","type":"RC"},{"code":"97167","type":"HCPCS"}],"standard_charges":[{"gross_charge":280.0,"discounted_cash":154.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Insert Repl Pulse Gen Sngl Chmbr","code_information":[{"code":"810286","type":"CDM"},{"code":"481","type":"RC"},{"code":"33212","type":"HCPCS"}],"standard_charges":[{"gross_charge":5195.0,"discounted_cash":2857.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Pt Reeval Est Plan 1 Rvu","code_information":[{"code":"8102868","type":"CDM"},{"code":"424","type":"RC"},{"code":"97164","type":"HCPCS"}],"standard_charges":[{"gross_charge":166.0,"discounted_cash":91.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Pt Reeval Est Plan 2 Rvu","code_information":[{"code":"8102869","type":"CDM"},{"code":"424","type":"RC"},{"code":"97164","type":"HCPCS"}],"standard_charges":[{"gross_charge":166.0,"discounted_cash":91.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Pt Reeval Est Plan 3 Rvu","code_information":[{"code":"8102870","type":"CDM"},{"code":"424","type":"RC"},{"code":"97164","type":"HCPCS"}],"standard_charges":[{"gross_charge":166.0,"discounted_cash":91.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Pt Reeval Est Plan 4 Rvu","code_information":[{"code":"8102871","type":"CDM"},{"code":"424","type":"RC"},{"code":"97164","type":"HCPCS"}],"standard_charges":[{"gross_charge":166.0,"discounted_cash":91.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ot Reeval Est Plan 1 Rvu","code_information":[{"code":"8102872","type":"CDM"},{"code":"434","type":"RC"},{"code":"97168","type":"HCPCS"}],"standard_charges":[{"gross_charge":155.0,"discounted_cash":85.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ot Reeval Est Plan 2 Rvu","code_information":[{"code":"8102873","type":"CDM"},{"code":"434","type":"RC"},{"code":"97168","type":"HCPCS"}],"standard_charges":[{"gross_charge":155.0,"discounted_cash":85.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ot Reeval Est Plan 3 Rvu","code_information":[{"code":"8102874","type":"CDM"},{"code":"434","type":"RC"},{"code":"97168","type":"HCPCS"}],"standard_charges":[{"gross_charge":155.0,"discounted_cash":85.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ot Reeval Est Plan 4 Rvu","code_information":[{"code":"8102875","type":"CDM"},{"code":"434","type":"RC"},{"code":"97168","type":"HCPCS"}],"standard_charges":[{"gross_charge":155.0,"discounted_cash":85.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Pl Stnt Perc Transcath Add Brnch Cor Art","code_information":[{"code":"810289","type":"CDM"},{"code":"481","type":"RC"},{"code":"92929","type":"HCPCS"}],"standard_charges":[{"gross_charge":12228.0,"discounted_cash":6725.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Pl Stent Perc Transcath Sngl Maj Cor Art","code_information":[{"code":"810290","type":"CDM"},{"code":"481","type":"RC"},{"code":"92928","type":"HCPCS"}],"standard_charges":[{"gross_charge":13204.0,"discounted_cash":7262.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ivus Or Oct Heart Ea Addl Vessel","code_information":[{"code":"810296","type":"CDM"},{"code":"481","type":"RC"},{"code":"92979","type":"HCPCS"}],"standard_charges":[{"gross_charge":4029.0,"discounted_cash":2215.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ivus Or Oct Heart Init Vessel","code_information":[{"code":"810297","type":"CDM"},{"code":"481","type":"RC"},{"code":"92978","type":"HCPCS"}],"standard_charges":[{"gross_charge":4236.0,"discounted_cash":2329.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Insert Or Repl Leadless Pacemaker Ventr","code_information":[{"code":"8103105","type":"CDM"},{"code":"481","type":"RC"},{"code":"33274","type":"HCPCS"}],"standard_charges":[{"gross_charge":24299.0,"discounted_cash":13364.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Observation Carveout Therapy","code_information":[{"code":"8103114","type":"CDM"},{"code":"762","type":"RC"},{"code":"G0378","type":"HCPCS"}],"standard_charges":[{"gross_charge":1.33,"discounted_cash":0.73,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Observation Carveout Surgery","code_information":[{"code":"8103115","type":"CDM"},{"code":"762","type":"RC"},{"code":"G0378","type":"HCPCS"}],"standard_charges":[{"gross_charge":1.33,"discounted_cash":0.73,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Observation Carveout Transfusion","code_information":[{"code":"8103116","type":"CDM"},{"code":"762","type":"RC"},{"code":"G0378","type":"HCPCS"}],"standard_charges":[{"gross_charge":1.33,"discounted_cash":0.73,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Observation Carveout Cardiology","code_information":[{"code":"8103117","type":"CDM"},{"code":"762","type":"RC"},{"code":"G0378","type":"HCPCS"}],"standard_charges":[{"gross_charge":1.33,"discounted_cash":0.73,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Rmvl Leadless Pacemaker Rt Ventr W Img","code_information":[{"code":"8103175","type":"CDM"},{"code":"481","type":"RC"},{"code":"33275","type":"HCPCS"}],"standard_charges":[{"gross_charge":4328.0,"discounted_cash":2380.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Noncdm Charge Record","code_information":[{"code":"8103181","type":"CDM"},{"code":"361","type":"RC"},{"code":"52317","type":"HCPCS"}],"standard_charges":[{"gross_charge":2217.6,"discounted_cash":1219.68,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Hc Cryoablation Lower Ext Periph Nrv W Img","code_information":[{"code":"8103199","type":"CDM"},{"code":"361","type":"RC"},{"code":"0441T","type":"HCPCS"}],"standard_charges":[{"gross_charge":6242.0,"discounted_cash":3433.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Perfusion Pump Stand By","code_information":[{"code":"8103216","type":"CDM"},{"code":"480","type":"RC"}],"standard_charges":[{"gross_charge":3903.0,"discounted_cash":2146.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ko Adj Joint Pos Rigid Prefab Ots","code_information":[{"code":"8103222","type":"CDM"},{"code":"274","type":"RC"},{"code":"L1833","type":"HCPCS"}],"standard_charges":[{"gross_charge":368.99,"discounted_cash":202.94,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Rpr Aorta Ir A-Ao Engft Non Rup","code_information":[{"code":"8103254","type":"CDM"},{"code":"360","type":"RC"},{"code":"34701","type":"HCPCS"}],"standard_charges":[{"gross_charge":21421.0,"discounted_cash":11781.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Rpr Aorta Ir Or Iliac Aui Endgft Non Rup","code_information":[{"code":"8103255","type":"CDM"},{"code":"360","type":"RC"},{"code":"34703","type":"HCPCS"}],"standard_charges":[{"gross_charge":20590.0,"discounted_cash":11324.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Rpr Aorta Ir Or Iliac Abi Endgft Non Rup","code_information":[{"code":"8103256","type":"CDM"},{"code":"360","type":"RC"},{"code":"34705","type":"HCPCS"}],"standard_charges":[{"gross_charge":21922.0,"discounted_cash":12057.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Biopsy And Aspiration Bone Marrow Dx","code_information":[{"code":"8103258","type":"CDM"},{"code":"361","type":"RC"},{"code":"38222","type":"HCPCS"}],"standard_charges":[{"gross_charge":4342.0,"discounted_cash":2388.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Xray Chest 1 View","code_information":[{"code":"8103259","type":"CDM"},{"code":"324","type":"RC"},{"code":"71045","type":"HCPCS"}],"standard_charges":[{"gross_charge":475.0,"discounted_cash":261.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Xray Chest 2 Views","code_information":[{"code":"8103260","type":"CDM"},{"code":"324","type":"RC"},{"code":"71046","type":"HCPCS"}],"standard_charges":[{"gross_charge":475.0,"discounted_cash":261.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Xray Chest 3 Views","code_information":[{"code":"8103261","type":"CDM"},{"code":"324","type":"RC"},{"code":"71047","type":"HCPCS"}],"standard_charges":[{"gross_charge":475.0,"discounted_cash":261.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Xray Chest 4 Or More Views","code_information":[{"code":"8103262","type":"CDM"},{"code":"324","type":"RC"},{"code":"71048","type":"HCPCS"}],"standard_charges":[{"gross_charge":475.0,"discounted_cash":261.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Xray Abdomen 1 View","code_information":[{"code":"8103263","type":"CDM"},{"code":"320","type":"RC"},{"code":"74018","type":"HCPCS"}],"standard_charges":[{"gross_charge":503.0,"discounted_cash":276.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Xray Abdomen 2 Views","code_information":[{"code":"8103264","type":"CDM"},{"code":"320","type":"RC"},{"code":"74019","type":"HCPCS"}],"standard_charges":[{"gross_charge":503.0,"discounted_cash":276.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Xray Abdomen 3 Or More Views","code_information":[{"code":"8103265","type":"CDM"},{"code":"320","type":"RC"},{"code":"74021","type":"HCPCS"}],"standard_charges":[{"gross_charge":503.0,"discounted_cash":276.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Mamm Screen Unilat Includes Cad/Ai","code_information":[{"code":"8103266","type":"CDM"},{"code":"403","type":"RC"},{"code":"77067","type":"HCPCS"}],"standard_charges":[{"gross_charge":198.0,"discounted_cash":108.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Exercise Test For Bronchospasm W Ekg","code_information":[{"code":"8103267","type":"CDM"},{"code":"460","type":"RC"},{"code":"94617","type":"HCPCS"}],"standard_charges":[{"gross_charge":950.0,"discounted_cash":522.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Stress Test Pulmonary","code_information":[{"code":"8103268","type":"CDM"},{"code":"460","type":"RC"},{"code":"94618","type":"HCPCS"}],"standard_charges":[{"gross_charge":950.0,"discounted_cash":522.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Orth Prosth Mgmt Trn Subseq Ea 15Min Ot","code_information":[{"code":"8103269","type":"CDM"},{"code":"430","type":"RC"},{"code":"97763","type":"HCPCS"}],"standard_charges":[{"gross_charge":89.0,"discounted_cash":48.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Arthrotomy Metacarpophalangl Each","code_information":[{"code":"8103289","type":"CDM"},{"code":"450","type":"RC"},{"code":"26075","type":"HCPCS"}],"standard_charges":[{"gross_charge":11144.0,"discounted_cash":6129.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Pacing External Temp","code_information":[{"code":"810329","type":"CDM"},{"code":"480","type":"RC"},{"code":"92953","type":"HCPCS"}],"standard_charges":[{"gross_charge":1784.0,"discounted_cash":981.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Exc Partial Distal Phalanx Finger","code_information":[{"code":"8103290","type":"CDM"},{"code":"450","type":"RC"},{"code":"26236","type":"HCPCS"}],"standard_charges":[{"gross_charge":6184.0,"discounted_cash":3401.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Percut Rpr Cong Atrial Defect W/ Impl","code_information":[{"code":"810330","type":"CDM"},{"code":"481","type":"RC"},{"code":"93580","type":"HCPCS"}],"standard_charges":[{"gross_charge":37681.0,"discounted_cash":20724.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Endov Rpr Visc Ao Endogrft W 2 Endopros","code_information":[{"code":"8103311","type":"CDM"},{"code":"360","type":"RC"},{"code":"34846","type":"HCPCS"}],"standard_charges":[{"gross_charge":16286.0,"discounted_cash":8957.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Endov Rpr Visc Infraren Ao Engft 3 Endpr","code_information":[{"code":"8103312","type":"CDM"},{"code":"360","type":"RC"},{"code":"34847","type":"HCPCS"}],"standard_charges":[{"gross_charge":25786.0,"discounted_cash":14182.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Perfusion Mid Cab Stand By","code_information":[{"code":"810332","type":"CDM"},{"code":"480","type":"RC"}],"standard_charges":[{"gross_charge":4254.0,"discounted_cash":2339.7,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Perfusion Service","code_information":[{"code":"810333","type":"CDM"},{"code":"360","type":"RC"}],"standard_charges":[{"gross_charge":15431.0,"discounted_cash":8487.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Us Guidance For Needle Placement","code_information":[{"code":"8103349","type":"CDM"},{"code":"450","type":"RC"},{"code":"76942","type":"HCPCS"}],"standard_charges":[{"gross_charge":856.0,"discounted_cash":470.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Tee For Monitoring","code_information":[{"code":"8103357","type":"CDM"},{"code":"480","type":"RC"},{"code":"93318","type":"HCPCS"}],"standard_charges":[{"gross_charge":1534.0,"discounted_cash":843.7,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Place Cath Select Art 1St Leg/Abd/Pelv","code_information":[{"code":"810336","type":"CDM"},{"code":"361","type":"RC"},{"code":"36245","type":"HCPCS"}],"standard_charges":[{"gross_charge":2671.0,"discounted_cash":1469.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Place Cath Select Art 1St Ord Thoracic","code_information":[{"code":"810337","type":"CDM"},{"code":"361","type":"RC"},{"code":"36215","type":"HCPCS"}],"standard_charges":[{"gross_charge":3067.0,"discounted_cash":1686.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Place Cath Select Art 2Nd Leg/Abd/Pelv","code_information":[{"code":"810338","type":"CDM"},{"code":"361","type":"RC"},{"code":"36246","type":"HCPCS"}],"standard_charges":[{"gross_charge":3707.0,"discounted_cash":2038.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Plcmt Prosth Exten Per Vessel Endv Rpr","code_information":[{"code":"8103380","type":"CDM"},{"code":"360","type":"RC"},{"code":"34709","type":"HCPCS"}],"standard_charges":[{"gross_charge":7176.0,"discounted_cash":3946.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Placmt Prosth Delayed Endv Rpr Init Vess","code_information":[{"code":"8103381","type":"CDM"},{"code":"360","type":"RC"},{"code":"34710","type":"HCPCS"}],"standard_charges":[{"gross_charge":14469.0,"discounted_cash":7957.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Transcath Deliv Enhanced Fix Device","code_information":[{"code":"8103383","type":"CDM"},{"code":"360","type":"RC"},{"code":"34712","type":"HCPCS"}],"standard_charges":[{"gross_charge":13152.0,"discounted_cash":7233.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Access Closure Fem Art W Lg Sheath Uni","code_information":[{"code":"8103384","type":"CDM"},{"code":"361","type":"RC"},{"code":"34713","type":"HCPCS"}],"standard_charges":[{"gross_charge":1595.0,"discounted_cash":877.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Endv Ablat W Chem Adhesive Ext Init Vein","code_information":[{"code":"8103387","type":"CDM"},{"code":"361","type":"RC"},{"code":"36482","type":"HCPCS"}],"standard_charges":[{"gross_charge":6189.0,"discounted_cash":3403.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Place Cath Select Art 3Rd Leg/Abd/Pelv","code_information":[{"code":"810340","type":"CDM"},{"code":"361","type":"RC"},{"code":"36247","type":"HCPCS"}],"standard_charges":[{"gross_charge":4216.0,"discounted_cash":2318.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Orth Prosth Mgmt Trn Subseq Ea 15Min Pt","code_information":[{"code":"8103403","type":"CDM"},{"code":"420","type":"RC"},{"code":"97763","type":"HCPCS"}],"standard_charges":[{"gross_charge":89.0,"discounted_cash":48.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Place Cath Select Art Add Leg/Abd/Pelv","code_information":[{"code":"810342","type":"CDM"},{"code":"361","type":"RC"},{"code":"36248","type":"HCPCS"}],"standard_charges":[{"gross_charge":5887.0,"discounted_cash":3237.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Asp &/Or Inj Ganglion Cyst(S)","code_information":[{"code":"8103430","type":"CDM"},{"code":"450","type":"RC"},{"code":"20612","type":"HCPCS"}],"standard_charges":[{"gross_charge":1093.0,"discounted_cash":601.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Cont Glucose Monitor Pt Prov Equip","code_information":[{"code":"8103446","type":"CDM"},{"code":"920","type":"RC"},{"code":"95249","type":"HCPCS"}],"standard_charges":[{"gross_charge":295.0,"discounted_cash":162.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ecmo Insert Periph Cannula Perq 6+Yrs","code_information":[{"code":"8103451","type":"CDM"},{"code":"360","type":"RC"},{"code":"33952","type":"HCPCS"}],"standard_charges":[{"gross_charge":2965.0,"discounted_cash":1630.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Plcmt Stent Drug Elut Addl Brnch Cor Art","code_information":[{"code":"810346","type":"CDM"},{"code":"481","type":"RC"},{"code":"C9601","type":"HCPCS"}],"standard_charges":[{"gross_charge":12287.0,"discounted_cash":6757.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Plcmt Stent Drug Elut Sngl Maj Cor Art","code_information":[{"code":"810347","type":"CDM"},{"code":"481","type":"RC"},{"code":"C9600","type":"HCPCS"}],"standard_charges":[{"gross_charge":13236.0,"discounted_cash":7279.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Burr Hole Implant Cath Device","code_information":[{"code":"8103496","type":"CDM"},{"code":"360","type":"RC"},{"code":"61210","type":"HCPCS"}],"standard_charges":[{"gross_charge":15337.0,"discounted_cash":8435.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Tmvi Prosthetic Valve Percutaneous","code_information":[{"code":"8103498","type":"CDM"},{"code":"360","type":"RC"},{"code":"0483T","type":"HCPCS"}],"standard_charges":[{"gross_charge":42830.0,"discounted_cash":23556.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Twist Drill Hole For Cath Ventr","code_information":[{"code":"8103504","type":"CDM"},{"code":"360","type":"RC"},{"code":"61107","type":"HCPCS"}],"standard_charges":[{"gross_charge":2787.0,"discounted_cash":1532.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Tc-99M Non Heu Add On/Dose","code_information":[{"code":"8103506","type":"CDM"},{"code":"343","type":"RC"},{"code":"Q9969","type":"HCPCS"}],"standard_charges":[{"gross_charge":23.0,"discounted_cash":12.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Pos Airway Pressure Cpap Limited","code_information":[{"code":"8103513","type":"CDM"},{"code":"410","type":"RC"},{"code":"94660","type":"HCPCS"}],"standard_charges":[{"gross_charge":421.0,"discounted_cash":231.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Lab Pt Poct Clw","code_information":[{"code":"81035612","type":"CDM"},{"code":"305","type":"RC"},{"code":"85610","type":"HCPCS"}],"standard_charges":[{"gross_charge":57.0,"discounted_cash":31.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ptca Ea Addl Branch Major Coronary Art","code_information":[{"code":"810359","type":"CDM"},{"code":"481","type":"RC"},{"code":"92921","type":"HCPCS"}],"standard_charges":[{"gross_charge":12625.0,"discounted_cash":6943.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ptca Single Major Coronary Artery","code_information":[{"code":"810360","type":"CDM"},{"code":"481","type":"RC"},{"code":"92920","type":"HCPCS"}],"standard_charges":[{"gross_charge":12023.0,"discounted_cash":6612.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Remv Gen Perm Pacer","code_information":[{"code":"810364","type":"CDM"},{"code":"481","type":"RC"},{"code":"33233","type":"HCPCS"}],"standard_charges":[{"gross_charge":9176.0,"discounted_cash":5046.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Fine Needle Asp W Us First Lsn","code_information":[{"code":"8103640","type":"CDM"},{"code":"361","type":"RC"},{"code":"10005","type":"HCPCS"}],"standard_charges":[{"gross_charge":2109.0,"discounted_cash":1159.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Fine Needle Asp W Us Ea Addl Lsn","code_information":[{"code":"8103641","type":"CDM"},{"code":"361","type":"RC"},{"code":"10006","type":"HCPCS"}],"standard_charges":[{"gross_charge":1803.0,"discounted_cash":991.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Fine Needle Asp W Fl First Lsn","code_information":[{"code":"8103642","type":"CDM"},{"code":"361","type":"RC"},{"code":"10007","type":"HCPCS"}],"standard_charges":[{"gross_charge":2416.0,"discounted_cash":1328.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Fine Needle Asp W Fl Ea Addl Lsn","code_information":[{"code":"8103643","type":"CDM"},{"code":"361","type":"RC"},{"code":"10008","type":"HCPCS"}],"standard_charges":[{"gross_charge":1772.0,"discounted_cash":974.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Fine Needle Asp W Ct First Lsn","code_information":[{"code":"8103644","type":"CDM"},{"code":"361","type":"RC"},{"code":"10009","type":"HCPCS"}],"standard_charges":[{"gross_charge":5193.0,"discounted_cash":2856.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Fine Needle Asp W Ct Ea Addl Lsn","code_information":[{"code":"8103645","type":"CDM"},{"code":"361","type":"RC"},{"code":"10010","type":"HCPCS"}],"standard_charges":[{"gross_charge":3895.0,"discounted_cash":2142.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Biopsy Skin Tangential Sngl Lsn","code_information":[{"code":"8103648","type":"CDM"},{"code":"361","type":"RC"},{"code":"11102","type":"HCPCS"}],"standard_charges":[{"gross_charge":1072.0,"discounted_cash":589.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Remove Defib Generator Only","code_information":[{"code":"810365","type":"CDM"},{"code":"481","type":"RC"},{"code":"33241","type":"HCPCS"}],"standard_charges":[{"gross_charge":4498.0,"discounted_cash":2473.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Biopsy Skin Tangential Ea Addl Lsn","code_information":[{"code":"8103650","type":"CDM"},{"code":"361","type":"RC"},{"code":"11103","type":"HCPCS"}],"standard_charges":[{"gross_charge":717.0,"discounted_cash":394.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Biopsy Skin Punch Sngl Lsn","code_information":[{"code":"8103652","type":"CDM"},{"code":"361","type":"RC"},{"code":"11104","type":"HCPCS"}],"standard_charges":[{"gross_charge":1076.0,"discounted_cash":591.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Biopsy Skin Punch Ea Addl Lsn","code_information":[{"code":"8103654","type":"CDM"},{"code":"361","type":"RC"},{"code":"11105","type":"HCPCS"}],"standard_charges":[{"gross_charge":717.0,"discounted_cash":394.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Biopsy Skin Incisional Sngl Lsn","code_information":[{"code":"8103656","type":"CDM"},{"code":"361","type":"RC"},{"code":"11106","type":"HCPCS"}],"standard_charges":[{"gross_charge":1699.0,"discounted_cash":934.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Biopsy Skin Incisional Sngl Lsn","code_information":[{"code":"8103657","type":"CDM"},{"code":"450","type":"RC"},{"code":"11106","type":"HCPCS"}],"standard_charges":[{"gross_charge":1953.0,"discounted_cash":1074.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Biopsy Skin Incisional Ea Addl Lsn","code_information":[{"code":"8103658","type":"CDM"},{"code":"361","type":"RC"},{"code":"11107","type":"HCPCS"}],"standard_charges":[{"gross_charge":1136.0,"discounted_cash":624.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Remv Transven Pacer Electrode 1 Lead Sys","code_information":[{"code":"810366","type":"CDM"},{"code":"481","type":"RC"},{"code":"33234","type":"HCPCS"}],"standard_charges":[{"gross_charge":3914.0,"discounted_cash":2152.7,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Insert Card Rhyth Monitor Subq W Prog","code_information":[{"code":"8103660","type":"CDM"},{"code":"481","type":"RC"},{"code":"33285","type":"HCPCS"}],"standard_charges":[{"gross_charge":13999.0,"discounted_cash":7699.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Remv Card Rhythm Monitor Subq","code_information":[{"code":"8103661","type":"CDM"},{"code":"481","type":"RC"},{"code":"33286","type":"HCPCS"}],"standard_charges":[{"gross_charge":1625.0,"discounted_cash":893.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Replc Gastro Tube Wo Img Wo Rev Gi Trct","code_information":[{"code":"8103662","type":"CDM"},{"code":"361","type":"RC"},{"code":"43762","type":"HCPCS"}],"standard_charges":[{"gross_charge":785.0,"discounted_cash":431.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Replc Gastro Tube Wo Img Wo Rev Gi Tr","code_information":[{"code":"8103663","type":"CDM"},{"code":"450","type":"RC"},{"code":"43762","type":"HCPCS"}],"standard_charges":[{"gross_charge":903.0,"discounted_cash":496.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Replc Gastro Tube Wo Img W Rev Gi Trct","code_information":[{"code":"8103664","type":"CDM"},{"code":"361","type":"RC"},{"code":"43763","type":"HCPCS"}],"standard_charges":[{"gross_charge":1209.0,"discounted_cash":664.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Remv Transven Pacer Electrode 2 Lead Sys","code_information":[{"code":"810367","type":"CDM"},{"code":"481","type":"RC"},{"code":"33235","type":"HCPCS"}],"standard_charges":[{"gross_charge":3373.0,"discounted_cash":1855.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Us Elastography Parenchyma","code_information":[{"code":"8103670","type":"CDM"},{"code":"402","type":"RC"},{"code":"76981","type":"HCPCS"}],"standard_charges":[{"gross_charge":377.0,"discounted_cash":207.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Us Elastography First Target Lesion","code_information":[{"code":"8103671","type":"CDM"},{"code":"402","type":"RC"},{"code":"76982","type":"HCPCS"}],"standard_charges":[{"gross_charge":377.0,"discounted_cash":207.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Us Elastography Ea Addl Target Lesion","code_information":[{"code":"8103672","type":"CDM"},{"code":"402","type":"RC"},{"code":"76983","type":"HCPCS"}],"standard_charges":[{"gross_charge":95.0,"discounted_cash":52.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Mri Breast Wo Contrast Unilateral","code_information":[{"code":"8103673","type":"CDM"},{"code":"614","type":"RC"},{"code":"77046","type":"HCPCS"}],"standard_charges":[{"gross_charge":4080.0,"discounted_cash":2244.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Mri Breast Wo Contrast Bilateral","code_information":[{"code":"8103674","type":"CDM"},{"code":"614","type":"RC"},{"code":"77047","type":"HCPCS"}],"standard_charges":[{"gross_charge":7620.0,"discounted_cash":4191.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Noncdm Charge Record","code_information":[{"code":"8103677","type":"CDM"},{"code":"920","type":"RC"},{"code":"95976","type":"HCPCS"}],"standard_charges":[{"gross_charge":393.6,"discounted_cash":216.48,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Hc Psychological Testing First Hr","code_information":[{"code":"8103687","type":"CDM"},{"code":"918","type":"RC"},{"code":"96130","type":"HCPCS"}],"standard_charges":[{"gross_charge":481.0,"discounted_cash":264.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Psychological Testing Ea Addl Hr","code_information":[{"code":"8103688","type":"CDM"},{"code":"918","type":"RC"},{"code":"96131","type":"HCPCS"}],"standard_charges":[{"gross_charge":362.0,"discounted_cash":199.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Neuropsych Test First Hour","code_information":[{"code":"8103689","type":"CDM"},{"code":"918","type":"RC"},{"code":"96132","type":"HCPCS"}],"standard_charges":[{"gross_charge":371.0,"discounted_cash":204.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Neuropsych Test Ea Addl Hour","code_information":[{"code":"8103690","type":"CDM"},{"code":"918","type":"RC"},{"code":"96133","type":"HCPCS"}],"standard_charges":[{"gross_charge":362.0,"discounted_cash":199.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Psych Or Neuropsy Test Via Elec Platform","code_information":[{"code":"8103691","type":"CDM"},{"code":"918","type":"RC"},{"code":"96146","type":"HCPCS"}],"standard_charges":[{"gross_charge":93.0,"discounted_cash":51.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Unlisted Fluoro Procedure","code_information":[{"code":"8103709","type":"CDM"},{"code":"320","type":"RC"},{"code":"76496","type":"HCPCS"}],"standard_charges":[{"gross_charge":913.0,"discounted_cash":502.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Reposition Electrode Transvenous","code_information":[{"code":"810371","type":"CDM"},{"code":"481","type":"RC"},{"code":"33215","type":"HCPCS"}],"standard_charges":[{"gross_charge":4205.0,"discounted_cash":2312.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Insert Picc Wo Sq Pt >=5Yrs W Img","code_information":[{"code":"8103729","type":"CDM"},{"code":"361","type":"RC"},{"code":"36573","type":"HCPCS"}],"standard_charges":[{"gross_charge":3533.0,"discounted_cash":1943.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Cath Percut Avf Wavelinq Or Ellipsys","code_information":[{"code":"8103746","type":"CDM"},{"code":"272","type":"RC"},{"code":"C1889","type":"HCPCS"}],"standard_charges":[{"gross_charge":24277.32,"discounted_cash":13352.53,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Relocate Pocket For Implantable Defib","code_information":[{"code":"810375","type":"CDM"},{"code":"481","type":"RC"},{"code":"33223","type":"HCPCS"}],"standard_charges":[{"gross_charge":3524.0,"discounted_cash":1938.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Relocate Pocket For Pacemaker","code_information":[{"code":"810376","type":"CDM"},{"code":"481","type":"RC"},{"code":"33222","type":"HCPCS"}],"standard_charges":[{"gross_charge":3524.0,"discounted_cash":1938.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Dry Needling 15 Min","code_information":[{"code":"8103778","type":"CDM"},{"code":"420","type":"RC"}],"standard_charges":[{"gross_charge":101.0,"discounted_cash":55.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Dry Needling 30 Min","code_information":[{"code":"8103779","type":"CDM"},{"code":"420","type":"RC"}],"standard_charges":[{"gross_charge":202.0,"discounted_cash":111.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Tenotomy Achilles Perc Local Ans Bilat","code_information":[{"code":"8103802","type":"CDM"},{"code":"361","type":"RC"},{"code":"27605","type":"HCPCS"}],"standard_charges":[{"gross_charge":9458.0,"discounted_cash":5201.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Trauma Activtn Lvl3 Class1 W Cc Non Ems","code_information":[{"code":"8103811","type":"CDM"},{"code":"450","type":"RC"},{"code":"99499","type":"HCPCS"}],"standard_charges":[{"gross_charge":7157.0,"discounted_cash":3936.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Trauma Activtn Lvl3 Class1 Wo Cc Non Ems","code_information":[{"code":"8103812","type":"CDM"},{"code":"450","type":"RC"},{"code":"99499","type":"HCPCS"}],"standard_charges":[{"gross_charge":7157.0,"discounted_cash":3936.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Trauma Activtn Lvl3 Class2 W Cc Non Ems","code_information":[{"code":"8103813","type":"CDM"},{"code":"450","type":"RC"},{"code":"99499","type":"HCPCS"}],"standard_charges":[{"gross_charge":4729.0,"discounted_cash":2600.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Trauma Activtn Lvl3 Class2 Wo Cc Non Ems","code_information":[{"code":"8103814","type":"CDM"},{"code":"450","type":"RC"},{"code":"99499","type":"HCPCS"}],"standard_charges":[{"gross_charge":4729.0,"discounted_cash":2600.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Perc Incis Hip Adductor","code_information":[{"code":"8103845","type":"CDM"},{"code":"360","type":"RC"},{"code":"27000","type":"HCPCS"}],"standard_charges":[{"gross_charge":4825.0,"discounted_cash":2653.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Perc Inc Adductor/Hamstring Tendon Multi","code_information":[{"code":"8103846","type":"CDM"},{"code":"360","type":"RC"},{"code":"27307","type":"HCPCS"}],"standard_charges":[{"gross_charge":4319.0,"discounted_cash":2375.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Inj Aa Strd Brachial Plexus Sngl W Img","code_information":[{"code":"8103849","type":"CDM"},{"code":"450","type":"RC"},{"code":"64415","type":"HCPCS"}],"standard_charges":[{"gross_charge":2393.0,"discounted_cash":1316.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Thrombectomy Coron Percut","code_information":[{"code":"810385","type":"CDM"},{"code":"481","type":"RC"},{"code":"92973","type":"HCPCS"}],"standard_charges":[{"gross_charge":2354.0,"discounted_cash":1294.7,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Tenotomy Perc Adduc/Hamstrng Sngl","code_information":[{"code":"8103857","type":"CDM"},{"code":"361","type":"RC"},{"code":"27306","type":"HCPCS"}],"standard_charges":[{"gross_charge":5637.0,"discounted_cash":3100.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Glucose Test Strips Per Bottle","code_information":[{"code":"8103946","type":"CDM"},{"code":"270","type":"RC"}],"standard_charges":[{"gross_charge":29.52,"discounted_cash":16.24,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Casting System 3","code_information":[{"code":"8103947","type":"CDM"},{"code":"272","type":"RC"}],"standard_charges":[{"gross_charge":387.16,"discounted_cash":212.94,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"},{"gross_charge":378.45,"discounted_cash":208.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Hc Casting System 4","code_information":[{"code":"8103948","type":"CDM"},{"code":"272","type":"RC"}],"standard_charges":[{"gross_charge":387.16,"discounted_cash":212.94,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"},{"gross_charge":378.45,"discounted_cash":208.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Hc Boot Regular","code_information":[{"code":"8103949","type":"CDM"},{"code":"271","type":"RC"}],"standard_charges":[{"gross_charge":237.28,"discounted_cash":130.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Boot Xl","code_information":[{"code":"8103950","type":"CDM"},{"code":"271","type":"RC"}],"standard_charges":[{"gross_charge":330.39,"discounted_cash":181.71,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"},{"gross_charge":322.96,"discounted_cash":177.63,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Hc Boot Large","code_information":[{"code":"8103951","type":"CDM"},{"code":"271","type":"RC"}],"standard_charges":[{"gross_charge":316.76,"discounted_cash":174.22,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"},{"gross_charge":309.64,"discounted_cash":170.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Hc Boot Charcot Lg","code_information":[{"code":"8103952","type":"CDM"},{"code":"271","type":"RC"}],"standard_charges":[{"gross_charge":353.09,"discounted_cash":194.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Boot Charcot Xl","code_information":[{"code":"8103953","type":"CDM"},{"code":"271","type":"RC"}],"standard_charges":[{"gross_charge":353.09,"discounted_cash":194.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Sensor Vaginal","code_information":[{"code":"8103955","type":"CDM"},{"code":"272","type":"RC"}],"standard_charges":[{"gross_charge":183.93,"discounted_cash":101.16,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Arch Support Ea","code_information":[{"code":"8103956","type":"CDM"},{"code":"274","type":"RC"},{"code":"L3010","type":"HCPCS"}],"standard_charges":[{"gross_charge":333.8,"discounted_cash":183.59,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Insert Metatarsal Foot Ea","code_information":[{"code":"8103957","type":"CDM"},{"code":"274","type":"RC"},{"code":"L3020","type":"HCPCS"}],"standard_charges":[{"gross_charge":380.34,"discounted_cash":209.19,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"},{"gross_charge":372.51,"discounted_cash":204.88,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."},{"gross_charge":372.36,"discounted_cash":204.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Hc Hand Orth Wo Jnts Cf","code_information":[{"code":"8103958","type":"CDM"},{"code":"274","type":"RC"},{"code":"L3919","type":"HCPCS"}],"standard_charges":[{"gross_charge":390.57,"discounted_cash":214.81,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"},{"gross_charge":381.79,"discounted_cash":209.98,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Hc Rb Pvt Med/Surg/Gyn Intermed","code_information":[{"code":"8103962","type":"CDM"},{"code":"111","type":"RC"}],"standard_charges":[{"gross_charge":2096.0,"discounted_cash":1152.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Rb Swing Bed Dept Corrections","code_information":[{"code":"8103963","type":"CDM"},{"code":"190","type":"RC"}],"standard_charges":[{"gross_charge":1203.0,"discounted_cash":661.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Rb Swing Bed Alt Care Unit","code_information":[{"code":"8103965","type":"CDM"},{"code":"190","type":"RC"}],"standard_charges":[{"gross_charge":284.0,"discounted_cash":156.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Rb Secured Unit","code_information":[{"code":"8103966","type":"CDM"},{"code":"110","type":"RC"}],"standard_charges":[{"gross_charge":3247.0,"discounted_cash":1785.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Tte Cong Cmplt Dop&Color Wo Con Pnl Mst","code_information":[{"code":"8103968","type":"CDM"},{"code":"998","type":"RC"}],"standard_charges":[{"gross_charge":2180.0,"discounted_cash":1199.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Tte Cong Cmplt W Dop&Color W Con Pnl Mst","code_information":[{"code":"8103969","type":"CDM"},{"code":"998","type":"RC"}],"standard_charges":[{"gross_charge":2180.0,"discounted_cash":1199.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Tee Cmplt W Color W Con Pnl Mstr","code_information":[{"code":"8103972","type":"CDM"},{"code":"998","type":"RC"}],"standard_charges":[{"gross_charge":2180.0,"discounted_cash":1199.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Card Rehab Exer Init Visit","code_information":[{"code":"810398","type":"CDM"},{"code":"943","type":"RC"},{"code":"93798","type":"HCPCS"}],"standard_charges":[{"gross_charge":551.0,"discounted_cash":303.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Card Rehab W/ Ekg Phase Ii","code_information":[{"code":"810399","type":"CDM"},{"code":"943","type":"RC"},{"code":"93798","type":"HCPCS"}],"standard_charges":[{"gross_charge":525.0,"discounted_cash":288.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Appl Cast Total Contact Leg Bilat","code_information":[{"code":"8104003","type":"CDM"},{"code":"361","type":"RC"},{"code":"29445","type":"HCPCS"}],"standard_charges":[{"gross_charge":1683.0,"discounted_cash":925.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Fibrinolysis Via Chest Tube Subseq Day","code_information":[{"code":"8104004","type":"CDM"},{"code":"361","type":"RC"},{"code":"32562","type":"HCPCS"}],"standard_charges":[{"gross_charge":1295.0,"discounted_cash":712.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Rpr Endov Ao Iliac W Endogrft Ruptr","code_information":[{"code":"8104005","type":"CDM"},{"code":"360","type":"RC"},{"code":"34706","type":"HCPCS"}],"standard_charges":[{"gross_charge":22782.0,"discounted_cash":12530.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Thromboendarterectomy Femoral Deep","code_information":[{"code":"8104006","type":"CDM"},{"code":"360","type":"RC"},{"code":"35372","type":"HCPCS"}],"standard_charges":[{"gross_charge":7013.0,"discounted_cash":3857.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Bypass Grft Fem Tib Or Distl Vessel","code_information":[{"code":"8104007","type":"CDM"},{"code":"360","type":"RC"},{"code":"35566","type":"HCPCS"}],"standard_charges":[{"gross_charge":21922.0,"discounted_cash":12057.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Bypass Grft Subclavian To Subclavian","code_information":[{"code":"8104008","type":"CDM"},{"code":"360","type":"RC"},{"code":"35612","type":"HCPCS"}],"standard_charges":[{"gross_charge":21922.0,"discounted_cash":12057.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Revise Av Fist W Thromb Open","code_information":[{"code":"8104009","type":"CDM"},{"code":"361","type":"RC"},{"code":"36833","type":"HCPCS"}],"standard_charges":[{"gross_charge":8024.0,"discounted_cash":4413.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Endo Sm Int >Second Port Duod W Jej Tb","code_information":[{"code":"8104010","type":"CDM"},{"code":"750","type":"RC"},{"code":"44372","type":"HCPCS"}],"standard_charges":[{"gross_charge":2144.0,"discounted_cash":1179.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Nephro Pyelostolithotomy Up To 2Cm","code_information":[{"code":"8104011","type":"CDM"},{"code":"361","type":"RC"},{"code":"50080","type":"HCPCS"}],"standard_charges":[{"gross_charge":7742.0,"discounted_cash":4258.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Actigraphy Test >73 Hrs 14 Cons Days","code_information":[{"code":"8104014","type":"CDM"},{"code":"740","type":"RC"},{"code":"95803","type":"HCPCS"}],"standard_charges":[{"gross_charge":374.0,"discounted_cash":205.7,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Cognitive Test By Hc Pro Per Hr Ot","code_information":[{"code":"8104015","type":"CDM"},{"code":"430","type":"RC"},{"code":"96125","type":"HCPCS"}],"standard_charges":[{"gross_charge":899.0,"discounted_cash":494.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Exam Sexual Assault","code_information":[{"code":"8104016","type":"CDM"},{"code":"450","type":"RC"},{"code":"99285","type":"HCPCS"}],"standard_charges":[{"gross_charge":1755.0,"discounted_cash":965.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc I123 Sodium Iodide Dx Per Mci","code_information":[{"code":"8104018","type":"CDM"},{"code":"343","type":"RC"},{"code":"A9509","type":"HCPCS"}],"standard_charges":[{"gross_charge":1352.0,"discounted_cash":743.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Multidisciplinary Team Conf W Pt","code_information":[{"code":"8104019","type":"CDM"},{"code":"761","type":"RC"},{"code":"G0175","type":"HCPCS"}],"standard_charges":[{"gross_charge":402.0,"discounted_cash":221.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Aki Dialysis Wo Ersd","code_information":[{"code":"8104021","type":"CDM"},{"code":"821","type":"RC"},{"code":"G0491","type":"HCPCS"}],"standard_charges":[{"gross_charge":1111.0,"discounted_cash":611.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Mod Sed Endo >5Yrs First 15 Min","code_information":[{"code":"8104022","type":"CDM"},{"code":"370","type":"RC"},{"code":"G0500","type":"HCPCS"}],"standard_charges":[{"gross_charge":173.0,"discounted_cash":95.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ads Half Day Level 1","code_information":[{"code":"8104024","type":"CDM"},{"code":"3103","type":"RC"},{"code":"S5101","type":"HCPCS"}],"standard_charges":[{"gross_charge":105.0,"discounted_cash":57.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ads Half Day Level 2","code_information":[{"code":"8104025","type":"CDM"},{"code":"3103","type":"RC"},{"code":"S5101","type":"HCPCS"}],"standard_charges":[{"gross_charge":115.0,"discounted_cash":63.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ads Half Day Level 3","code_information":[{"code":"8104026","type":"CDM"},{"code":"3103","type":"RC"},{"code":"S5101","type":"HCPCS"}],"standard_charges":[{"gross_charge":126.67,"discounted_cash":69.67,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ads Half Day Level 4","code_information":[{"code":"8104027","type":"CDM"},{"code":"3103","type":"RC"},{"code":"S5101","type":"HCPCS"}],"standard_charges":[{"gross_charge":140.0,"discounted_cash":77.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ads Half Day Level 5","code_information":[{"code":"8104028","type":"CDM"},{"code":"3103","type":"RC"},{"code":"S5101","type":"HCPCS"}],"standard_charges":[{"gross_charge":151.67,"discounted_cash":83.42,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ads Full Day Level 1","code_information":[{"code":"8104029","type":"CDM"},{"code":"3103","type":"RC"},{"code":"S5102","type":"HCPCS"}],"standard_charges":[{"gross_charge":115.0,"discounted_cash":63.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ads Full Day Level 2","code_information":[{"code":"8104030","type":"CDM"},{"code":"3103","type":"RC"},{"code":"S5102","type":"HCPCS"}],"standard_charges":[{"gross_charge":125.0,"discounted_cash":68.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ads Full Day Level 3","code_information":[{"code":"8104031","type":"CDM"},{"code":"3103","type":"RC"},{"code":"S5102","type":"HCPCS"}],"standard_charges":[{"gross_charge":136.67,"discounted_cash":75.17,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ads Full Day Level 4","code_information":[{"code":"8104033","type":"CDM"},{"code":"3103","type":"RC"},{"code":"S5102","type":"HCPCS"}],"standard_charges":[{"gross_charge":150.0,"discounted_cash":82.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ads Full Day Level 5","code_information":[{"code":"8104034","type":"CDM"},{"code":"3103","type":"RC"},{"code":"S5102","type":"HCPCS"}],"standard_charges":[{"gross_charge":161.67,"discounted_cash":88.92,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ads Bathing Service 1 Assist Lcd/Self","code_information":[{"code":"8104036","type":"CDM"},{"code":"3109","type":"RC"},{"code":"S5136","type":"HCPCS"}],"standard_charges":[{"gross_charge":50.0,"discounted_cash":27.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ads Bathing Service 2 Assist Lcd/Self","code_information":[{"code":"8104037","type":"CDM"},{"code":"3109","type":"RC"},{"code":"S5136","type":"HCPCS"}],"standard_charges":[{"gross_charge":61.0,"discounted_cash":33.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ads Hair Washing","code_information":[{"code":"8104038","type":"CDM"},{"code":"3109","type":"RC"},{"code":"S5136","type":"HCPCS"}],"standard_charges":[{"gross_charge":23.0,"discounted_cash":12.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ads Bathing Srvc 1 Assist Attend Day Prg","code_information":[{"code":"8104039","type":"CDM"},{"code":"3101","type":"RC"},{"code":"S5126","type":"HCPCS"}],"standard_charges":[{"gross_charge":50.0,"discounted_cash":27.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ads Bathing Service 2 Assist All Cw","code_information":[{"code":"8104040","type":"CDM"},{"code":"3101","type":"RC"},{"code":"S5105","type":"HCPCS"}],"standard_charges":[{"gross_charge":61.0,"discounted_cash":33.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Cardiac Rehab Phase 3 W Monitor","code_information":[{"code":"8104042","type":"CDM"},{"code":"943","type":"RC"}],"standard_charges":[{"gross_charge":90.0,"discounted_cash":49.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Biliblanket","code_information":[{"code":"8104043","type":"CDM"},{"code":"271","type":"RC"}],"standard_charges":[{"gross_charge":841.31,"discounted_cash":462.72,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"},{"gross_charge":825.09,"discounted_cash":453.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."},{"gross_charge":822.39,"discounted_cash":452.31,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Hc Respite Care Linen Charge","code_information":[{"code":"8104045","type":"CDM"},{"code":"999","type":"RC"}],"standard_charges":[{"gross_charge":7.0,"discounted_cash":3.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Respite Care Saturday Day","code_information":[{"code":"8104046","type":"CDM"},{"code":"999","type":"RC"}],"standard_charges":[{"gross_charge":165.0,"discounted_cash":90.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Respite Care Saturday Pm","code_information":[{"code":"8104047","type":"CDM"},{"code":"999","type":"RC"}],"standard_charges":[{"gross_charge":165.0,"discounted_cash":90.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Respite Care Sunday Day","code_information":[{"code":"8104048","type":"CDM"},{"code":"999","type":"RC"}],"standard_charges":[{"gross_charge":165.0,"discounted_cash":90.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Respite Care Sunday Pm","code_information":[{"code":"8104049","type":"CDM"},{"code":"999","type":"RC"}],"standard_charges":[{"gross_charge":61.0,"discounted_cash":33.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Respite Care Saturday Night","code_information":[{"code":"8104050","type":"CDM"},{"code":"999","type":"RC"}],"standard_charges":[{"gross_charge":60.0,"discounted_cash":33.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Respite Care Meals Snack Daily","code_information":[{"code":"8104051","type":"CDM"},{"code":"999","type":"RC"}],"standard_charges":[{"gross_charge":25.0,"discounted_cash":13.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Cath Tlum 5Fr Lf Picc Max Solo","code_information":[{"code":"8104056","type":"CDM"},{"code":"272","type":"RC"},{"code":"C1751","type":"HCPCS"}],"standard_charges":[{"gross_charge":953.34,"discounted_cash":524.34,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Hc Polysom <6Yrs 4 Or More Param <7Hrs","code_information":[{"code":"8104057","type":"CDM"},{"code":"920","type":"RC"},{"code":"95782","type":"HCPCS"}],"standard_charges":[{"gross_charge":5873.0,"discounted_cash":3230.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Polysom W/Cpap >=6Yrs <6Hrs","code_information":[{"code":"8104058","type":"CDM"},{"code":"920","type":"RC"},{"code":"95811","type":"HCPCS"}],"standard_charges":[{"gross_charge":6052.0,"discounted_cash":3328.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Polysom <6Yrs 4 Param Cpap Bipap <7Hrs","code_information":[{"code":"8104060","type":"CDM"},{"code":"920","type":"RC"},{"code":"95783","type":"HCPCS"}],"standard_charges":[{"gross_charge":6053.0,"discounted_cash":3329.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Psychophys Therapy Indiv W Biofeed 30 Min","code_information":[{"code":"8104061","type":"CDM"},{"code":"914","type":"RC"},{"code":"90875","type":"HCPCS"}],"standard_charges":[{"gross_charge":288.0,"discounted_cash":158.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Therapy Activity Day Tx >=45 Min","code_information":[{"code":"8104068","type":"CDM"},{"code":"904","type":"RC"},{"code":"G0176","type":"HCPCS"}],"standard_charges":[{"gross_charge":149.0,"discounted_cash":81.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Surgery Acne Remv Marsup Cyst","code_information":[{"code":"8104069","type":"CDM"},{"code":"450","type":"RC"},{"code":"10040","type":"HCPCS"}],"standard_charges":[{"gross_charge":751.0,"discounted_cash":413.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Card Rehab W/ Ekg","code_information":[{"code":"810407","type":"CDM"},{"code":"943","type":"RC"},{"code":"93798","type":"HCPCS"}],"standard_charges":[{"gross_charge":672.0,"discounted_cash":369.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Inj Erector Spine Plan Block","code_information":[{"code":"8104070","type":"CDM"},{"code":"361","type":"RC"},{"code":"64999","type":"HCPCS"}],"standard_charges":[{"gross_charge":714.0,"discounted_cash":392.7,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Inj Quadratus Lumborum Block","code_information":[{"code":"8104071","type":"CDM"},{"code":"361","type":"RC"},{"code":"64999","type":"HCPCS"}],"standard_charges":[{"gross_charge":714.0,"discounted_cash":392.7,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Elec Stim Unattended Non Wound","code_information":[{"code":"8104078","type":"CDM"},{"code":"951","type":"RC"},{"code":"G0283","type":"HCPCS"}],"standard_charges":[{"gross_charge":124.0,"discounted_cash":68.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Aquatic Therapy W Ther Exercise","code_information":[{"code":"8104079","type":"CDM"},{"code":"951","type":"RC"},{"code":"97113","type":"HCPCS"}],"standard_charges":[{"gross_charge":162.0,"discounted_cash":89.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Card Rehab W/O Ekg","code_information":[{"code":"810408","type":"CDM"},{"code":"943","type":"RC"},{"code":"93797","type":"HCPCS"}],"standard_charges":[{"gross_charge":434.0,"discounted_cash":238.7,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Orth Prosth Mgmt Trn Subseq Ea 15Min","code_information":[{"code":"8104080","type":"CDM"},{"code":"951","type":"RC"},{"code":"97763","type":"HCPCS"}],"standard_charges":[{"gross_charge":89.0,"discounted_cash":48.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Biofeedback Electromyogram","code_information":[{"code":"8104081","type":"CDM"},{"code":"951","type":"RC"},{"code":"90901","type":"HCPCS"}],"standard_charges":[{"gross_charge":215.0,"discounted_cash":118.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Trauma Activation Lvl4 Class 1 Wo Cc","code_information":[{"code":"8104082","type":"CDM"},{"code":"684","type":"RC"},{"code":"99499","type":"HCPCS"}],"standard_charges":[{"gross_charge":9912.0,"discounted_cash":5451.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Trauma Activation Lvl4 Class 2 W Cc","code_information":[{"code":"8104083","type":"CDM"},{"code":"684","type":"RC"},{"code":"G0390","type":"HCPCS"}],"standard_charges":[{"gross_charge":6551.0,"discounted_cash":3603.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Trauma Activation Lvl4 Class 2 Wo Cc","code_information":[{"code":"8104084","type":"CDM"},{"code":"684","type":"RC"},{"code":"99499","type":"HCPCS"}],"standard_charges":[{"gross_charge":6551.0,"discounted_cash":3603.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Trauma Activtn Lvl4 Class1 W Cc Non Ems","code_information":[{"code":"8104085","type":"CDM"},{"code":"450","type":"RC"},{"code":"99499","type":"HCPCS"}],"standard_charges":[{"gross_charge":7088.0,"discounted_cash":3898.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Trauma Activtn Lvl4 Class1 Wo Cc Non Ems","code_information":[{"code":"8104086","type":"CDM"},{"code":"450","type":"RC"},{"code":"99499","type":"HCPCS"}],"standard_charges":[{"gross_charge":7088.0,"discounted_cash":3898.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Trauma Activtn Lvl4 Class2 W Cc Non Ems","code_information":[{"code":"8104087","type":"CDM"},{"code":"450","type":"RC"},{"code":"99499","type":"HCPCS"}],"standard_charges":[{"gross_charge":4685.0,"discounted_cash":2576.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Trauma Activtn Lvl4 Class2 Wo Cc Non Ems","code_information":[{"code":"8104088","type":"CDM"},{"code":"450","type":"RC"},{"code":"99499","type":"HCPCS"}],"standard_charges":[{"gross_charge":4685.0,"discounted_cash":2576.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Trauma Activation Lvl4 Class 1 W Cc","code_information":[{"code":"8104094","type":"CDM"},{"code":"684","type":"RC"},{"code":"G0390","type":"HCPCS"}],"standard_charges":[{"gross_charge":9912.0,"discounted_cash":5451.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Prep Of Report Pt Psych Status","code_information":[{"code":"8104110","type":"CDM"},{"code":"900","type":"RC"},{"code":"90889","type":"HCPCS"}],"standard_charges":[{"gross_charge":260.0,"discounted_cash":143.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Neurobehavioral Status Exam Ea Addl Hr","code_information":[{"code":"8104112","type":"CDM"},{"code":"918","type":"RC"},{"code":"96121","type":"HCPCS"}],"standard_charges":[{"gross_charge":162.0,"discounted_cash":89.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Psy Neuropsy Test >=2 By Dr Qhp 1St 30M","code_information":[{"code":"8104113","type":"CDM"},{"code":"918","type":"RC"},{"code":"96136","type":"HCPCS"}],"standard_charges":[{"gross_charge":91.0,"discounted_cash":50.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Psy Neuropsy Test >=2 By Dr Qhp Addl 30M","code_information":[{"code":"8104114","type":"CDM"},{"code":"918","type":"RC"},{"code":"96137","type":"HCPCS"}],"standard_charges":[{"gross_charge":91.0,"discounted_cash":50.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Psy Neuropsy Test >=2 By Tech 1St 30M","code_information":[{"code":"8104115","type":"CDM"},{"code":"918","type":"RC"},{"code":"96138","type":"HCPCS"}],"standard_charges":[{"gross_charge":168.0,"discounted_cash":92.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Psy Neuropsy Test >=2 By Tech Addl 30M","code_information":[{"code":"8104119","type":"CDM"},{"code":"918","type":"RC"},{"code":"96139","type":"HCPCS"}],"standard_charges":[{"gross_charge":170.0,"discounted_cash":93.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed I And D Tongue/Floor Sublngl Supfc","code_information":[{"code":"8104123","type":"CDM"},{"code":"450","type":"RC"},{"code":"41005","type":"HCPCS"}],"standard_charges":[{"gross_charge":1178.0,"discounted_cash":647.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Pericardiocentesis Including Img","code_information":[{"code":"8104149","type":"CDM"},{"code":"361","type":"RC"},{"code":"33016","type":"HCPCS"}],"standard_charges":[{"gross_charge":2260.0,"discounted_cash":1243.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Pericard Drn W Indw Cth W Us Fl >=6Yrs","code_information":[{"code":"8104150","type":"CDM"},{"code":"360","type":"RC"},{"code":"33017","type":"HCPCS"}],"standard_charges":[{"gross_charge":2260.0,"discounted_cash":1243.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Rpr Evasc Iliac W Ao Endogft Unilat","code_information":[{"code":"8104152","type":"CDM"},{"code":"360","type":"RC"},{"code":"34717","type":"HCPCS"}],"standard_charges":[{"gross_charge":12591.0,"discounted_cash":6925.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Rpr Evasc Iliac Wo Ao Endogft Unilat","code_information":[{"code":"8104153","type":"CDM"},{"code":"360","type":"RC"},{"code":"34718","type":"HCPCS"}],"standard_charges":[{"gross_charge":12591.0,"discounted_cash":6925.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Lumbar Puncture Dx W Fl Or Ct","code_information":[{"code":"8104154","type":"CDM"},{"code":"361","type":"RC"},{"code":"62328","type":"HCPCS"}],"standard_charges":[{"gross_charge":3660.0,"discounted_cash":2013.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Lumbar Puncture Tx Drain W Fl Or Ct","code_information":[{"code":"8104155","type":"CDM"},{"code":"361","type":"RC"},{"code":"62329","type":"HCPCS"}],"standard_charges":[{"gross_charge":2806.0,"discounted_cash":1543.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Inj Aa Strd Nerves Sacroiliac Jt W Img","code_information":[{"code":"8104156","type":"CDM"},{"code":"361","type":"RC"},{"code":"64451","type":"HCPCS"}],"standard_charges":[{"gross_charge":3488.0,"discounted_cash":1918.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ablate Rf Nerves Sacroiliac Jt W Img","code_information":[{"code":"8104157","type":"CDM"},{"code":"361","type":"RC"},{"code":"64625","type":"HCPCS"}],"standard_charges":[{"gross_charge":3114.0,"discounted_cash":1712.7,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Inj Aa Strd Genicular Nrv Branch W Img","code_information":[{"code":"8104158","type":"CDM"},{"code":"361","type":"RC"},{"code":"64454","type":"HCPCS"}],"standard_charges":[{"gross_charge":3488.0,"discounted_cash":1918.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Destruct Genicular Nrv Neurolytic W Img","code_information":[{"code":"8104159","type":"CDM"},{"code":"361","type":"RC"},{"code":"64624","type":"HCPCS"}],"standard_charges":[{"gross_charge":7165.0,"discounted_cash":3940.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Xray Sm Intestine Follow Through","code_information":[{"code":"8104160","type":"CDM"},{"code":"320","type":"RC"},{"code":"74248","type":"HCPCS"}],"standard_charges":[{"gross_charge":328.0,"discounted_cash":180.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Xray Esoph Double Contrast","code_information":[{"code":"8104161","type":"CDM"},{"code":"320","type":"RC"},{"code":"74221","type":"HCPCS"}],"standard_charges":[{"gross_charge":503.0,"discounted_cash":276.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Rp Localzn Tmr Spect W Ct 1 Area 1 Day","code_information":[{"code":"8104163","type":"CDM"},{"code":"341","type":"RC"},{"code":"78830","type":"HCPCS"}],"standard_charges":[{"gross_charge":4118.0,"discounted_cash":2264.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Rp Localzn Tmr Spect Mult Area Or Day","code_information":[{"code":"8104164","type":"CDM"},{"code":"341","type":"RC"},{"code":"78831","type":"HCPCS"}],"standard_charges":[{"gross_charge":4838.0,"discounted_cash":2660.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Biofeedback Perin Or Sphinc 1St 15Min","code_information":[{"code":"8104167","type":"CDM"},{"code":"750","type":"RC"},{"code":"90912","type":"HCPCS"}],"standard_charges":[{"gross_charge":245.0,"discounted_cash":134.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Biofeedback Perin Or Sphinc Addl 15Min","code_information":[{"code":"8104168","type":"CDM"},{"code":"750","type":"RC"},{"code":"90913","type":"HCPCS"}],"standard_charges":[{"gross_charge":245.0,"discounted_cash":134.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Duplex Scan For Hemodialysis Cmplt Bilat","code_information":[{"code":"8104169","type":"CDM"},{"code":"921","type":"RC"},{"code":"93985","type":"HCPCS"}],"standard_charges":[{"gross_charge":1638.0,"discounted_cash":900.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Phys Perf Test Indiv Ea 15 Min","code_information":[{"code":"810418","type":"CDM"},{"code":"410","type":"RC"},{"code":"G0238","type":"HCPCS"}],"standard_charges":[{"gross_charge":76.0,"discounted_cash":41.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Cognitive Func W Patient Init 15 Min Ot","code_information":[{"code":"8104188","type":"CDM"},{"code":"430","type":"RC"},{"code":"97129","type":"HCPCS"}],"standard_charges":[{"gross_charge":99.0,"discounted_cash":54.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Cognitive Func W Patient Ea Add 15Min Ot","code_information":[{"code":"8104189","type":"CDM"},{"code":"430","type":"RC"},{"code":"97130","type":"HCPCS"}],"standard_charges":[{"gross_charge":99.0,"discounted_cash":54.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Cognitive Func W Patient Init 15 Min St","code_information":[{"code":"8104190","type":"CDM"},{"code":"440","type":"RC"},{"code":"97129","type":"HCPCS"}],"standard_charges":[{"gross_charge":99.0,"discounted_cash":54.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Cognitive Func W Patient Ea Add 15Min St","code_information":[{"code":"8104191","type":"CDM"},{"code":"440","type":"RC"},{"code":"97130","type":"HCPCS"}],"standard_charges":[{"gross_charge":99.0,"discounted_cash":54.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Pericardiocentesis Including Img","code_information":[{"code":"8104192","type":"CDM"},{"code":"450","type":"RC"},{"code":"33016","type":"HCPCS"}],"standard_charges":[{"gross_charge":2599.0,"discounted_cash":1429.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Supplies V60 Phillips Rt","code_information":[{"code":"8104206","type":"CDM"},{"code":"272","type":"RC"}],"standard_charges":[{"gross_charge":223.66,"discounted_cash":123.01,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Pericard Drn W Indw Cth W Ct","code_information":[{"code":"8104210","type":"CDM"},{"code":"360","type":"RC"},{"code":"33019","type":"HCPCS"}],"standard_charges":[{"gross_charge":2260.0,"discounted_cash":1243.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Interview Psych Dx Gl","code_information":[{"code":"8104234","type":"CDM"},{"code":"900","type":"RC"},{"code":"90791","type":"HCPCS"}],"standard_charges":[{"gross_charge":596.0,"discounted_cash":327.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Psychotherapy W Pt 45 Min Gl","code_information":[{"code":"8104235","type":"CDM"},{"code":"914","type":"RC"},{"code":"90834","type":"HCPCS"}],"standard_charges":[{"gross_charge":507.0,"discounted_cash":278.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Psychotherapy W Pt 60 Min Gl","code_information":[{"code":"8104236","type":"CDM"},{"code":"914","type":"RC"},{"code":"90837","type":"HCPCS"}],"standard_charges":[{"gross_charge":631.0,"discounted_cash":347.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Op Psychotherapy For Crisis Addl 30Min","code_information":[{"code":"8104241","type":"CDM"},{"code":"914","type":"RC"},{"code":"90840","type":"HCPCS"}],"standard_charges":[{"gross_charge":186.0,"discounted_cash":102.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Op Family Psychotherapy Wo Pt 50Min","code_information":[{"code":"8104242","type":"CDM"},{"code":"916","type":"RC"},{"code":"90846","type":"HCPCS"}],"standard_charges":[{"gross_charge":238.0,"discounted_cash":130.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Op Multi Family Group Psychotherapy","code_information":[{"code":"8104243","type":"CDM"},{"code":"916","type":"RC"},{"code":"90849","type":"HCPCS"}],"standard_charges":[{"gross_charge":186.0,"discounted_cash":102.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Enviornmental Manipulation","code_information":[{"code":"8104244","type":"CDM"},{"code":"916","type":"RC"},{"code":"90882","type":"HCPCS"}],"standard_charges":[{"gross_charge":199.0,"discounted_cash":109.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Consultation With Family To Assist Pt","code_information":[{"code":"8104245","type":"CDM"},{"code":"914","type":"RC"},{"code":"90887","type":"HCPCS"}],"standard_charges":[{"gross_charge":193.0,"discounted_cash":106.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Therapy Strength Endur Indiv Ea 15 Min","code_information":[{"code":"810425","type":"CDM"},{"code":"410","type":"RC"},{"code":"G0237","type":"HCPCS"}],"standard_charges":[{"gross_charge":90.0,"discounted_cash":49.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Op Group Therapy Day Rate","code_information":[{"code":"8104336","type":"CDM"},{"code":"915","type":"RC"},{"code":"90853","type":"HCPCS"}],"standard_charges":[{"gross_charge":226.0,"discounted_cash":124.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Probe Watchpat","code_information":[{"code":"8104339","type":"CDM"},{"code":"272","type":"RC"}],"standard_charges":[{"gross_charge":180.52,"discounted_cash":99.29,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"},{"gross_charge":176.6,"discounted_cash":97.13,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Hc Ct Whole Body Scan","code_information":[{"code":"8104344","type":"CDM"},{"code":"350","type":"RC"},{"code":"76497","type":"HCPCS"}],"standard_charges":[{"gross_charge":249.0,"discounted_cash":136.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Applic Splint Short Arm Static","code_information":[{"code":"810437","type":"CDM"},{"code":"361","type":"RC"},{"code":"29125","type":"HCPCS"}],"standard_charges":[{"gross_charge":451.0,"discounted_cash":248.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Telephone Assess Est Pt Non Md 5-10Min","code_information":[{"code":"8104382","type":"CDM"},{"code":"780","type":"RC"},{"code":"98966","type":"HCPCS"}],"standard_charges":[{"gross_charge":84.0,"discounted_cash":46.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Telephone Assess Est Pt Non Md 11-20Min","code_information":[{"code":"8104383","type":"CDM"},{"code":"780","type":"RC"},{"code":"98967","type":"HCPCS"}],"standard_charges":[{"gross_charge":167.0,"discounted_cash":91.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Telephone Assess Est Pt Non Md 21-30Min","code_information":[{"code":"8104384","type":"CDM"},{"code":"780","type":"RC"},{"code":"98968","type":"HCPCS"}],"standard_charges":[{"gross_charge":250.0,"discounted_cash":137.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Qnhp Ol Dig E/M Sv Es Pt <7 D 5-10Min Pt","code_information":[{"code":"8104386","type":"CDM"},{"code":"420","type":"RC"},{"code":"98970","type":"HCPCS"}],"standard_charges":[{"gross_charge":79.0,"discounted_cash":43.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Qnhp Ol Dig E/M Sv Es Pt <7D11-20Min Pt","code_information":[{"code":"8104387","type":"CDM"},{"code":"420","type":"RC"},{"code":"98971","type":"HCPCS"}],"standard_charges":[{"gross_charge":139.0,"discounted_cash":76.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Qnhp Ol Dig E/M Sv Es Pt <7 D 21+Min Pt","code_information":[{"code":"8104388","type":"CDM"},{"code":"420","type":"RC"},{"code":"98972","type":"HCPCS"}],"standard_charges":[{"gross_charge":219.0,"discounted_cash":120.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Spinal Hardware Pain Injection","code_information":[{"code":"8104392","type":"CDM"},{"code":"361","type":"RC"},{"code":"64999","type":"HCPCS"}],"standard_charges":[{"gross_charge":3078.0,"discounted_cash":1692.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Arthrocentesis Joint Intermed Wo Us","code_information":[{"code":"810441","type":"CDM"},{"code":"361","type":"RC"},{"code":"20605","type":"HCPCS"}],"standard_charges":[{"gross_charge":1516.0,"discounted_cash":833.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Us Dx Eye B Scan","code_information":[{"code":"8104462","type":"CDM"},{"code":"402","type":"RC"},{"code":"76512","type":"HCPCS"}],"standard_charges":[{"gross_charge":670.0,"discounted_cash":368.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Carpal Tunnel Release Unilat","code_information":[{"code":"8104511","type":"CDM"},{"code":"450","type":"RC"},{"code":"64721","type":"HCPCS"}],"standard_charges":[{"gross_charge":8305.0,"discounted_cash":4567.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Inj Ipack Block","code_information":[{"code":"8104553","type":"CDM"},{"code":"361","type":"RC"},{"code":"64999","type":"HCPCS"}],"standard_charges":[{"gross_charge":714.0,"discounted_cash":392.7,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Biopsy Needle Lung Percut W Img","code_information":[{"code":"8104577","type":"CDM"},{"code":"361","type":"RC"},{"code":"32408","type":"HCPCS"}],"standard_charges":[{"gross_charge":9166.0,"discounted_cash":5041.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Aep Screen Hearing Newborn","code_information":[{"code":"8104579","type":"CDM"},{"code":"471","type":"RC"},{"code":"92650","type":"HCPCS"}],"standard_charges":[{"gross_charge":718.0,"discounted_cash":394.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ekg >7Days To 15 Days Cont Record","code_information":[{"code":"8104584","type":"CDM"},{"code":"731","type":"RC"},{"code":"93246","type":"HCPCS"}],"standard_charges":[{"gross_charge":233.0,"discounted_cash":128.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ekg >48Hrs To 7 Days Cont Record","code_information":[{"code":"8104591","type":"CDM"},{"code":"731","type":"RC"},{"code":"93242","type":"HCPCS"}],"standard_charges":[{"gross_charge":233.0,"discounted_cash":128.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Repair Of Foot Tendon","code_information":[{"code":"8104593","type":"CDM"},{"code":"450","type":"RC"},{"code":"28200","type":"HCPCS"}],"standard_charges":[{"gross_charge":10972.0,"discounted_cash":6034.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Circuit High Flow Disp","code_information":[{"code":"8104594","type":"CDM"},{"code":"270","type":"RC"}],"standard_charges":[{"gross_charge":205.4,"discounted_cash":112.97,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."},{"gross_charge":205.94,"discounted_cash":113.27,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."},{"gross_charge":206.17,"discounted_cash":113.39,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Hc Revasc Tib Per W Intrv Litho","code_information":[{"code":"8104634","type":"CDM"},{"code":"361","type":"RC"},{"code":"C9772","type":"HCPCS"}],"standard_charges":[{"gross_charge":26034.0,"discounted_cash":14318.7,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Probe Kit Coolief 17Ga 50Mm 4Mm","code_information":[{"code":"8104646","type":"CDM"},{"code":"272","type":"RC"}],"standard_charges":[{"gross_charge":2223.02,"discounted_cash":1222.66,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"},{"gross_charge":2173.05,"discounted_cash":1195.18,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Hc Probe Kit Coolief 17Ga 75Mm 2Mm","code_information":[{"code":"8104647","type":"CDM"},{"code":"272","type":"RC"}],"standard_charges":[{"gross_charge":2223.02,"discounted_cash":1222.66,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"},{"gross_charge":2181.38,"discounted_cash":1199.76,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Hc Probe Kit Coolief 17Ga 75Mm 4Mm","code_information":[{"code":"8104648","type":"CDM"},{"code":"272","type":"RC"}],"standard_charges":[{"gross_charge":2223.02,"discounted_cash":1222.66,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"},{"gross_charge":2189.71,"discounted_cash":1204.34,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Hc Probe Kit Coolief 17Ga 100Mm 4Mm","code_information":[{"code":"8104649","type":"CDM"},{"code":"272","type":"RC"}],"standard_charges":[{"gross_charge":2223.02,"discounted_cash":1222.66,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"},{"gross_charge":2180.36,"discounted_cash":1199.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Hc Probe Kit Coolief 17Ga 150Mm 4Mm","code_information":[{"code":"8104650","type":"CDM"},{"code":"272","type":"RC"}],"standard_charges":[{"gross_charge":2223.02,"discounted_cash":1222.66,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"},{"gross_charge":2176.62,"discounted_cash":1197.14,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Hc Probe Kit Coolief 17Ga 75Mm 5.5Mm","code_information":[{"code":"8104651","type":"CDM"},{"code":"272","type":"RC"}],"standard_charges":[{"gross_charge":2223.02,"discounted_cash":1222.66,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"},{"gross_charge":2173.05,"discounted_cash":1195.18,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Hc Ed Interr Pm Icd Remo Tech Suprt <=90Day","code_information":[{"code":"8104661","type":"CDM"},{"code":"450","type":"RC"},{"code":"93296","type":"HCPCS"}],"standard_charges":[{"gross_charge":291.0,"discounted_cash":160.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Exercise Test For Bronchospasm Wo Ekg","code_information":[{"code":"8104663","type":"CDM"},{"code":"460","type":"RC"},{"code":"94619","type":"HCPCS"}],"standard_charges":[{"gross_charge":267.0,"discounted_cash":146.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Revasc Except Tib Per W Intrv Litho","code_information":[{"code":"8104673","type":"CDM"},{"code":"361","type":"RC"},{"code":"C9764","type":"HCPCS"}],"standard_charges":[{"gross_charge":31044.0,"discounted_cash":17074.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Revasc Except Tib Per W Intrv Litho Stnt","code_information":[{"code":"8104674","type":"CDM"},{"code":"361","type":"RC"},{"code":"C9765","type":"HCPCS"}],"standard_charges":[{"gross_charge":32131.0,"discounted_cash":17672.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Burn Dress Debrid No Anesthes Sm","code_information":[{"code":"810468","type":"CDM"},{"code":"361","type":"RC"},{"code":"16020","type":"HCPCS"}],"standard_charges":[{"gross_charge":901.0,"discounted_cash":495.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Mental Health Service Nos","code_information":[{"code":"8104684","type":"CDM"},{"code":"919","type":"RC"},{"code":"H0046","type":"HCPCS"}],"standard_charges":[{"gross_charge":152.0,"discounted_cash":83.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Us Aaa Screening (Self Pay)","code_information":[{"code":"8104689","type":"CDM"},{"code":"402","type":"RC"},{"code":"76706","type":"HCPCS"}],"standard_charges":[{"gross_charge":46.0,"discounted_cash":25.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Device Cryoanalgesia Iovera","code_information":[{"code":"81046941","type":"CDM"},{"code":"272","type":"RC"},{"code":"C9809","type":"HCPCS"}],"standard_charges":[{"gross_charge":1544.08,"discounted_cash":849.24,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"},{"gross_charge":1509.36,"discounted_cash":830.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."},{"gross_charge":1513.22,"discounted_cash":832.27,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Hc Prolong Outpt E+M Visit Ea Addl 15 Min","code_information":[{"code":"8104706","type":"CDM"},{"code":"761","type":"RC"},{"code":"99417","type":"HCPCS"}],"standard_charges":[{"gross_charge":139.0,"discounted_cash":76.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ecmo Ecls Repos Periph Cann Perq 6+ Yrs","code_information":[{"code":"8104713","type":"CDM"},{"code":"360","type":"RC"},{"code":"33958","type":"HCPCS"}],"standard_charges":[{"gross_charge":332.0,"discounted_cash":182.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ecmo Ecls Removl Periph Cann Perq 6+ Yrs","code_information":[{"code":"8104714","type":"CDM"},{"code":"360","type":"RC"},{"code":"33966","type":"HCPCS"}],"standard_charges":[{"gross_charge":681.0,"discounted_cash":374.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Emergency Dept Visit Level 4","code_information":[{"code":"810476","type":"CDM"},{"code":"450","type":"RC"},{"code":"99284","type":"HCPCS"}],"standard_charges":[{"gross_charge":1841.64,"discounted_cash":1012.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Transcath Rmv Dblk Intracard Mass Percut","code_information":[{"code":"8104878","type":"CDM"},{"code":"361","type":"RC"},{"code":"0644T","type":"HCPCS"}],"standard_charges":[{"gross_charge":15256.0,"discounted_cash":8390.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Remov/Repl Extern Ureter Stnt W Fl Bilat","code_information":[{"code":"8104886","type":"CDM"},{"code":"361","type":"RC"},{"code":"50387","type":"HCPCS"}],"standard_charges":[{"gross_charge":7815.0,"discounted_cash":4298.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ads Bathing Srvc 1 Assist Comm Membr Cw","code_information":[{"code":"8104887","type":"CDM"},{"code":"3101","type":"RC"},{"code":"S5105","type":"HCPCS"}],"standard_charges":[{"gross_charge":50.0,"discounted_cash":27.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ads Hair Washing Inclusa","code_information":[{"code":"8104890","type":"CDM"},{"code":"3109","type":"RC"},{"code":"S5105","type":"HCPCS"}],"standard_charges":[{"gross_charge":22.0,"discounted_cash":12.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc I&D Abscess Smpl Sngl","code_information":[{"code":"810493","type":"CDM"},{"code":"361","type":"RC"},{"code":"10060","type":"HCPCS"}],"standard_charges":[{"gross_charge":889.0,"discounted_cash":488.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Op Pulm Rehab Wo Cont Oximetry Monitor","code_information":[{"code":"8104934","type":"CDM"},{"code":"948","type":"RC"},{"code":"94625","type":"HCPCS"}],"standard_charges":[{"gross_charge":241.0,"discounted_cash":132.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Op Pulm Rehab W Cont Oximetry Monitor","code_information":[{"code":"8104935","type":"CDM"},{"code":"948","type":"RC"},{"code":"94626","type":"HCPCS"}],"standard_charges":[{"gross_charge":269.0,"discounted_cash":147.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Trab Bone Score Prep Trans Of Data","code_information":[{"code":"8104936","type":"CDM"},{"code":"320","type":"RC"},{"code":"77090","type":"HCPCS"}],"standard_charges":[{"gross_charge":263.0,"discounted_cash":144.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Piflufolastat F18 Diag 1Mci","code_information":[{"code":"8104945","type":"CDM"},{"code":"343","type":"RC"},{"code":"A9595","type":"HCPCS"}],"standard_charges":[{"gross_charge":1425.27,"discounted_cash":783.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Echo Img 3D During Tee Or Tte Cong Anom","code_information":[{"code":"8104966","type":"CDM"},{"code":"483","type":"RC"},{"code":"93319","type":"HCPCS"}],"standard_charges":[{"gross_charge":655.0,"discounted_cash":360.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Insert Implnt Drug Elut Lacrimal Canal","code_information":[{"code":"8104970","type":"CDM"},{"code":"361","type":"RC"},{"code":"68841","type":"HCPCS"}],"standard_charges":[{"gross_charge":477.0,"discounted_cash":262.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Trab Bone Score Tech Calculation","code_information":[{"code":"8104971","type":"CDM"},{"code":"320","type":"RC"},{"code":"77091","type":"HCPCS"}],"standard_charges":[{"gross_charge":263.0,"discounted_cash":144.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Deep Sedation Physician Admin Initial 15 Min","code_information":[{"code":"8104993","type":"CDM"},{"code":"370","type":"RC"}],"standard_charges":[{"gross_charge":548.0,"discounted_cash":301.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Deep Sedation Phys Admin Ea Addl 15 Min","code_information":[{"code":"8105003","type":"CDM"},{"code":"370","type":"RC"}],"standard_charges":[{"gross_charge":259.0,"discounted_cash":142.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Inj Lumb Epidur Blood/Clot Patch","code_information":[{"code":"810501","type":"CDM"},{"code":"361","type":"RC"},{"code":"62273","type":"HCPCS"}],"standard_charges":[{"gross_charge":2373.0,"discounted_cash":1305.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Orthotic Device Repair/Replc Minor Parts","code_information":[{"code":"8105033","type":"CDM"},{"code":"274","type":"RC"},{"code":"L4210","type":"HCPCS"}],"standard_charges":[{"gross_charge":59.03,"discounted_cash":32.47,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Insert Cath Straight","code_information":[{"code":"810505","type":"CDM"},{"code":"761","type":"RC"},{"code":"51701","type":"HCPCS"}],"standard_charges":[{"gross_charge":488.0,"discounted_cash":268.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Insert Cath Temp Indwell Bladder Cmplx","code_information":[{"code":"810506","type":"CDM"},{"code":"761","type":"RC"},{"code":"51703","type":"HCPCS"}],"standard_charges":[{"gross_charge":848.0,"discounted_cash":466.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Insert Cath Temp Indwell Bladder Smpl","code_information":[{"code":"810507","type":"CDM"},{"code":"761","type":"RC"},{"code":"51702","type":"HCPCS"}],"standard_charges":[{"gross_charge":753.0,"discounted_cash":414.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Bx Soft Tissue Shoulder","code_information":[{"code":"8105092","type":"CDM"},{"code":"361","type":"RC"},{"code":"23065","type":"HCPCS"}],"standard_charges":[{"gross_charge":5899.0,"discounted_cash":3244.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Intubation Endotracheal Emergent","code_information":[{"code":"810513","type":"CDM"},{"code":"361","type":"RC"},{"code":"31500","type":"HCPCS"}],"standard_charges":[{"gross_charge":1399.0,"discounted_cash":769.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Drainage Of Deep Rectal Abscess","code_information":[{"code":"8105130","type":"CDM"},{"code":"450","type":"RC"},{"code":"45020","type":"HCPCS"}],"standard_charges":[{"gross_charge":10756.0,"discounted_cash":5915.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Simple Bladder Irrig Lavage Or Instill","code_information":[{"code":"810514","type":"CDM"},{"code":"361","type":"RC"},{"code":"51700","type":"HCPCS"}],"standard_charges":[{"gross_charge":992.0,"discounted_cash":545.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ecmo Insert Periph Cannula Open 6+ Yrs","code_information":[{"code":"8105142","type":"CDM"},{"code":"360","type":"RC"},{"code":"33954","type":"HCPCS"}],"standard_charges":[{"gross_charge":4810.0,"discounted_cash":2645.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Noncdm Charge Record","code_information":[{"code":"8105178","type":"CDM"},{"code":"360","type":"RC"},{"code":"64561","type":"HCPCS"}],"standard_charges":[{"gross_charge":5023.8,"discounted_cash":2763.09,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Hc Perc Transluminal Coronary Lithotripsy","code_information":[{"code":"8105180","type":"CDM"},{"code":"481","type":"RC"},{"code":"92972","type":"HCPCS"}],"standard_charges":[{"gross_charge":4495.0,"discounted_cash":2472.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Noncdm Charge Record","code_information":[{"code":"8105289","type":"CDM"},{"code":"361","type":"RC"},{"code":"52287","type":"HCPCS"}],"standard_charges":[{"gross_charge":1605.15,"discounted_cash":882.83,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Hc Phlebotomy Ther","code_information":[{"code":"810531","type":"CDM"},{"code":"940","type":"RC"},{"code":"99195","type":"HCPCS"}],"standard_charges":[{"gross_charge":334.0,"discounted_cash":183.7,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Remove Cerumen Impacted W Instrument Uni","code_information":[{"code":"810536","type":"CDM"},{"code":"361","type":"RC"},{"code":"69210","type":"HCPCS"}],"standard_charges":[{"gross_charge":333.0,"discounted_cash":183.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Fetal Non Stress Test","code_information":[{"code":"8105434","type":"CDM"},{"code":"450","type":"RC"},{"code":"59025","type":"HCPCS"}],"standard_charges":[{"gross_charge":779.0,"discounted_cash":428.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Noncdm Charge Record","code_information":[{"code":"810546","type":"CDM"},{"code":"361","type":"RC"},{"code":"46320","type":"HCPCS"}],"standard_charges":[{"gross_charge":762.0,"discounted_cash":419.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Hc Ed Tx Miscarriage Missed Surg 1St Tri","code_information":[{"code":"8105523","type":"CDM"},{"code":"450","type":"RC"},{"code":"59820","type":"HCPCS"}],"standard_charges":[{"gross_charge":11152.0,"discounted_cash":6133.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Ligation Major Artery Neck","code_information":[{"code":"8105527","type":"CDM"},{"code":"450","type":"RC"},{"code":"37615","type":"HCPCS"}],"standard_charges":[{"gross_charge":10392.0,"discounted_cash":5715.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Us Ob < 14 Wks Single Gest","code_information":[{"code":"8105549","type":"CDM"},{"code":"450","type":"RC"},{"code":"76801","type":"HCPCS"}],"standard_charges":[{"gross_charge":838.0,"discounted_cash":460.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Heart Flow Rsrv Measr Ifr Init Wo Pharm","code_information":[{"code":"8105552","type":"CDM"},{"code":"481","type":"RC"},{"code":"93799","type":"HCPCS"}],"standard_charges":[{"gross_charge":6523.0,"discounted_cash":3587.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Heart Flow Rsrv Measr Ifr Addl Wo Pharm","code_information":[{"code":"8105553","type":"CDM"},{"code":"481","type":"RC"},{"code":"93799","type":"HCPCS"}],"standard_charges":[{"gross_charge":4442.0,"discounted_cash":2443.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Noncdm Charge Record","code_information":[{"code":"8105568","type":"CDM"},{"code":"361","type":"RC"},{"code":"15853","type":"HCPCS"}],"standard_charges":[{"gross_charge":55.0,"discounted_cash":30.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Hc Admin Vaccine Covid19 1 Dose","code_information":[{"code":"8105598","type":"CDM"},{"code":"771","type":"RC"},{"code":"90480","type":"HCPCS"}],"standard_charges":[{"gross_charge":121.0,"discounted_cash":66.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Tavr Prosthetic Perc Non Femoral","code_information":[{"code":"8105610","type":"CDM"},{"code":"360","type":"RC"},{"code":"33999","type":"HCPCS"}],"standard_charges":[{"gross_charge":42624.0,"discounted_cash":23443.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Admin Rsv Mono Antibody W Counsel","code_information":[{"code":"8105619","type":"CDM"},{"code":"771","type":"RC"},{"code":"96380","type":"HCPCS"}],"standard_charges":[{"gross_charge":94.0,"discounted_cash":51.7,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Admin Rsv Mono Antibody Wo Counsel","code_information":[{"code":"8105620","type":"CDM"},{"code":"771","type":"RC"},{"code":"96381","type":"HCPCS"}],"standard_charges":[{"gross_charge":89.0,"discounted_cash":48.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Noncdm Charge Record","code_information":[{"code":"8105621","type":"CDM"},{"code":"361","type":"RC"},{"code":"52001","type":"HCPCS"}],"standard_charges":[{"gross_charge":1557.6,"discounted_cash":856.68,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Noncdm Charge Record","code_information":[{"code":"8105624","type":"CDM"},{"code":"361","type":"RC"},{"code":"52318","type":"HCPCS"}],"standard_charges":[{"gross_charge":2520.0,"discounted_cash":1386.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Noncdm Charge Record","code_information":[{"code":"8105630","type":"CDM"},{"code":"361","type":"RC"},{"code":"52356","type":"HCPCS"}],"standard_charges":[{"gross_charge":5105.4,"discounted_cash":2807.97,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Hc Ffr Ai Noninvas Est From Cta","code_information":[{"code":"8105688","type":"CDM"},{"code":"350","type":"RC"},{"code":"75580","type":"HCPCS"}],"standard_charges":[{"gross_charge":3422.0,"discounted_cash":1882.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Cg Train Adl Functional 1St 30Min Pt","code_information":[{"code":"8105690","type":"CDM"},{"code":"420","type":"RC"},{"code":"97550","type":"HCPCS"}],"standard_charges":[{"gross_charge":138.0,"discounted_cash":75.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Cg Train Adl Funtional Ea Addl 15Min Pt","code_information":[{"code":"8105691","type":"CDM"},{"code":"420","type":"RC"},{"code":"97551","type":"HCPCS"}],"standard_charges":[{"gross_charge":120.0,"discounted_cash":66.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Cg Train Adl Functional Group Pt","code_information":[{"code":"8105692","type":"CDM"},{"code":"420","type":"RC"},{"code":"97552","type":"HCPCS"}],"standard_charges":[{"gross_charge":156.0,"discounted_cash":85.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Noncdm Charge Record","code_information":[{"code":"8105729","type":"CDM"},{"code":"761","type":"RC"},{"code":"99459","type":"HCPCS"}],"standard_charges":[{"gross_charge":64.2,"discounted_cash":35.31,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Hc Ed Us Pelvis Limited","code_information":[{"code":"8105743","type":"CDM"},{"code":"450","type":"RC"},{"code":"76857","type":"HCPCS"}],"standard_charges":[{"gross_charge":838.0,"discounted_cash":460.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Rpr Sclp/Trnk/Extrm Smpl <= 2.5Cm","code_information":[{"code":"810577","type":"CDM"},{"code":"361","type":"RC"},{"code":"12001","type":"HCPCS"}],"standard_charges":[{"gross_charge":779.0,"discounted_cash":428.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Us Joint Or Nonvasc Ext Limited","code_information":[{"code":"8105797","type":"CDM"},{"code":"450","type":"RC"},{"code":"76882","type":"HCPCS"}],"standard_charges":[{"gross_charge":856.0,"discounted_cash":470.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Rpr Sclp/Trnk/Extrm Smpl 2.6-7.5 Cm","code_information":[{"code":"810580","type":"CDM"},{"code":"361","type":"RC"},{"code":"12002","type":"HCPCS"}],"standard_charges":[{"gross_charge":889.0,"discounted_cash":488.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Marker Thread Breast Tuflex","code_information":[{"code":"8105804","type":"CDM"},{"code":"278","type":"RC"},{"code":"C1889","type":"HCPCS"}],"standard_charges":[{"gross_charge":1578.11,"discounted_cash":867.96,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Noncdm Charge Record","code_information":[{"code":"8105807","type":"CDM"},{"code":"510","type":"RC"},{"code":"99483","type":"HCPCS"}],"standard_charges":[{"gross_charge":771.0,"discounted_cash":424.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Hc Sympathectomy Lumbar","code_information":[{"code":"8105809","type":"CDM"},{"code":"360","type":"RC"},{"code":"64818","type":"HCPCS"}],"standard_charges":[{"gross_charge":2087.0,"discounted_cash":1147.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Eval Device Program Icd In Person","code_information":[{"code":"8105811","type":"CDM"},{"code":"450","type":"RC"},{"code":"93289","type":"HCPCS"}],"standard_charges":[{"gross_charge":306.0,"discounted_cash":168.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Us Ob >=14 Wks Single Gest","code_information":[{"code":"8105823","type":"CDM"},{"code":"450","type":"RC"},{"code":"76805","type":"HCPCS"}],"standard_charges":[{"gross_charge":838.0,"discounted_cash":460.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Us Dx Eye Quant A Scan","code_information":[{"code":"8105845","type":"CDM"},{"code":"450","type":"RC"},{"code":"76511","type":"HCPCS"}],"standard_charges":[{"gross_charge":612.0,"discounted_cash":336.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Inhalation Treatment W/Med","code_information":[{"code":"8105847","type":"CDM"},{"code":"450","type":"RC"},{"code":"94640","type":"HCPCS"}],"standard_charges":[{"gross_charge":236.0,"discounted_cash":129.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Cont Inhalation Tx 1St Hr","code_information":[{"code":"8105848","type":"CDM"},{"code":"450","type":"RC"},{"code":"94644","type":"HCPCS"}],"standard_charges":[{"gross_charge":568.0,"discounted_cash":312.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Cont Inhalation Tx Addl Hr","code_information":[{"code":"8105849","type":"CDM"},{"code":"450","type":"RC"},{"code":"94645","type":"HCPCS"}],"standard_charges":[{"gross_charge":542.0,"discounted_cash":298.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Cg Train Adl Functional 1St 30Min Ot","code_information":[{"code":"8105854","type":"CDM"},{"code":"430","type":"RC"},{"code":"97550","type":"HCPCS"}],"standard_charges":[{"gross_charge":138.0,"discounted_cash":75.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Cg Train Adl Funtional Ea Addl 15Min Ot","code_information":[{"code":"8105855","type":"CDM"},{"code":"430","type":"RC"},{"code":"97551","type":"HCPCS"}],"standard_charges":[{"gross_charge":120.0,"discounted_cash":66.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Cg Train Adl Functional Group Ot","code_information":[{"code":"8105856","type":"CDM"},{"code":"430","type":"RC"},{"code":"97552","type":"HCPCS"}],"standard_charges":[{"gross_charge":156.0,"discounted_cash":85.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Cg Train Adl Functional 1St 30Min St","code_information":[{"code":"8105857","type":"CDM"},{"code":"440","type":"RC"},{"code":"97550","type":"HCPCS"}],"standard_charges":[{"gross_charge":138.0,"discounted_cash":75.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Cg Train Adl Funtional Ea Addl 15Min St","code_information":[{"code":"8105858","type":"CDM"},{"code":"440","type":"RC"},{"code":"97551","type":"HCPCS"}],"standard_charges":[{"gross_charge":120.0,"discounted_cash":66.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Cg Train Adl Functional Group St","code_information":[{"code":"8105859","type":"CDM"},{"code":"440","type":"RC"},{"code":"97552","type":"HCPCS"}],"standard_charges":[{"gross_charge":156.0,"discounted_cash":85.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Us Guide Vascular Access","code_information":[{"code":"8105895","type":"CDM"},{"code":"450","type":"RC"},{"code":"76937","type":"HCPCS"}],"standard_charges":[{"gross_charge":534.0,"discounted_cash":293.7,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Img Guide Drain W Cath Periton Perc","code_information":[{"code":"8105933","type":"CDM"},{"code":"450","type":"RC"},{"code":"49406","type":"HCPCS"}],"standard_charges":[{"gross_charge":5990.0,"discounted_cash":3294.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Us Dx Eye B Scan","code_information":[{"code":"8105934","type":"CDM"},{"code":"450","type":"RC"},{"code":"76512","type":"HCPCS"}],"standard_charges":[{"gross_charge":771.0,"discounted_cash":424.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Us Aaa Screening","code_information":[{"code":"8105935","type":"CDM"},{"code":"450","type":"RC"},{"code":"76706","type":"HCPCS"}],"standard_charges":[{"gross_charge":723.0,"discounted_cash":397.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Us Joint Complete","code_information":[{"code":"8105936","type":"CDM"},{"code":"450","type":"RC"},{"code":"76881","type":"HCPCS"}],"standard_charges":[{"gross_charge":856.0,"discounted_cash":470.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Strapping Knee","code_information":[{"code":"810595","type":"CDM"},{"code":"361","type":"RC"},{"code":"29530","type":"HCPCS"}],"standard_charges":[{"gross_charge":486.0,"discounted_cash":267.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Us Breast Unilateral Limited","code_information":[{"code":"8105997","type":"CDM"},{"code":"450","type":"RC"},{"code":"76642","type":"HCPCS"}],"standard_charges":[{"gross_charge":817.0,"discounted_cash":449.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Lwr Extr Fascial Plane Blk Unilat Inj","code_information":[{"code":"8106085","type":"CDM"},{"code":"360","type":"RC"},{"code":"64473","type":"HCPCS"}],"standard_charges":[{"gross_charge":7030.0,"discounted_cash":3866.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Thoracic Fascial Plane Blk Bilat Inj","code_information":[{"code":"8106101","type":"CDM"},{"code":"361","type":"RC"},{"code":"64468","type":"HCPCS"}],"standard_charges":[{"gross_charge":14060.0,"discounted_cash":7733.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Thoracic Fascial Plane Blk Unilat Inj","code_information":[{"code":"8106112","type":"CDM"},{"code":"361","type":"RC"},{"code":"64466","type":"HCPCS"}],"standard_charges":[{"gross_charge":7030.0,"discounted_cash":3866.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Tx Fx Ankle Bimall Clsd W/ Manip","code_information":[{"code":"810617","type":"CDM"},{"code":"361","type":"RC"},{"code":"27810","type":"HCPCS"}],"standard_charges":[{"gross_charge":5437.0,"discounted_cash":2990.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Tx Fx Fibula Distal Clsd W/O Manip","code_information":[{"code":"810626","type":"CDM"},{"code":"361","type":"RC"},{"code":"27786","type":"HCPCS"}],"standard_charges":[{"gross_charge":1044.0,"discounted_cash":574.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Eeg Extended Monitoring 61-119 Min","code_information":[{"code":"810660","type":"CDM"},{"code":"740","type":"RC"},{"code":"95813","type":"HCPCS"}],"standard_charges":[{"gross_charge":1548.0,"discounted_cash":851.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Eeg During Nonintracranial Surgery","code_information":[{"code":"810661","type":"CDM"},{"code":"740","type":"RC"},{"code":"95955","type":"HCPCS"}],"standard_charges":[{"gross_charge":780.0,"discounted_cash":429.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Eeg Eval Cerebral Death","code_information":[{"code":"810662","type":"CDM"},{"code":"740","type":"RC"},{"code":"95824","type":"HCPCS"}],"standard_charges":[{"gross_charge":1377.0,"discounted_cash":757.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Eeg Record Awake & Asleep","code_information":[{"code":"810665","type":"CDM"},{"code":"740","type":"RC"},{"code":"95819","type":"HCPCS"}],"standard_charges":[{"gross_charge":1416.0,"discounted_cash":778.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Eeg Record Awake & Drowsy","code_information":[{"code":"810666","type":"CDM"},{"code":"740","type":"RC"},{"code":"95816","type":"HCPCS"}],"standard_charges":[{"gross_charge":1203.0,"discounted_cash":661.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Eeg Record Coma Or Asleep","code_information":[{"code":"810667","type":"CDM"},{"code":"740","type":"RC"},{"code":"95822","type":"HCPCS"}],"standard_charges":[{"gross_charge":594.0,"discounted_cash":326.7,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Emg Needle Lmtd Nonparaspinal","code_information":[{"code":"810670","type":"CDM"},{"code":"922","type":"RC"},{"code":"95870","type":"HCPCS"}],"standard_charges":[{"gross_charge":251.0,"discounted_cash":138.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Emg Needle One Extrm","code_information":[{"code":"810671","type":"CDM"},{"code":"922","type":"RC"},{"code":"95860","type":"HCPCS"}],"standard_charges":[{"gross_charge":302.0,"discounted_cash":166.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Emg Needle Two Extrm","code_information":[{"code":"810674","type":"CDM"},{"code":"922","type":"RC"},{"code":"95861","type":"HCPCS"}],"standard_charges":[{"gross_charge":410.0,"discounted_cash":225.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Intraop Neuro Monitor In Or Ea 15Min","code_information":[{"code":"810677","type":"CDM"},{"code":"920","type":"RC"},{"code":"95940","type":"HCPCS"}],"standard_charges":[{"gross_charge":69.0,"discounted_cash":37.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Somatosensory Test Lower Extrm","code_information":[{"code":"810681","type":"CDM"},{"code":"922","type":"RC"},{"code":"95926","type":"HCPCS"}],"standard_charges":[{"gross_charge":1443.0,"discounted_cash":793.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Somatosensory Test Upper Extrm","code_information":[{"code":"810682","type":"CDM"},{"code":"922","type":"RC"},{"code":"95925","type":"HCPCS"}],"standard_charges":[{"gross_charge":1435.0,"discounted_cash":789.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Visual Evoked Potential Test","code_information":[{"code":"810683","type":"CDM"},{"code":"922","type":"RC"},{"code":"95930","type":"HCPCS"}],"standard_charges":[{"gross_charge":1428.0,"discounted_cash":785.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Endoscopy Services 1","code_information":[{"code":"810713","type":"CDM"},{"code":"750","type":"RC"}],"standard_charges":[{"gross_charge":3373.0,"discounted_cash":1855.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Endoscopy Services 2","code_information":[{"code":"810714","type":"CDM"},{"code":"750","type":"RC"}],"standard_charges":[{"gross_charge":3813.0,"discounted_cash":2097.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Endoscopy Services 3","code_information":[{"code":"810715","type":"CDM"},{"code":"750","type":"RC"}],"standard_charges":[{"gross_charge":4421.0,"discounted_cash":2431.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Endoscopy Services 4","code_information":[{"code":"810716","type":"CDM"},{"code":"750","type":"RC"}],"standard_charges":[{"gross_charge":5306.0,"discounted_cash":2918.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Endoscopy Services 5","code_information":[{"code":"810717","type":"CDM"},{"code":"750","type":"RC"}],"standard_charges":[{"gross_charge":5721.0,"discounted_cash":3146.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Endoscopy Services 6","code_information":[{"code":"810718","type":"CDM"},{"code":"750","type":"RC"}],"standard_charges":[{"gross_charge":11734.0,"discounted_cash":6453.7,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Admin Vac Hepatitis B","code_information":[{"code":"810828","type":"CDM"},{"code":"771","type":"RC"},{"code":"G0010","type":"HCPCS"}],"standard_charges":[{"gross_charge":64.0,"discounted_cash":35.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Admin Vac Influenza","code_information":[{"code":"810829","type":"CDM"},{"code":"771","type":"RC"},{"code":"G0008","type":"HCPCS"}],"standard_charges":[{"gross_charge":90.0,"discounted_cash":49.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Admin Vac Pneumococcal","code_information":[{"code":"810830","type":"CDM"},{"code":"771","type":"RC"},{"code":"G0009","type":"HCPCS"}],"standard_charges":[{"gross_charge":90.0,"discounted_cash":49.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Chemo Hormonal Antineopl Subq/Im","code_information":[{"code":"810842","type":"CDM"},{"code":"331","type":"RC"},{"code":"96402","type":"HCPCS"}],"standard_charges":[{"gross_charge":257.0,"discounted_cash":141.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Noncdm Charge Record","code_information":[{"code":"810844","type":"CDM"},{"code":"331","type":"RC"},{"code":"96411","type":"HCPCS"}],"standard_charges":[{"gross_charge":432.58,"discounted_cash":237.92,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Hc Chemo Ivp Sngl Or Init Drug","code_information":[{"code":"810845","type":"CDM"},{"code":"331","type":"RC"},{"code":"96409","type":"HCPCS"}],"standard_charges":[{"gross_charge":563.0,"discounted_cash":309.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Chemo Non-Hormonal Antineopl Subq/Im","code_information":[{"code":"810846","type":"CDM"},{"code":"331","type":"RC"},{"code":"96401","type":"HCPCS"}],"standard_charges":[{"gross_charge":254.0,"discounted_cash":139.7,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Circumcision Clamp W Regional Ans","code_information":[{"code":"810847","type":"CDM"},{"code":"361","type":"RC"},{"code":"54150","type":"HCPCS"}],"standard_charges":[{"gross_charge":172.0,"discounted_cash":94.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Collection Blood Implanted Vad","code_information":[{"code":"810848","type":"CDM"},{"code":"761","type":"RC"},{"code":"36591","type":"HCPCS"}],"standard_charges":[{"gross_charge":200.0,"discounted_cash":110.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Collection Blood Venipuncture","code_information":[{"code":"810849","type":"CDM"},{"code":"300","type":"RC"},{"code":"36415","type":"HCPCS"}],"standard_charges":[{"gross_charge":38.0,"discounted_cash":20.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Diabetes Op Self Mgmt Grp Ea 30 Min","code_information":[{"code":"810852","type":"CDM"},{"code":"942","type":"RC"},{"code":"G0109","type":"HCPCS"}],"standard_charges":[{"gross_charge":109.0,"discounted_cash":59.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Diabetes Op Self Mgmt Indiv Ea 30Min","code_information":[{"code":"810854","type":"CDM"},{"code":"942","type":"RC"},{"code":"G0108","type":"HCPCS"}],"standard_charges":[{"gross_charge":190.0,"discounted_cash":104.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Hemodialysis Acute","code_information":[{"code":"810855","type":"CDM"},{"code":"801","type":"RC"},{"code":"90999","type":"HCPCS"}],"standard_charges":[{"gross_charge":1358.0,"discounted_cash":746.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Dialysis Peritoneal Inpatient","code_information":[{"code":"810858","type":"CDM"},{"code":"802","type":"RC"}],"standard_charges":[{"gross_charge":783.0,"discounted_cash":430.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Duplex Scan Hemodialysis Access","code_information":[{"code":"810862","type":"CDM"},{"code":"921","type":"RC"},{"code":"93990","type":"HCPCS"}],"standard_charges":[{"gross_charge":1638.0,"discounted_cash":900.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Fetal Non Stress Test","code_information":[{"code":"810866","type":"CDM"},{"code":"920","type":"RC"},{"code":"59025","type":"HCPCS"}],"standard_charges":[{"gross_charge":677.0,"discounted_cash":372.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Hemodialysis Home","code_information":[{"code":"810867","type":"CDM"},{"code":"821","type":"RC"},{"code":"90999","type":"HCPCS"}],"standard_charges":[{"gross_charge":1300.0,"discounted_cash":715.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Immuniz Admin 1 Sngl/Comb Vac/Toxoid","code_information":[{"code":"810873","type":"CDM"},{"code":"771","type":"RC"},{"code":"90471","type":"HCPCS"}],"standard_charges":[{"gross_charge":90.0,"discounted_cash":49.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Immuniz Admin Ea Addl Sngl/Comb Vac","code_information":[{"code":"810874","type":"CDM"},{"code":"771","type":"RC"},{"code":"90472","type":"HCPCS"}],"standard_charges":[{"gross_charge":79.0,"discounted_cash":43.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Inj Ther/Diag Ivp Ea Addl New Drug","code_information":[{"code":"810876","type":"CDM"},{"code":"940","type":"RC"},{"code":"96375","type":"HCPCS"}],"standard_charges":[{"gross_charge":338.0,"discounted_cash":185.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Inj Ther/Proph/Diag Intrarterial","code_information":[{"code":"810877","type":"CDM"},{"code":"940","type":"RC"},{"code":"96373","type":"HCPCS"}],"standard_charges":[{"gross_charge":165.0,"discounted_cash":90.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Inj Ther/Proph/Diag Ivp Sngl Or Init","code_information":[{"code":"810878","type":"CDM"},{"code":"940","type":"RC"},{"code":"96374","type":"HCPCS"}],"standard_charges":[{"gross_charge":338.0,"discounted_cash":185.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Inj Ther/Proph/Diag Subq/Im","code_information":[{"code":"810879","type":"CDM"},{"code":"940","type":"RC"},{"code":"96372","type":"HCPCS"}],"standard_charges":[{"gross_charge":94.0,"discounted_cash":51.7,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Irrigation Vad","code_information":[{"code":"810882","type":"CDM"},{"code":"940","type":"RC"},{"code":"96523","type":"HCPCS"}],"standard_charges":[{"gross_charge":130.0,"discounted_cash":71.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Iv Inf Chemo 1 Hr","code_information":[{"code":"810883","type":"CDM"},{"code":"335","type":"RC"},{"code":"96413","type":"HCPCS"}],"standard_charges":[{"gross_charge":908.0,"discounted_cash":499.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Iv Inf Chemo Ea Addl Hr","code_information":[{"code":"810884","type":"CDM"},{"code":"335","type":"RC"},{"code":"96415","type":"HCPCS"}],"standard_charges":[{"gross_charge":388.0,"discounted_cash":213.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Iv Inf Chemo Ea Seq Inf To 1Hr","code_information":[{"code":"810885","type":"CDM"},{"code":"335","type":"RC"},{"code":"96417","type":"HCPCS"}],"standard_charges":[{"gross_charge":337.0,"discounted_cash":185.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Iv Inf Ther/Proph/Diag Concurrent","code_information":[{"code":"810889","type":"CDM"},{"code":"260","type":"RC"},{"code":"96368","type":"HCPCS"}],"standard_charges":[{"gross_charge":240.0,"discounted_cash":132.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Iv Inf Ther/Proph/Diag Seq Inf 1St Hr","code_information":[{"code":"810891","type":"CDM"},{"code":"260","type":"RC"},{"code":"96367","type":"HCPCS"}],"standard_charges":[{"gross_charge":240.0,"discounted_cash":132.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Faclty Op Est Pt Level 1","code_information":[{"code":"810901","type":"CDM"},{"code":"761","type":"RC"},{"code":"99211","type":"HCPCS"}],"standard_charges":[{"gross_charge":223.0,"discounted_cash":122.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Faclty Op Est Pt Level 2","code_information":[{"code":"810902","type":"CDM"},{"code":"761","type":"RC"},{"code":"99212","type":"HCPCS"}],"standard_charges":[{"gross_charge":321.0,"discounted_cash":176.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"},{"gross_charge":97.0,"discounted_cash":53.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Op Bhs Fsc 3252"}]},{"description":"Hc Office Outpt Visit Est Level 3","code_information":[{"code":"810903","type":"CDM"},{"code":"761","type":"RC"},{"code":"99213","type":"HCPCS"}],"standard_charges":[{"gross_charge":340.0,"discounted_cash":187.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"},{"gross_charge":119.0,"discounted_cash":65.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Op Bhs Fsc 3252"}]},{"description":"Hc Faclty Op Est Pt Level 5","code_information":[{"code":"810905","type":"CDM"},{"code":"761","type":"RC"},{"code":"99215","type":"HCPCS"}],"standard_charges":[{"gross_charge":411.0,"discounted_cash":226.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Recovery Room Intensive Care","code_information":[{"code":"810915","type":"CDM"},{"code":"710","type":"RC"}],"standard_charges":[{"gross_charge":940.0,"discounted_cash":517.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Hemodialysis Home W Training","code_information":[{"code":"810920","type":"CDM"},{"code":"821","type":"RC"},{"code":"90989","type":"HCPCS"}],"standard_charges":[{"gross_charge":1358.0,"discounted_cash":746.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Circumcision Clamp Wo Regional Ans","code_information":[{"code":"810930","type":"CDM"},{"code":"361","type":"RC"},{"code":"54150","type":"HCPCS"}],"standard_charges":[{"gross_charge":150.0,"discounted_cash":82.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Mnt Init Indiv Ea 15 Min","code_information":[{"code":"810940","type":"CDM"},{"code":"942","type":"RC"},{"code":"97802","type":"HCPCS"}],"standard_charges":[{"gross_charge":119.0,"discounted_cash":65.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Cephalic Version External","code_information":[{"code":"810965","type":"CDM"},{"code":"361","type":"RC"},{"code":"59412","type":"HCPCS"}],"standard_charges":[{"gross_charge":805.0,"discounted_cash":442.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Delivery Placenta","code_information":[{"code":"810975","type":"CDM"},{"code":"722","type":"RC"},{"code":"59414","type":"HCPCS"}],"standard_charges":[{"gross_charge":6020.0,"discounted_cash":3311.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Delivery Vaginal Level 1","code_information":[{"code":"810977","type":"CDM"},{"code":"722","type":"RC"}],"standard_charges":[{"gross_charge":1005.0,"discounted_cash":552.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Delivery Vaginal Level 2","code_information":[{"code":"810978","type":"CDM"},{"code":"722","type":"RC"}],"standard_charges":[{"gross_charge":1388.0,"discounted_cash":763.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Curettage Postpartum","code_information":[{"code":"810982","type":"CDM"},{"code":"360","type":"RC"},{"code":"59160","type":"HCPCS"}],"standard_charges":[{"gross_charge":8393.0,"discounted_cash":4616.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Direct Admit Hospital Obsv","code_information":[{"code":"810983","type":"CDM"},{"code":"762","type":"RC"},{"code":"G0379","type":"HCPCS"}],"standard_charges":[{"gross_charge":136.0,"discounted_cash":74.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Epidural Labor","code_information":[{"code":"810990","type":"CDM"},{"code":"370","type":"RC"}],"standard_charges":[{"gross_charge":1154.0,"discounted_cash":634.7,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Insert Cervical Dilator","code_information":[{"code":"810999","type":"CDM"},{"code":"361","type":"RC"},{"code":"59200","type":"HCPCS"}],"standard_charges":[{"gross_charge":676.0,"discounted_cash":371.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Labor Level 1","code_information":[{"code":"811005","type":"CDM"},{"code":"721","type":"RC"}],"standard_charges":[{"gross_charge":304.0,"discounted_cash":167.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Labor Level 2","code_information":[{"code":"811006","type":"CDM"},{"code":"721","type":"RC"}],"standard_charges":[{"gross_charge":315.0,"discounted_cash":173.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Labor Level 3","code_information":[{"code":"811007","type":"CDM"},{"code":"721","type":"RC"}],"standard_charges":[{"gross_charge":322.0,"discounted_cash":177.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Labor Level 4","code_information":[{"code":"811008","type":"CDM"},{"code":"721","type":"RC"}],"standard_charges":[{"gross_charge":329.0,"discounted_cash":180.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Iontophoresis Ea 15 Min","code_information":[{"code":"811042","type":"CDM"},{"code":"951","type":"RC"},{"code":"97033","type":"HCPCS"}],"standard_charges":[{"gross_charge":120.0,"discounted_cash":66.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Manual Ther Tech 1+Regions Ea 15 Min","code_information":[{"code":"811044","type":"CDM"},{"code":"951","type":"RC"},{"code":"97140","type":"HCPCS"}],"standard_charges":[{"gross_charge":124.0,"discounted_cash":68.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Neuromusc Reeducat 1+ Areas Ea 15 Min","code_information":[{"code":"811047","type":"CDM"},{"code":"951","type":"RC"},{"code":"97112","type":"HCPCS"}],"standard_charges":[{"gross_charge":121.0,"discounted_cash":66.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Orthotic Mgmt And Training Ea 15 Min Pt","code_information":[{"code":"811048","type":"CDM"},{"code":"420","type":"RC"},{"code":"97760","type":"HCPCS"}],"standard_charges":[{"gross_charge":122.0,"discounted_cash":67.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ther Activities Ea 15 Min","code_information":[{"code":"811068","type":"CDM"},{"code":"951","type":"RC"},{"code":"97530","type":"HCPCS"}],"standard_charges":[{"gross_charge":112.0,"discounted_cash":61.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ther Exercise Ea 15 Min Pt","code_information":[{"code":"811070","type":"CDM"},{"code":"420","type":"RC"},{"code":"97110","type":"HCPCS"}],"standard_charges":[{"gross_charge":125.0,"discounted_cash":68.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ultrasound Therapy Ea 15 Min","code_information":[{"code":"811075","type":"CDM"},{"code":"951","type":"RC"},{"code":"97035","type":"HCPCS"}],"standard_charges":[{"gross_charge":96.0,"discounted_cash":52.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Inj Sacroiliac Joint","code_information":[{"code":"811101","type":"CDM"},{"code":"361","type":"RC"},{"code":"27096","type":"HCPCS"}],"standard_charges":[{"gross_charge":3130.0,"discounted_cash":1721.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Inj Trigger Point 1 Or 2 Musc","code_information":[{"code":"811102","type":"CDM"},{"code":"361","type":"RC"},{"code":"20552","type":"HCPCS"}],"standard_charges":[{"gross_charge":1134.0,"discounted_cash":623.7,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Debrid Selective 1St 20Sq Cm Or Less","code_information":[{"code":"811115","type":"CDM"},{"code":"761","type":"RC"},{"code":"97597","type":"HCPCS"}],"standard_charges":[{"gross_charge":443.0,"discounted_cash":243.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Debrid Selective Ea Addl 20Sq Cm","code_information":[{"code":"811116","type":"CDM"},{"code":"761","type":"RC"},{"code":"97598","type":"HCPCS"}],"standard_charges":[{"gross_charge":446.0,"discounted_cash":245.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Mechanical Traction Therapy Pt","code_information":[{"code":"811125","type":"CDM"},{"code":"420","type":"RC"},{"code":"97012","type":"HCPCS"}],"standard_charges":[{"gross_charge":101.0,"discounted_cash":55.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Orthotic Mgmt And Training Ea 15 Min","code_information":[{"code":"811127","type":"CDM"},{"code":"951","type":"RC"},{"code":"97760","type":"HCPCS"}],"standard_charges":[{"gross_charge":122.0,"discounted_cash":67.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Consult Radn Physics Continuing","code_information":[{"code":"811158","type":"CDM"},{"code":"333","type":"RC"},{"code":"77336","type":"HCPCS"}],"standard_charges":[{"gross_charge":1008.0,"discounted_cash":554.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Consult Radn Physics Special","code_information":[{"code":"811159","type":"CDM"},{"code":"333","type":"RC"},{"code":"77370","type":"HCPCS"}],"standard_charges":[{"gross_charge":809.0,"discounted_cash":444.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Imrt Planning W/Dose Vol Histogram","code_information":[{"code":"811167","type":"CDM"},{"code":"333","type":"RC"},{"code":"77301","type":"HCPCS"}],"standard_charges":[{"gross_charge":10828.0,"discounted_cash":5955.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Basic Rad Dosimetry Calculation","code_information":[{"code":"811189","type":"CDM"},{"code":"333","type":"RC"},{"code":"77300","type":"HCPCS"}],"standard_charges":[{"gross_charge":692.0,"discounted_cash":380.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc 3D Radiother Plan W Dose Vol Histogrm","code_information":[{"code":"811196","type":"CDM"},{"code":"333","type":"RC"},{"code":"77295","type":"HCPCS"}],"standard_charges":[{"gross_charge":6614.0,"discounted_cash":3637.7,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Set Radn Therapy Field Intermed","code_information":[{"code":"811198","type":"CDM"},{"code":"333","type":"RC"},{"code":"77285","type":"HCPCS"}],"standard_charges":[{"gross_charge":1879.0,"discounted_cash":1033.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Telether Iso-Port Plan","code_information":[{"code":"811206","type":"CDM"},{"code":"333","type":"RC"},{"code":"77321","type":"HCPCS"}],"standard_charges":[{"gross_charge":1726.0,"discounted_cash":949.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Recovery Post Proc Per Hr","code_information":[{"code":"811216","type":"CDM"},{"code":"710","type":"RC"}],"standard_charges":[{"gross_charge":97.0,"discounted_cash":53.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Bronchodilator Pre/Post Test","code_information":[{"code":"811227","type":"CDM"},{"code":"460","type":"RC"},{"code":"94060","type":"HCPCS"}],"standard_charges":[{"gross_charge":551.0,"discounted_cash":303.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Bronchospasm Prov Mult Determinations","code_information":[{"code":"811232","type":"CDM"},{"code":"460","type":"RC"},{"code":"94070","type":"HCPCS"}],"standard_charges":[{"gross_charge":2120.0,"discounted_cash":1166.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Card Stress Test Routine","code_information":[{"code":"811236","type":"CDM"},{"code":"482","type":"RC"},{"code":"93017","type":"HCPCS"}],"standard_charges":[{"gross_charge":1821.0,"discounted_cash":1001.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Chest Wall Manipulation Init","code_information":[{"code":"811241","type":"CDM"},{"code":"410","type":"RC"},{"code":"94667","type":"HCPCS"}],"standard_charges":[{"gross_charge":215.0,"discounted_cash":118.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Chest Wall Manipulation Subseq","code_information":[{"code":"811242","type":"CDM"},{"code":"410","type":"RC"},{"code":"94668","type":"HCPCS"}],"standard_charges":[{"gross_charge":166.0,"discounted_cash":91.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Cont Inhalation Tx 1St Hr","code_information":[{"code":"811244","type":"CDM"},{"code":"410","type":"RC"},{"code":"94644","type":"HCPCS"}],"standard_charges":[{"gross_charge":494.0,"discounted_cash":271.7,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Demo And/Or Eval Pt Use Aerosol Device","code_information":[{"code":"811249","type":"CDM"},{"code":"410","type":"RC"},{"code":"94664","type":"HCPCS"}],"standard_charges":[{"gross_charge":205.0,"discounted_cash":112.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Exhaled Carbon Dioxide Monitoring","code_information":[{"code":"811255","type":"CDM"},{"code":"460","type":"RC"},{"code":"94799","type":"HCPCS"}],"standard_charges":[{"gross_charge":362.0,"discounted_cash":199.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Mult Sleep Latency Test","code_information":[{"code":"811281","type":"CDM"},{"code":"740","type":"RC"},{"code":"95805","type":"HCPCS"}],"standard_charges":[{"gross_charge":4151.0,"discounted_cash":2283.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Noninvas Oxygen Saturation Cont","code_information":[{"code":"811285","type":"CDM"},{"code":"410","type":"RC"},{"code":"94762","type":"HCPCS"}],"standard_charges":[{"gross_charge":497.0,"discounted_cash":273.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Noninvasive Oxygen Saturation Mult","code_information":[{"code":"811287","type":"CDM"},{"code":"410","type":"RC"},{"code":"94761","type":"HCPCS"}],"standard_charges":[{"gross_charge":119.0,"discounted_cash":65.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Oxygen Per Hr","code_information":[{"code":"811296","type":"CDM"},{"code":"272","type":"RC"}],"standard_charges":[{"gross_charge":11.35,"discounted_cash":6.24,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"},{"gross_charge":11.15,"discounted_cash":6.13,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Hc Peak Flow Measurement","code_information":[{"code":"811299","type":"CDM"},{"code":"460","type":"RC"},{"code":"94799","type":"HCPCS"}],"standard_charges":[{"gross_charge":413.0,"discounted_cash":227.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Triamcinolone Acetonide Cream 0.1%","drug_information":{"unit":15.0,"type":"GM"},"code_information":[{"code":"8113","type":"CDM"},{"code":"67877025115","type":"NDC"}],"standard_charges":[{"gross_charge":42.97,"discounted_cash":23.63,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Hc Polysomn 4 Or More >=6Yrs","code_information":[{"code":"811302","type":"CDM"},{"code":"740","type":"RC"},{"code":"95810","type":"HCPCS"}],"standard_charges":[{"gross_charge":7129.0,"discounted_cash":3920.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Polysomn W/Cpap >=6Yrs","code_information":[{"code":"811303","type":"CDM"},{"code":"740","type":"RC"},{"code":"95811","type":"HCPCS"}],"standard_charges":[{"gross_charge":7646.0,"discounted_cash":4205.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Pos Airway Pressure Cpap","code_information":[{"code":"811306","type":"CDM"},{"code":"410","type":"RC"},{"code":"94660","type":"HCPCS"}],"standard_charges":[{"gross_charge":421.0,"discounted_cash":231.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Pulm Rehab Ph 3 Monthly","code_information":[{"code":"811308","type":"CDM"},{"code":"943","type":"RC"}],"standard_charges":[{"gross_charge":107.0,"discounted_cash":58.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Sleep Study Attended","code_information":[{"code":"811322","type":"CDM"},{"code":"740","type":"RC"},{"code":"95807","type":"HCPCS"}],"standard_charges":[{"gross_charge":6543.0,"discounted_cash":3598.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Spirometry","code_information":[{"code":"811323","type":"CDM"},{"code":"460","type":"RC"},{"code":"94010","type":"HCPCS"}],"standard_charges":[{"gross_charge":313.0,"discounted_cash":172.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Vent Mgmt Ip/Obsv Subseq Days","code_information":[{"code":"811333","type":"CDM"},{"code":"410","type":"RC"},{"code":"94003","type":"HCPCS"}],"standard_charges":[{"gross_charge":1545.0,"discounted_cash":849.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Arterial Study Extrem Bilateral Multilvl","code_information":[{"code":"811346","type":"CDM"},{"code":"921","type":"RC"},{"code":"93923","type":"HCPCS"}],"standard_charges":[{"gross_charge":1005.0,"discounted_cash":552.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Duplex Ao Ivc Iliac Or Bypass Cmplt","code_information":[{"code":"811348","type":"CDM"},{"code":"921","type":"RC"},{"code":"93978","type":"HCPCS"}],"standard_charges":[{"gross_charge":1364.0,"discounted_cash":750.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Duplex Artery Or Bypass Le Bilat","code_information":[{"code":"811350","type":"CDM"},{"code":"921","type":"RC"},{"code":"93925","type":"HCPCS"}],"standard_charges":[{"gross_charge":2649.0,"discounted_cash":1456.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Duplex Artery Or Bypass Ue Unilat","code_information":[{"code":"811353","type":"CDM"},{"code":"921","type":"RC"},{"code":"93931","type":"HCPCS"}],"standard_charges":[{"gross_charge":764.0,"discounted_cash":420.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Duplex Scan Extracranial Lmtd/Unilat","code_information":[{"code":"811356","type":"CDM"},{"code":"921","type":"RC"},{"code":"93882","type":"HCPCS"}],"standard_charges":[{"gross_charge":876.0,"discounted_cash":481.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Duplex Vein Extrem Bilat","code_information":[{"code":"811357","type":"CDM"},{"code":"921","type":"RC"},{"code":"93970","type":"HCPCS"}],"standard_charges":[{"gross_charge":2470.0,"discounted_cash":1358.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Duplex Vein Extrem Unilat","code_information":[{"code":"811358","type":"CDM"},{"code":"921","type":"RC"},{"code":"93971","type":"HCPCS"}],"standard_charges":[{"gross_charge":1236.0,"discounted_cash":679.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Arterial Study Extrem Bilateral Limited","code_information":[{"code":"811360","type":"CDM"},{"code":"921","type":"RC"},{"code":"93922","type":"HCPCS"}],"standard_charges":[{"gross_charge":979.0,"discounted_cash":538.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Noninvas Artery Le W/ Stress Bilat","code_information":[{"code":"811361","type":"CDM"},{"code":"921","type":"RC"},{"code":"93924","type":"HCPCS"}],"standard_charges":[{"gross_charge":1364.0,"discounted_cash":750.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Cont Inhalation Tx Addl Hr","code_information":[{"code":"811362","type":"CDM"},{"code":"410","type":"RC"},{"code":"94645","type":"HCPCS"}],"standard_charges":[{"gross_charge":471.0,"discounted_cash":259.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Insert Rplc Perm Defib System W Tv Leads","code_information":[{"code":"811365","type":"CDM"},{"code":"481","type":"RC"},{"code":"33249","type":"HCPCS"}],"standard_charges":[{"gross_charge":36420.0,"discounted_cash":20031.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Or Surgery Level 1","code_information":[{"code":"811383","type":"CDM"},{"code":"360","type":"RC"}],"standard_charges":[{"gross_charge":2631.0,"discounted_cash":1447.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"},{"gross_charge":1236.0,"discounted_cash":679.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Saf Surgery Ctr Fsc 3053"}]},{"description":"Hc Or Surgery Level 2","code_information":[{"code":"811384","type":"CDM"},{"code":"360","type":"RC"}],"standard_charges":[{"gross_charge":3600.0,"discounted_cash":1980.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"},{"gross_charge":1751.0,"discounted_cash":963.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Saf Surgery Ctr Fsc 3053"}]},{"description":"Hc Or Surgery Level 3","code_information":[{"code":"811385","type":"CDM"},{"code":"360","type":"RC"}],"standard_charges":[{"gross_charge":4846.0,"discounted_cash":2665.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"},{"gross_charge":2369.0,"discounted_cash":1302.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Saf Surgery Ctr Fsc 3053"}]},{"description":"Hc Or Surgery Level 4","code_information":[{"code":"811386","type":"CDM"},{"code":"360","type":"RC"}],"standard_charges":[{"gross_charge":6369.0,"discounted_cash":3502.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"},{"gross_charge":2884.0,"discounted_cash":1586.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Saf Surgery Ctr Fsc 3053"}]},{"description":"Triamcinolone Acetonide Cream 0.5%","drug_information":{"unit":15.0,"type":"GM"},"code_information":[{"code":"8114","type":"CDM"},{"code":"45802006535","type":"NDC"}],"standard_charges":[{"gross_charge":61.99,"discounted_cash":34.09,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Hc Recovery Phase I Standard Per Min Optime","code_information":[{"code":"811403","type":"CDM"},{"code":"710","type":"RC"}],"standard_charges":[{"gross_charge":42.0,"discounted_cash":23.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"},{"gross_charge":18.54,"discounted_cash":10.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Saf Surgery Ctr Fsc 3053"}]},{"description":"Hc Recovery Phase I Complex Per Min Optime","code_information":[{"code":"811404","type":"CDM"},{"code":"710","type":"RC"}],"standard_charges":[{"gross_charge":52.0,"discounted_cash":28.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"},{"gross_charge":26.78,"discounted_cash":14.73,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Saf Surgery Ctr Fsc 3053"}]},{"description":"Hc Angio Pulmon Bilat Select","code_information":[{"code":"811423","type":"CDM"},{"code":"323","type":"RC"},{"code":"75743","type":"HCPCS"}],"standard_charges":[{"gross_charge":10110.0,"discounted_cash":5560.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Angio Pulmon Unilat Select","code_information":[{"code":"811424","type":"CDM"},{"code":"323","type":"RC"},{"code":"75741","type":"HCPCS"}],"standard_charges":[{"gross_charge":5993.0,"discounted_cash":3296.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Angio Visceral Selectv/Subselec","code_information":[{"code":"811427","type":"CDM"},{"code":"323","type":"RC"},{"code":"75726","type":"HCPCS"}],"standard_charges":[{"gross_charge":5977.0,"discounted_cash":3287.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Angio Existing Cath Followup Nonthromb","code_information":[{"code":"811428","type":"CDM"},{"code":"323","type":"RC"},{"code":"75898","type":"HCPCS"}],"standard_charges":[{"gross_charge":1225.0,"discounted_cash":673.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Capd Dialysis W Training","code_information":[{"code":"811457","type":"CDM"},{"code":"841","type":"RC"},{"code":"90989","type":"HCPCS"}],"standard_charges":[{"gross_charge":1300.0,"discounted_cash":715.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ccpd Dialysis W Training","code_information":[{"code":"811462","type":"CDM"},{"code":"851","type":"RC"},{"code":"90989","type":"HCPCS"}],"standard_charges":[{"gross_charge":1300.0,"discounted_cash":715.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Destruct Nerve Neurolytic Periph","code_information":[{"code":"811470","type":"CDM"},{"code":"361","type":"RC"},{"code":"64640","type":"HCPCS"}],"standard_charges":[{"gross_charge":2622.0,"discounted_cash":1442.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Destruct Nrve Neurolytic Intercostal","code_information":[{"code":"811471","type":"CDM"},{"code":"361","type":"RC"},{"code":"64620","type":"HCPCS"}],"standard_charges":[{"gross_charge":3453.0,"discounted_cash":1899.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Kit Adl","code_information":[{"code":"811472","type":"CDM"},{"code":"270","type":"RC"}],"standard_charges":[{"gross_charge":35.59,"discounted_cash":19.57,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."},{"gross_charge":35.52,"discounted_cash":19.54,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."},{"gross_charge":35.54,"discounted_cash":19.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Hc Emg Cranial Nerve Bilat","code_information":[{"code":"811482","type":"CDM"},{"code":"922","type":"RC"},{"code":"95868","type":"HCPCS"}],"standard_charges":[{"gross_charge":657.0,"discounted_cash":361.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Emg Cranial Nerve Unilat","code_information":[{"code":"811483","type":"CDM"},{"code":"922","type":"RC"},{"code":"95867","type":"HCPCS"}],"standard_charges":[{"gross_charge":329.0,"discounted_cash":180.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ep Lv Recordings Only","code_information":[{"code":"811485","type":"CDM"},{"code":"480","type":"RC"},{"code":"93622","type":"HCPCS"}],"standard_charges":[{"gross_charge":6582.0,"discounted_cash":3620.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Exc Skin Benign Trnk/Extrm 0.6-1.0Cm","code_information":[{"code":"811490","type":"CDM"},{"code":"361","type":"RC"},{"code":"11401","type":"HCPCS"}],"standard_charges":[{"gross_charge":1509.0,"discounted_cash":829.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Noncdm Charge Record","code_information":[{"code":"811501","type":"CDM"},{"code":"361","type":"RC"},{"code":"11602","type":"HCPCS"}],"standard_charges":[{"gross_charge":711.0,"discounted_cash":391.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Noncdm Charge Record","code_information":[{"code":"811502","type":"CDM"},{"code":"361","type":"RC"},{"code":"11604","type":"HCPCS"}],"standard_charges":[{"gross_charge":1128.0,"discounted_cash":620.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Hc Inf Chemo Intra-Art To 1 Hr","code_information":[{"code":"811516","type":"CDM"},{"code":"335","type":"RC"},{"code":"96422","type":"HCPCS"}],"standard_charges":[{"gross_charge":386.0,"discounted_cash":212.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Inf Chemo Iv W/Pump >8Hrs","code_information":[{"code":"811518","type":"CDM"},{"code":"335","type":"RC"},{"code":"96416","type":"HCPCS"}],"standard_charges":[{"gross_charge":894.0,"discounted_cash":491.7,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Inj Aa Strd Brachial Plexus Sngl W Img","code_information":[{"code":"811522","type":"CDM"},{"code":"361","type":"RC"},{"code":"64415","type":"HCPCS"}],"standard_charges":[{"gross_charge":2081.0,"discounted_cash":1144.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Inj Ans Ganglion Stellate","code_information":[{"code":"811528","type":"CDM"},{"code":"361","type":"RC"},{"code":"64510","type":"HCPCS"}],"standard_charges":[{"gross_charge":1916.0,"discounted_cash":1053.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Inj Aa Strd Peripheral Nerve","code_information":[{"code":"811533","type":"CDM"},{"code":"361","type":"RC"},{"code":"64450","type":"HCPCS"}],"standard_charges":[{"gross_charge":1423.0,"discounted_cash":782.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Insert Pacing Electrode W/ Prev Device","code_information":[{"code":"811547","type":"CDM"},{"code":"481","type":"RC"},{"code":"33224","type":"HCPCS"}],"standard_charges":[{"gross_charge":38888.0,"discounted_cash":21388.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Noncdm Charge Record","code_information":[{"code":"811548","type":"CDM"},{"code":"361","type":"RC"},{"code":"51720","type":"HCPCS"}],"standard_charges":[{"gross_charge":996.89,"discounted_cash":548.29,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Noncdm Charge Record","code_information":[{"code":"811567","type":"CDM"},{"code":"922","type":"RC"},{"code":"95937","type":"HCPCS"}],"standard_charges":[{"gross_charge":500.4,"discounted_cash":275.22,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Hc Perfusionist Support In Icu","code_information":[{"code":"811588","type":"CDM"},{"code":"369","type":"RC"}],"standard_charges":[{"gross_charge":10803.0,"discounted_cash":5941.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Place Cath Select Art Add 2/3 Ord Thor","code_information":[{"code":"811589","type":"CDM"},{"code":"361","type":"RC"},{"code":"36218","type":"HCPCS"}],"standard_charges":[{"gross_charge":6848.0,"discounted_cash":3766.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Radiation Tx Delivery Complex =>1Mev","code_information":[{"code":"811608","type":"CDM"},{"code":"333","type":"RC"},{"code":"77412","type":"HCPCS"}],"standard_charges":[{"gross_charge":1230.0,"discounted_cash":676.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Radiation Tx Delivery Simple =>1Mev","code_information":[{"code":"811610","type":"CDM"},{"code":"333","type":"RC"},{"code":"77402","type":"HCPCS"}],"standard_charges":[{"gross_charge":766.0,"discounted_cash":421.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Reposit Prev Implanted Cardiac Electrode","code_information":[{"code":"811624","type":"CDM"},{"code":"481","type":"RC"},{"code":"33226","type":"HCPCS"}],"standard_charges":[{"gross_charge":5119.0,"discounted_cash":2815.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Therapeutic Hypothermia","code_information":[{"code":"811645","type":"CDM"},{"code":"940","type":"RC"}],"standard_charges":[{"gross_charge":455.0,"discounted_cash":250.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Therapeutic Procedures Group 30 Min Ot","code_information":[{"code":"811647","type":"CDM"},{"code":"433","type":"RC"},{"code":"97150","type":"HCPCS"}],"standard_charges":[{"gross_charge":91.0,"discounted_cash":50.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Trim Nails Nondystrophic","code_information":[{"code":"811653","type":"CDM"},{"code":"361","type":"RC"},{"code":"11719","type":"HCPCS"}],"standard_charges":[{"gross_charge":99.0,"discounted_cash":54.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Valvuloplasty Valve Aortic","code_information":[{"code":"811667","type":"CDM"},{"code":"481","type":"RC"},{"code":"92986","type":"HCPCS"}],"standard_charges":[{"gross_charge":11215.0,"discounted_cash":6168.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Declot By Thrombolytic Agent Vad Cath","code_information":[{"code":"811676","type":"CDM"},{"code":"361","type":"RC"},{"code":"36593","type":"HCPCS"}],"standard_charges":[{"gross_charge":808.0,"discounted_cash":444.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Mnt Subseq Change Dx Group Ea 30 Min","code_information":[{"code":"811686","type":"CDM"},{"code":"942","type":"RC"},{"code":"G0271","type":"HCPCS"}],"standard_charges":[{"gross_charge":103.0,"discounted_cash":56.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Inj Ans Sphenopalatine Ganglion","code_information":[{"code":"811693","type":"CDM"},{"code":"361","type":"RC"},{"code":"64505","type":"HCPCS"}],"standard_charges":[{"gross_charge":1204.0,"discounted_cash":662.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Inj Therapeutic Carpal Tunnel","code_information":[{"code":"811697","type":"CDM"},{"code":"361","type":"RC"},{"code":"20526","type":"HCPCS"}],"standard_charges":[{"gross_charge":833.0,"discounted_cash":458.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Dialysis Unscheduled Outpatient","code_information":[{"code":"811711","type":"CDM"},{"code":"829","type":"RC"},{"code":"G0257","type":"HCPCS"}],"standard_charges":[{"gross_charge":1238.0,"discounted_cash":680.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Inj Aa Strd Sciatic Nerve W Img","code_information":[{"code":"811717","type":"CDM"},{"code":"361","type":"RC"},{"code":"64445","type":"HCPCS"}],"standard_charges":[{"gross_charge":1600.0,"discounted_cash":880.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Inj Ans Celiac Plexus","code_information":[{"code":"811718","type":"CDM"},{"code":"361","type":"RC"},{"code":"64530","type":"HCPCS"}],"standard_charges":[{"gross_charge":2140.0,"discounted_cash":1177.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Counsel Smoking/Tobacco Intermed 3-10Min","code_information":[{"code":"811756","type":"CDM"},{"code":"942","type":"RC"},{"code":"99406","type":"HCPCS"}],"standard_charges":[{"gross_charge":56.0,"discounted_cash":30.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Triamcinolone Acetonide Oint 0.1%","drug_information":{"unit":15.0,"type":"GM"},"code_information":[{"code":"8118","type":"CDM"},{"code":"33342033315","type":"NDC"}],"standard_charges":[{"gross_charge":41.76,"discounted_cash":22.97,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Triamcinolone Acetonide Oint 0.1%","drug_information":{"unit":454.0,"type":"GM"},"code_information":[{"code":"8118","type":"CDM"},{"code":"45802005505","type":"NDC"}],"standard_charges":[{"gross_charge":200.85,"discounted_cash":110.47,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Noncdm Charge Record","code_information":[{"code":"811837","type":"CDM"},{"code":"920","type":"RC"},{"code":"51741","type":"HCPCS"}],"standard_charges":[{"gross_charge":412.48,"discounted_cash":226.86,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Noncdm Charge Record","code_information":[{"code":"811840","type":"CDM"},{"code":"361","type":"RC"},{"code":"51784","type":"HCPCS"}],"standard_charges":[{"gross_charge":845.4,"discounted_cash":464.97,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Hc Emg Anal Urethral Sphinc Needle","code_information":[{"code":"811843","type":"CDM"},{"code":"361","type":"RC"},{"code":"51785","type":"HCPCS"}],"standard_charges":[{"gross_charge":1096.0,"discounted_cash":602.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Bronchoscopy Procedure I","code_information":[{"code":"811872","type":"CDM"},{"code":"360","type":"RC"}],"standard_charges":[{"gross_charge":4752.0,"discounted_cash":2613.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Bronchoscopy Procedure Ii","code_information":[{"code":"811873","type":"CDM"},{"code":"360","type":"RC"}],"standard_charges":[{"gross_charge":6097.0,"discounted_cash":3353.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Maximum Breathing Capacity","code_information":[{"code":"811878","type":"CDM"},{"code":"460","type":"RC"},{"code":"94200","type":"HCPCS"}],"standard_charges":[{"gross_charge":672.0,"discounted_cash":369.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Exc Skin Benign Sc/Nk/Hd/Ft 0.6-1.0Cm","code_information":[{"code":"811880","type":"CDM"},{"code":"361","type":"RC"},{"code":"11421","type":"HCPCS"}],"standard_charges":[{"gross_charge":4126.0,"discounted_cash":2269.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Heated High Flow O2 Initial","code_information":[{"code":"811885","type":"CDM"},{"code":"410","type":"RC"},{"code":"94799","type":"HCPCS"}],"standard_charges":[{"gross_charge":723.0,"discounted_cash":397.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Cancelled Procedure Prior Enter Room","code_information":[{"code":"811886","type":"CDM"},{"code":"761","type":"RC"},{"code":"99211","type":"HCPCS"}],"standard_charges":[{"gross_charge":216.0,"discounted_cash":118.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Arthrocentesis Joint Small Wo Us","code_information":[{"code":"811892","type":"CDM"},{"code":"361","type":"RC"},{"code":"20600","type":"HCPCS"}],"standard_charges":[{"gross_charge":1184.0,"discounted_cash":651.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ans Mac Regional Spinal Per Minute","code_information":[{"code":"811894","type":"CDM"},{"code":"370","type":"RC"}],"standard_charges":[{"gross_charge":56.0,"discounted_cash":30.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"},{"gross_charge":41.2,"discounted_cash":22.66,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Saf Surgery Ctr Fsc 3053"}]},{"description":"Hc Ans Epidural Flat Rate","code_information":[{"code":"811896","type":"CDM"},{"code":"370","type":"RC"}],"standard_charges":[{"gross_charge":1667.0,"discounted_cash":916.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Pad Rehab","code_information":[{"code":"811906","type":"CDM"},{"code":"480","type":"RC"},{"code":"93668","type":"HCPCS"}],"standard_charges":[{"gross_charge":433.0,"discounted_cash":238.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Cr Maintenance","code_information":[{"code":"811915","type":"CDM"},{"code":"943","type":"RC"}],"standard_charges":[{"gross_charge":67.0,"discounted_cash":36.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Card Rehab Eval Phase Iii","code_information":[{"code":"811926","type":"CDM"},{"code":"943","type":"RC"}],"standard_charges":[{"gross_charge":162.0,"discounted_cash":89.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Tte 2D W Stress W Contrast","code_information":[{"code":"811927","type":"CDM"},{"code":"483","type":"RC"},{"code":"C8928","type":"HCPCS"}],"standard_charges":[{"gross_charge":1608.0,"discounted_cash":884.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Inhalation Treatment W/Med Subsequent","code_information":[{"code":"811993","type":"CDM"},{"code":"410","type":"RC"},{"code":"94640","type":"HCPCS"}],"standard_charges":[{"gross_charge":205.0,"discounted_cash":112.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Inhalation Treatment W/Med","code_information":[{"code":"811994","type":"CDM"},{"code":"410","type":"RC"},{"code":"94640","type":"HCPCS"}],"standard_charges":[{"gross_charge":205.0,"discounted_cash":112.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Triamcinolone Acetonide Inj Susp 40 MG/ML","drug_information":{"unit":1.0,"type":"ML"},"code_information":[{"code":"8120","type":"CDM"},{"code":"3029320","type":"NDC"}],"standard_charges":[{"gross_charge":62.36,"discounted_cash":34.30,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Triamcinolone Acetonide Inj Susp 40 MG/ML","drug_information":{"unit":1.0,"type":"ML"},"code_information":[{"code":"8120","type":"CDM"},{"code":"70121104905","type":"NDC"}],"standard_charges":[{"gross_charge":59.05,"discounted_cash":32.48,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Triamcinolone Acetonide Inj Susp 40 MG/ML","drug_information":{"unit":1.0,"type":"ML"},"code_information":[{"code":"8120","type":"CDM"},{"code":"70121165201","type":"NDC"}],"standard_charges":[{"gross_charge":59.61,"discounted_cash":32.79,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Triamcinolone Acetonide Inj Susp 40 MG/ML","drug_information":{"unit":1.0,"type":"ML"},"code_information":[{"code":"8120","type":"CDM"},{"code":"70121104902","type":"NDC"}],"standard_charges":[{"gross_charge":59.05,"discounted_cash":32.48,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Noncdm Charge Record","code_information":[{"code":"812001","type":"CDM"},{"code":"361","type":"RC"},{"code":"17110","type":"HCPCS"}],"standard_charges":[{"gross_charge":279.0,"discounted_cash":153.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Hc Chemical Cautery Granulation Tissue","code_information":[{"code":"812003","type":"CDM"},{"code":"361","type":"RC"},{"code":"17250","type":"HCPCS"}],"standard_charges":[{"gross_charge":894.0,"discounted_cash":491.7,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Noncdm Charge Record","code_information":[{"code":"812037","type":"CDM"},{"code":"361","type":"RC"},{"code":"17003","type":"HCPCS"}],"standard_charges":[{"gross_charge":46.8,"discounted_cash":25.74,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Hc Capsule Endoscpy Esoph Thru Ileum","code_information":[{"code":"812042","type":"CDM"},{"code":"750","type":"RC"},{"code":"91110","type":"HCPCS"}],"standard_charges":[{"gross_charge":4637.0,"discounted_cash":2550.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Exc Skin Benign Trunk/Arm/Leg >4Cm","code_information":[{"code":"812054","type":"CDM"},{"code":"361","type":"RC"},{"code":"11406","type":"HCPCS"}],"standard_charges":[{"gross_charge":6695.0,"discounted_cash":3682.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Collection Blood Centrl Or Periph Cath","code_information":[{"code":"812066","type":"CDM"},{"code":"761","type":"RC"},{"code":"36592","type":"HCPCS"}],"standard_charges":[{"gross_charge":200.0,"discounted_cash":110.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Mammotome Probe 9G W/Vacuum","code_information":[{"code":"812077","type":"CDM"},{"code":"272","type":"RC"}],"standard_charges":[{"gross_charge":909.42,"discounted_cash":500.18,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"},{"gross_charge":890.2,"discounted_cash":489.61,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."},{"gross_charge":888.97,"discounted_cash":488.93,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Hc Probe Rf Cooled Coolief","code_information":[{"code":"812078","type":"CDM"},{"code":"272","type":"RC"}],"standard_charges":[{"gross_charge":1181.91,"discounted_cash":650.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Inj Nerve Block Sympathetic Lumb Thorac","code_information":[{"code":"812085","type":"CDM"},{"code":"361","type":"RC"},{"code":"64520","type":"HCPCS"}],"standard_charges":[{"gross_charge":2155.0,"discounted_cash":1185.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Iop Group Psychotherapy Session","code_information":[{"code":"812088","type":"CDM"},{"code":"905","type":"RC"},{"code":"90853","type":"HCPCS"}],"standard_charges":[{"gross_charge":207.0,"discounted_cash":113.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ep Intra Artrial Recording","code_information":[{"code":"812109","type":"CDM"},{"code":"480","type":"RC"},{"code":"93602","type":"HCPCS"}],"standard_charges":[{"gross_charge":13334.0,"discounted_cash":7333.7,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Family Psychotherapy W Pt 50 Min","code_information":[{"code":"812143","type":"CDM"},{"code":"905","type":"RC"},{"code":"90847","type":"HCPCS"}],"standard_charges":[{"gross_charge":216.0,"discounted_cash":118.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Educ And Train Mental Hlth 45Min Or More","code_information":[{"code":"812146","type":"CDM"},{"code":"942","type":"RC"},{"code":"G0177","type":"HCPCS"}],"standard_charges":[{"gross_charge":194.0,"discounted_cash":106.7,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Treatment Speech Disorder Grp 15 Min","code_information":[{"code":"812148","type":"CDM"},{"code":"443","type":"RC"},{"code":"92508","type":"HCPCS"}],"standard_charges":[{"gross_charge":29.0,"discounted_cash":15.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Treatment Speech Disorder Grp 30 Min","code_information":[{"code":"812149","type":"CDM"},{"code":"443","type":"RC"},{"code":"92508","type":"HCPCS"}],"standard_charges":[{"gross_charge":29.0,"discounted_cash":15.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Treatment Speech Disorder Grp 45 Min","code_information":[{"code":"812150","type":"CDM"},{"code":"443","type":"RC"},{"code":"92508","type":"HCPCS"}],"standard_charges":[{"gross_charge":29.0,"discounted_cash":15.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Treatment Speech Disorder Grp 60 Min","code_information":[{"code":"812151","type":"CDM"},{"code":"443","type":"RC"},{"code":"92508","type":"HCPCS"}],"standard_charges":[{"gross_charge":29.0,"discounted_cash":15.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Inj Aa Strd Femoral Nerve W Img","code_information":[{"code":"812153","type":"CDM"},{"code":"361","type":"RC"},{"code":"64447","type":"HCPCS"}],"standard_charges":[{"gross_charge":1430.0,"discounted_cash":786.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Inj Ans Tranfor L/S Ea Addl Level Bil","code_information":[{"code":"812158","type":"CDM"},{"code":"361","type":"RC"},{"code":"64484","type":"HCPCS"}],"standard_charges":[{"gross_charge":5459.0,"discounted_cash":3002.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Dialysis Non Hemo Crrt Per Day","code_information":[{"code":"812164","type":"CDM"},{"code":"889","type":"RC"},{"code":"90947","type":"HCPCS"}],"standard_charges":[{"gross_charge":966.0,"discounted_cash":531.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Eval Device Program Pm Dual","code_information":[{"code":"812168","type":"CDM"},{"code":"480","type":"RC"},{"code":"93280","type":"HCPCS"}],"standard_charges":[{"gross_charge":207.0,"discounted_cash":113.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Interrogate Device Pm Or Leadls Pm","code_information":[{"code":"812169","type":"CDM"},{"code":"480","type":"RC"},{"code":"93288","type":"HCPCS"}],"standard_charges":[{"gross_charge":226.0,"discounted_cash":124.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Eval Device Program Pm Sngl Or Leadls","code_information":[{"code":"812171","type":"CDM"},{"code":"480","type":"RC"},{"code":"93279","type":"HCPCS"}],"standard_charges":[{"gross_charge":175.0,"discounted_cash":96.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Eval Device Program Icd Sngl","code_information":[{"code":"812172","type":"CDM"},{"code":"480","type":"RC"},{"code":"93282","type":"HCPCS"}],"standard_charges":[{"gross_charge":221.0,"discounted_cash":121.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Eval Device Program Icd In Person","code_information":[{"code":"812173","type":"CDM"},{"code":"480","type":"RC"},{"code":"93289","type":"HCPCS"}],"standard_charges":[{"gross_charge":306.0,"discounted_cash":168.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Eval Device Program Icd Dual","code_information":[{"code":"812176","type":"CDM"},{"code":"480","type":"RC"},{"code":"93283","type":"HCPCS"}],"standard_charges":[{"gross_charge":264.0,"discounted_cash":145.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Evaluation Psych Adult","code_information":[{"code":"812304","type":"CDM"},{"code":"900","type":"RC"},{"code":"90791","type":"HCPCS"}],"standard_charges":[{"gross_charge":348.0,"discounted_cash":191.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Op Group Psychotherapy Session","code_information":[{"code":"812333","type":"CDM"},{"code":"915","type":"RC"},{"code":"90853","type":"HCPCS"}],"standard_charges":[{"gross_charge":226.0,"discounted_cash":124.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Psychotherapy W Pt 30 Min Gl","code_information":[{"code":"812334","type":"CDM"},{"code":"914","type":"RC"},{"code":"90832","type":"HCPCS"}],"standard_charges":[{"gross_charge":168.0,"discounted_cash":92.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Amputation Finger Or Thumb Single","code_information":[{"code":"812351","type":"CDM"},{"code":"360","type":"RC"},{"code":"26951","type":"HCPCS"}],"standard_charges":[{"gross_charge":5860.0,"discounted_cash":3223.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Burn Dress Debrid No Anesthes Lg","code_information":[{"code":"812353","type":"CDM"},{"code":"361","type":"RC"},{"code":"16030","type":"HCPCS"}],"standard_charges":[{"gross_charge":991.0,"discounted_cash":545.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Burn Dress Debrid No Anesthes Med","code_information":[{"code":"812354","type":"CDM"},{"code":"361","type":"RC"},{"code":"16025","type":"HCPCS"}],"standard_charges":[{"gross_charge":958.0,"discounted_cash":526.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Noncdm Charge Record","code_information":[{"code":"812425","type":"CDM"},{"code":"361","type":"RC"},{"code":"12001","type":"HCPCS"}],"standard_charges":[{"gross_charge":820.0,"discounted_cash":451.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Noncdm Charge Record","code_information":[{"code":"812443","type":"CDM"},{"code":"361","type":"RC"},{"code":"17000","type":"HCPCS"}],"standard_charges":[{"gross_charge":224.4,"discounted_cash":123.42,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Hc Deliv Out Hosp Recovery","code_information":[{"code":"812559","type":"CDM"},{"code":"722","type":"RC"}],"standard_charges":[{"gross_charge":621.0,"discounted_cash":341.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Tb Skin Test","code_information":[{"code":"812567","type":"CDM"},{"code":"302","type":"RC"},{"code":"86580","type":"HCPCS"}],"standard_charges":[{"gross_charge":62.0,"discounted_cash":34.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Whirlpool","code_information":[{"code":"812615","type":"CDM"},{"code":"951","type":"RC"},{"code":"97022","type":"HCPCS"}],"standard_charges":[{"gross_charge":85.0,"discounted_cash":46.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Elec Stim Attended Ea 15 Min","code_information":[{"code":"812617","type":"CDM"},{"code":"951","type":"RC"},{"code":"97032","type":"HCPCS"}],"standard_charges":[{"gross_charge":99.0,"discounted_cash":54.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Physical Performance Test Ea 15Min Ot","code_information":[{"code":"812621","type":"CDM"},{"code":"430","type":"RC"},{"code":"97750","type":"HCPCS"}],"standard_charges":[{"gross_charge":138.0,"discounted_cash":75.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Work Hardening Addl Hour Pt","code_information":[{"code":"812624","type":"CDM"},{"code":"420","type":"RC"},{"code":"97546","type":"HCPCS"}],"standard_charges":[{"gross_charge":189.0,"discounted_cash":103.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Wheelchair Mgmnt Training Ea 15Min Ot","code_information":[{"code":"812625","type":"CDM"},{"code":"430","type":"RC"},{"code":"97542","type":"HCPCS"}],"standard_charges":[{"gross_charge":89.0,"discounted_cash":48.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Biofeedback Electromyogram Ot","code_information":[{"code":"812631","type":"CDM"},{"code":"430","type":"RC"},{"code":"90901","type":"HCPCS"}],"standard_charges":[{"gross_charge":215.0,"discounted_cash":118.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Vasopneumatic Compression Ot","code_information":[{"code":"812632","type":"CDM"},{"code":"430","type":"RC"},{"code":"97016","type":"HCPCS"}],"standard_charges":[{"gross_charge":85.0,"discounted_cash":46.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Neg Pressure Wnd Tx <=50 Sq Cm W Dme Eq","code_information":[{"code":"812637","type":"CDM"},{"code":"761","type":"RC"},{"code":"97605","type":"HCPCS"}],"standard_charges":[{"gross_charge":490.0,"discounted_cash":269.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Neg Pressure Wnd Tx >50 Sq Cm W Dme Eq","code_information":[{"code":"812638","type":"CDM"},{"code":"761","type":"RC"},{"code":"97606","type":"HCPCS"}],"standard_charges":[{"gross_charge":548.0,"discounted_cash":301.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Elec Stim Unattended Non Wound Pt","code_information":[{"code":"812639","type":"CDM"},{"code":"420","type":"RC"},{"code":"G0283","type":"HCPCS"}],"standard_charges":[{"gross_charge":124.0,"discounted_cash":68.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Vasopneumatic Compression","code_information":[{"code":"812646","type":"CDM"},{"code":"420","type":"RC"},{"code":"97016","type":"HCPCS"}],"standard_charges":[{"gross_charge":85.0,"discounted_cash":46.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Biofeedback Electromyogram Pt","code_information":[{"code":"812647","type":"CDM"},{"code":"420","type":"RC"},{"code":"90901","type":"HCPCS"}],"standard_charges":[{"gross_charge":215.0,"discounted_cash":118.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Rb Hospital Obs Per Hr Wo Order","code_information":[{"code":"812666","type":"CDM"},{"code":"762","type":"RC"}],"standard_charges":[{"gross_charge":1.33,"discounted_cash":0.73,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Eval Speech Gen Device First Hour","code_information":[{"code":"812681","type":"CDM"},{"code":"444","type":"RC"},{"code":"92607","type":"HCPCS"}],"standard_charges":[{"gross_charge":475.0,"discounted_cash":261.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Psychotherapy W Pt 30 Min","code_information":[{"code":"812694","type":"CDM"},{"code":"905","type":"RC"},{"code":"90832","type":"HCPCS"}],"standard_charges":[{"gross_charge":186.0,"discounted_cash":102.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc I&D Abscess Complex Or Multiple","code_information":[{"code":"812744","type":"CDM"},{"code":"361","type":"RC"},{"code":"10061","type":"HCPCS"}],"standard_charges":[{"gross_charge":1060.0,"discounted_cash":583.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Insert Non Tun Cvc >=5 Yrs","code_information":[{"code":"812749","type":"CDM"},{"code":"361","type":"RC"},{"code":"36556","type":"HCPCS"}],"standard_charges":[{"gross_charge":2037.0,"discounted_cash":1120.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Tte 2D Wo Con W Doppler And Color Cmpl","code_information":[{"code":"812798","type":"CDM"},{"code":"483","type":"RC"},{"code":"93306","type":"HCPCS"}],"standard_charges":[{"gross_charge":3082.0,"discounted_cash":1695.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Tte 2D W Con W Doppler And Color Cmplt","code_information":[{"code":"812801","type":"CDM"},{"code":"483","type":"RC"},{"code":"C8929","type":"HCPCS"}],"standard_charges":[{"gross_charge":3943.0,"discounted_cash":2168.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Aquatic Therapy/Exercise Ea 15Min Ot","code_information":[{"code":"812808","type":"CDM"},{"code":"430","type":"RC"},{"code":"97113","type":"HCPCS"}],"standard_charges":[{"gross_charge":162.0,"discounted_cash":89.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Faclty Op Est Pt Level 3","code_information":[{"code":"812833","type":"CDM"},{"code":"761","type":"RC"},{"code":"99213","type":"HCPCS"}],"standard_charges":[{"gross_charge":340.0,"discounted_cash":187.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Faclty Op Est Pt Level 4","code_information":[{"code":"812834","type":"CDM"},{"code":"761","type":"RC"},{"code":"99214","type":"HCPCS"}],"standard_charges":[{"gross_charge":383.0,"discounted_cash":210.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Faclty Op New Level 5","code_information":[{"code":"812835","type":"CDM"},{"code":"761","type":"RC"},{"code":"99205","type":"HCPCS"}],"standard_charges":[{"gross_charge":538.0,"discounted_cash":295.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"},{"gross_charge":167.0,"discounted_cash":91.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Op Bhs Fsc 3252"}]},{"description":"Hc Faclty Op New Level 4","code_information":[{"code":"812837","type":"CDM"},{"code":"761","type":"RC"},{"code":"99204","type":"HCPCS"}],"standard_charges":[{"gross_charge":473.0,"discounted_cash":260.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"},{"gross_charge":146.0,"discounted_cash":80.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Op Bhs Fsc 3252"}]},{"description":"Hc Prosthetic Train Extrem Ea 15 Min Pt","code_information":[{"code":"812865","type":"CDM"},{"code":"420","type":"RC"},{"code":"97761","type":"HCPCS"}],"standard_charges":[{"gross_charge":92.0,"discounted_cash":50.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Pulmonary Strength Training Group","code_information":[{"code":"812867","type":"CDM"},{"code":"410","type":"RC"},{"code":"G0239","type":"HCPCS"}],"standard_charges":[{"gross_charge":235.0,"discounted_cash":129.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Vital Capacity Test","code_information":[{"code":"812875","type":"CDM"},{"code":"460","type":"RC"},{"code":"94150","type":"HCPCS"}],"standard_charges":[{"gross_charge":170.0,"discounted_cash":93.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Vent Mgmt Ip/Obsv Initial Day","code_information":[{"code":"812877","type":"CDM"},{"code":"410","type":"RC"},{"code":"94002","type":"HCPCS"}],"standard_charges":[{"gross_charge":1545.0,"discounted_cash":849.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Work Hardening Initial 2 Hrs","code_information":[{"code":"812878","type":"CDM"},{"code":"420","type":"RC"},{"code":"97545","type":"HCPCS"}],"standard_charges":[{"gross_charge":403.0,"discounted_cash":221.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Arterial Puncture W Withdraw","code_information":[{"code":"812928","type":"CDM"},{"code":"410","type":"RC"},{"code":"36600","type":"HCPCS"}],"standard_charges":[{"gross_charge":150.0,"discounted_cash":82.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Echo Tte Cong Anom Complt W/Contrast","code_information":[{"code":"812932","type":"CDM"},{"code":"483","type":"RC"},{"code":"C8921","type":"HCPCS"}],"standard_charges":[{"gross_charge":2180.0,"discounted_cash":1199.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Therapeutic Procedures Group 15 Min Ot","code_information":[{"code":"812961","type":"CDM"},{"code":"433","type":"RC"},{"code":"97150","type":"HCPCS"}],"standard_charges":[{"gross_charge":91.0,"discounted_cash":50.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Therapeutic Procedures Group 45 Min Ot","code_information":[{"code":"812962","type":"CDM"},{"code":"433","type":"RC"},{"code":"97150","type":"HCPCS"}],"standard_charges":[{"gross_charge":91.0,"discounted_cash":50.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Therapeutic Procedures Group 60 Min Ot","code_information":[{"code":"812963","type":"CDM"},{"code":"433","type":"RC"},{"code":"97150","type":"HCPCS"}],"standard_charges":[{"gross_charge":91.0,"discounted_cash":50.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Bronchos W Alveolar Lavage","code_information":[{"code":"812964","type":"CDM"},{"code":"360","type":"RC"},{"code":"31624","type":"HCPCS"}],"standard_charges":[{"gross_charge":3135.0,"discounted_cash":1724.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Eval Swallow Eval Endoscopy Cine/Video","code_information":[{"code":"812971","type":"CDM"},{"code":"440","type":"RC"},{"code":"92612","type":"HCPCS"}],"standard_charges":[{"gross_charge":717.0,"discounted_cash":394.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ivp Tpd Ea Add Push Same Drug","code_information":[{"code":"812991","type":"CDM"},{"code":"940","type":"RC"},{"code":"96376","type":"HCPCS"}],"standard_charges":[{"gross_charge":338.0,"discounted_cash":185.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Rad Therapy Simulation Simple","code_information":[{"code":"812998","type":"CDM"},{"code":"333","type":"RC"},{"code":"77280","type":"HCPCS"}],"standard_charges":[{"gross_charge":1151.0,"discounted_cash":633.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Rad Therapy Simulation Complex","code_information":[{"code":"812999","type":"CDM"},{"code":"333","type":"RC"},{"code":"77290","type":"HCPCS"}],"standard_charges":[{"gross_charge":2459.0,"discounted_cash":1352.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Special Dosimetry Px'd","code_information":[{"code":"813000","type":"CDM"},{"code":"333","type":"RC"},{"code":"77331","type":"HCPCS"}],"standard_charges":[{"gross_charge":810.0,"discounted_cash":445.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Tx Device Simple","code_information":[{"code":"813001","type":"CDM"},{"code":"333","type":"RC"},{"code":"77332","type":"HCPCS"}],"standard_charges":[{"gross_charge":611.0,"discounted_cash":336.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Tx Device Intermediate","code_information":[{"code":"813002","type":"CDM"},{"code":"333","type":"RC"},{"code":"77333","type":"HCPCS"}],"standard_charges":[{"gross_charge":783.0,"discounted_cash":430.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Tx Device Complex","code_information":[{"code":"813003","type":"CDM"},{"code":"333","type":"RC"},{"code":"77334","type":"HCPCS"}],"standard_charges":[{"gross_charge":1769.0,"discounted_cash":972.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Therapeutic Port Film(S)","code_information":[{"code":"813017","type":"CDM"},{"code":"333","type":"RC"},{"code":"77417","type":"HCPCS"}],"standard_charges":[{"gross_charge":313.0,"discounted_cash":172.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Special Treatment Procedure","code_information":[{"code":"813018","type":"CDM"},{"code":"333","type":"RC"},{"code":"77470","type":"HCPCS"}],"standard_charges":[{"gross_charge":2943.0,"discounted_cash":1618.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Op Psychotherapy W Pt 30 Min","code_information":[{"code":"813043","type":"CDM"},{"code":"914","type":"RC"},{"code":"90832","type":"HCPCS"}],"standard_charges":[{"gross_charge":186.0,"discounted_cash":102.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Op Psychotherapy W Pt 45 Min","code_information":[{"code":"813044","type":"CDM"},{"code":"914","type":"RC"},{"code":"90834","type":"HCPCS"}],"standard_charges":[{"gross_charge":186.0,"discounted_cash":102.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Interr Pm Icd Remote Tech Suprt <=90Day","code_information":[{"code":"813046","type":"CDM"},{"code":"480","type":"RC"},{"code":"93296","type":"HCPCS"}],"standard_charges":[{"gross_charge":253.0,"discounted_cash":139.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Interr Card Rhy Remote Tech Sup <=30 Day","code_information":[{"code":"813065","type":"CDM"},{"code":"480","type":"RC"},{"code":"93799","type":"HCPCS"}],"standard_charges":[{"gross_charge":247.0,"discounted_cash":135.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Refill Implnt Pump Spine Brain","code_information":[{"code":"813073","type":"CDM"},{"code":"761","type":"RC"},{"code":"95990","type":"HCPCS"}],"standard_charges":[{"gross_charge":919.0,"discounted_cash":505.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Debrid Non Select Wo Ans Per Session","code_information":[{"code":"813093","type":"CDM"},{"code":"761","type":"RC"},{"code":"97602","type":"HCPCS"}],"standard_charges":[{"gross_charge":310.0,"discounted_cash":170.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Hot Or Cold Packs Therapy Ot","code_information":[{"code":"813094","type":"CDM"},{"code":"430","type":"RC"},{"code":"97010","type":"HCPCS"}],"standard_charges":[{"gross_charge":22.0,"discounted_cash":12.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Eval Swallow Function 15 Min St","code_information":[{"code":"813117","type":"CDM"},{"code":"440","type":"RC"},{"code":"92610","type":"HCPCS"}],"standard_charges":[{"gross_charge":449.0,"discounted_cash":246.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Eval Swallow Function 30 Min St","code_information":[{"code":"813118","type":"CDM"},{"code":"440","type":"RC"},{"code":"92610","type":"HCPCS"}],"standard_charges":[{"gross_charge":449.0,"discounted_cash":246.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Eval Swallow Function 45 Min St","code_information":[{"code":"813119","type":"CDM"},{"code":"440","type":"RC"},{"code":"92610","type":"HCPCS"}],"standard_charges":[{"gross_charge":449.0,"discounted_cash":246.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Eval Swallow Function 60 Min St","code_information":[{"code":"813120","type":"CDM"},{"code":"440","type":"RC"},{"code":"92610","type":"HCPCS"}],"standard_charges":[{"gross_charge":449.0,"discounted_cash":246.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Slp Stdy Home W/ Type 3 Mntr Unattend","code_information":[{"code":"813127","type":"CDM"},{"code":"740","type":"RC"},{"code":"G0399","type":"HCPCS"}],"standard_charges":[{"gross_charge":1146.0,"discounted_cash":630.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Aerosol Inhalation Tx Pentamidine","code_information":[{"code":"813131","type":"CDM"},{"code":"410","type":"RC"},{"code":"94642","type":"HCPCS"}],"standard_charges":[{"gross_charge":432.0,"discounted_cash":237.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Inject Tndn Origin Insert","code_information":[{"code":"813139","type":"CDM"},{"code":"361","type":"RC"},{"code":"20551","type":"HCPCS"}],"standard_charges":[{"gross_charge":1176.0,"discounted_cash":646.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Rev Remv Sp Neurostim Gen Recv W Dtch Cn","code_information":[{"code":"813146","type":"CDM"},{"code":"361","type":"RC"},{"code":"63688","type":"HCPCS"}],"standard_charges":[{"gross_charge":11881.0,"discounted_cash":6534.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Inj Aa Strd Pudendal Nerve","code_information":[{"code":"813149","type":"CDM"},{"code":"361","type":"RC"},{"code":"64430","type":"HCPCS"}],"standard_charges":[{"gross_charge":1940.0,"discounted_cash":1067.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Noncdm Charge Record","code_information":[{"code":"813150","type":"CDM"},{"code":"920","type":"RC"},{"code":"95970","type":"HCPCS"}],"standard_charges":[{"gross_charge":638.1,"discounted_cash":350.96,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Hc Refill Maint Portable Pump","code_information":[{"code":"813152","type":"CDM"},{"code":"260","type":"RC"},{"code":"96521","type":"HCPCS"}],"standard_charges":[{"gross_charge":692.0,"discounted_cash":380.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Inj Aa Strd Greater Occipitl Nerve Bil","code_information":[{"code":"813154","type":"CDM"},{"code":"361","type":"RC"},{"code":"64405","type":"HCPCS"}],"standard_charges":[{"gross_charge":2506.0,"discounted_cash":1378.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Tc Motor Evoke Potentials Upper","code_information":[{"code":"813157","type":"CDM"},{"code":"920","type":"RC"},{"code":"95928","type":"HCPCS"}],"standard_charges":[{"gross_charge":1286.0,"discounted_cash":707.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Noncdm Charge Record","code_information":[{"code":"813178","type":"CDM"},{"code":"361","type":"RC"},{"code":"56605","type":"HCPCS"}],"standard_charges":[{"gross_charge":413.0,"discounted_cash":227.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Noncdm Charge Record","code_information":[{"code":"813180","type":"CDM"},{"code":"360","type":"RC"},{"code":"57160","type":"HCPCS"}],"standard_charges":[{"gross_charge":283.0,"discounted_cash":155.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Hc Emg Larynx","code_information":[{"code":"813192","type":"CDM"},{"code":"922","type":"RC"},{"code":"95865","type":"HCPCS"}],"standard_charges":[{"gross_charge":343.0,"discounted_cash":188.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Triamterene & Hydrochlorothiazide Tab 37.5-25 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"8132","type":"CDM"},{"code":"68382085601","type":"NDC"}],"standard_charges":[{"gross_charge":9.75,"discounted_cash":5.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Hc Insert Midline >= 3Yrs","code_information":[{"code":"813206","type":"CDM"},{"code":"761","type":"RC"},{"code":"36410","type":"HCPCS"}],"standard_charges":[{"gross_charge":90.0,"discounted_cash":49.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Noncdm Charge Record","code_information":[{"code":"813227","type":"CDM"},{"code":"361","type":"RC"},{"code":"11301","type":"HCPCS"}],"standard_charges":[{"gross_charge":321.0,"discounted_cash":176.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Hc Exc Nail Permanent","code_information":[{"code":"813229","type":"CDM"},{"code":"361","type":"RC"},{"code":"11750","type":"HCPCS"}],"standard_charges":[{"gross_charge":1846.0,"discounted_cash":1015.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Inj Intralesional <= 7 Lesions","code_information":[{"code":"813231","type":"CDM"},{"code":"361","type":"RC"},{"code":"11900","type":"HCPCS"}],"standard_charges":[{"gross_charge":692.0,"discounted_cash":380.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Physical Performance Test Ea 15Min Pt","code_information":[{"code":"813256","type":"CDM"},{"code":"420","type":"RC"},{"code":"97750","type":"HCPCS"}],"standard_charges":[{"gross_charge":131.0,"discounted_cash":72.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Cont Glucose Monitor >= 72Hrs Offc Equip","code_information":[{"code":"813267","type":"CDM"},{"code":"920","type":"RC"},{"code":"95250","type":"HCPCS"}],"standard_charges":[{"gross_charge":791.0,"discounted_cash":435.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Gastroesph Reflx Muc Tel Ph Anl Intrep","code_information":[{"code":"813270","type":"CDM"},{"code":"750","type":"RC"},{"code":"91035","type":"HCPCS"}],"standard_charges":[{"gross_charge":3973.0,"discounted_cash":2185.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Breath Hydrogen Or Methane Test","code_information":[{"code":"813272","type":"CDM"},{"code":"761","type":"RC"},{"code":"91065","type":"HCPCS"}],"standard_charges":[{"gross_charge":1105.0,"discounted_cash":607.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Noncdm Charge Record","code_information":[{"code":"813285","type":"CDM"},{"code":"361","type":"RC"},{"code":"57454","type":"HCPCS"}],"standard_charges":[{"gross_charge":1110.0,"discounted_cash":610.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Hc Catheterization Umbil Artery Newborn","code_information":[{"code":"813324","type":"CDM"},{"code":"360","type":"RC"},{"code":"36660","type":"HCPCS"}],"standard_charges":[{"gross_charge":97.0,"discounted_cash":53.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Catheterization Umbil Vein Newborn","code_information":[{"code":"813325","type":"CDM"},{"code":"361","type":"RC"},{"code":"36510","type":"HCPCS"}],"standard_charges":[{"gross_charge":193.0,"discounted_cash":106.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc I And D Complex Post Op Wound","code_information":[{"code":"813326","type":"CDM"},{"code":"361","type":"RC"},{"code":"10180","type":"HCPCS"}],"standard_charges":[{"gross_charge":9294.0,"discounted_cash":5111.7,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Echo Transesophageal Place Probe Only","code_information":[{"code":"813329","type":"CDM"},{"code":"483","type":"RC"},{"code":"93313","type":"HCPCS"}],"standard_charges":[{"gross_charge":1789.0,"discounted_cash":983.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Dialysis Non Hemo Single Eval Capd","code_information":[{"code":"813331","type":"CDM"},{"code":"803","type":"RC"},{"code":"90945","type":"HCPCS"}],"standard_charges":[{"gross_charge":136.0,"discounted_cash":74.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Chemo Inj Subarac Intravent Reservoir","code_information":[{"code":"813350","type":"CDM"},{"code":"331","type":"RC"},{"code":"96542","type":"HCPCS"}],"standard_charges":[{"gross_charge":707.0,"discounted_cash":388.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Remvl Tun Cvc Wo Sq Pt/Pp","code_information":[{"code":"813351","type":"CDM"},{"code":"361","type":"RC"},{"code":"36589","type":"HCPCS"}],"standard_charges":[{"gross_charge":1819.0,"discounted_cash":1000.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Remvl Tun Cvad W Sq Pt/Pmp","code_information":[{"code":"813352","type":"CDM"},{"code":"361","type":"RC"},{"code":"36590","type":"HCPCS"}],"standard_charges":[{"gross_charge":4439.0,"discounted_cash":2441.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Applic Cast Finger","code_information":[{"code":"813366","type":"CDM"},{"code":"361","type":"RC"},{"code":"29086","type":"HCPCS"}],"standard_charges":[{"gross_charge":525.0,"discounted_cash":288.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Family Psychotherapy Wo Pt 50 Min","code_information":[{"code":"813394","type":"CDM"},{"code":"905","type":"RC"},{"code":"90846","type":"HCPCS"}],"standard_charges":[{"gross_charge":217.0,"discounted_cash":119.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Inj Facet Jnt L/S 2Nd Lvl","code_information":[{"code":"813401","type":"CDM"},{"code":"361","type":"RC"},{"code":"64494","type":"HCPCS"}],"standard_charges":[{"gross_charge":3596.0,"discounted_cash":1977.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Inj Facet Jnt L/S 3Rd Lvl","code_information":[{"code":"813402","type":"CDM"},{"code":"361","type":"RC"},{"code":"64495","type":"HCPCS"}],"standard_charges":[{"gross_charge":3596.0,"discounted_cash":1977.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Inj Facet Jnt C/T 2Nd Lvl Bilat","code_information":[{"code":"813405","type":"CDM"},{"code":"361","type":"RC"},{"code":"64491","type":"HCPCS"}],"standard_charges":[{"gross_charge":7191.0,"discounted_cash":3955.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Inj Facet Jnt C/T 3Rd Lvl Bilat","code_information":[{"code":"813406","type":"CDM"},{"code":"361","type":"RC"},{"code":"64492","type":"HCPCS"}],"standard_charges":[{"gross_charge":5817.0,"discounted_cash":3199.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Inj Facet Jnt L/S Sngl Lvl Bilat","code_information":[{"code":"813407","type":"CDM"},{"code":"361","type":"RC"},{"code":"64493","type":"HCPCS"}],"standard_charges":[{"gross_charge":8174.0,"discounted_cash":4495.7,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Inj Facet Jnt C/T 3Rd Lvl","code_information":[{"code":"813414","type":"CDM"},{"code":"361","type":"RC"},{"code":"64492","type":"HCPCS"}],"standard_charges":[{"gross_charge":2908.0,"discounted_cash":1599.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Apply Multlay Comprs Lwr Leg","code_information":[{"code":"813539","type":"CDM"},{"code":"361","type":"RC"},{"code":"29581","type":"HCPCS"}],"standard_charges":[{"gross_charge":638.0,"discounted_cash":350.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Eval Device Program Pm Mult","code_information":[{"code":"813549","type":"CDM"},{"code":"480","type":"RC"},{"code":"93281","type":"HCPCS"}],"standard_charges":[{"gross_charge":197.0,"discounted_cash":108.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Allergen Immunotherapy 2 Or More Inj","code_information":[{"code":"813559","type":"CDM"},{"code":"940","type":"RC"},{"code":"95117","type":"HCPCS"}],"standard_charges":[{"gross_charge":55.0,"discounted_cash":30.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Eeg Extended Monitioring 41-60 Min","code_information":[{"code":"813560","type":"CDM"},{"code":"740","type":"RC"},{"code":"95812","type":"HCPCS"}],"standard_charges":[{"gross_charge":1739.0,"discounted_cash":956.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Mnt Reassess Indiv Ea 15 Min","code_information":[{"code":"813569","type":"CDM"},{"code":"942","type":"RC"},{"code":"97803","type":"HCPCS"}],"standard_charges":[{"gross_charge":98.0,"discounted_cash":53.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Noncdm Charge Record","code_information":[{"code":"813572","type":"CDM"},{"code":"510","type":"RC"},{"code":"99173","type":"HCPCS"}],"standard_charges":[{"gross_charge":12.0,"discounted_cash":6.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Hc Hemodialysis Outpatient","code_information":[{"code":"813581","type":"CDM"},{"code":"821","type":"RC"},{"code":"90999","type":"HCPCS"}],"standard_charges":[{"gross_charge":1358.0,"discounted_cash":746.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Capd Dialysis","code_information":[{"code":"813582","type":"CDM"},{"code":"841","type":"RC"},{"code":"90999","type":"HCPCS"}],"standard_charges":[{"gross_charge":1300.0,"discounted_cash":715.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Incision Lingual Frenum","code_information":[{"code":"813606","type":"CDM"},{"code":"361","type":"RC"},{"code":"41010","type":"HCPCS"}],"standard_charges":[{"gross_charge":5597.0,"discounted_cash":3078.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Eval Device Program Icd Mult","code_information":[{"code":"813612","type":"CDM"},{"code":"480","type":"RC"},{"code":"93284","type":"HCPCS"}],"standard_charges":[{"gross_charge":246.0,"discounted_cash":135.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Trauma Activation Lvl3 Class 2 W Cc","code_information":[{"code":"813643","type":"CDM"},{"code":"683","type":"RC"},{"code":"G0390","type":"HCPCS"}],"standard_charges":[{"gross_charge":6612.0,"discounted_cash":3636.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Trauma Activation Lvl3 Class 1 W Cc","code_information":[{"code":"813644","type":"CDM"},{"code":"683","type":"RC"},{"code":"G0390","type":"HCPCS"}],"standard_charges":[{"gross_charge":10007.0,"discounted_cash":5503.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Trauma Activation Lvl3 Class 2 Wo Cc","code_information":[{"code":"813645","type":"CDM"},{"code":"683","type":"RC"},{"code":"99499","type":"HCPCS"}],"standard_charges":[{"gross_charge":6612.0,"discounted_cash":3636.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Trauma Activation Lvl3 Class 1 Wo Cc","code_information":[{"code":"813646","type":"CDM"},{"code":"683","type":"RC"},{"code":"99499","type":"HCPCS"}],"standard_charges":[{"gross_charge":10007.0,"discounted_cash":5503.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Inj Facet Jnt L/S Sngl Lvl","code_information":[{"code":"813652","type":"CDM"},{"code":"361","type":"RC"},{"code":"64493","type":"HCPCS"}],"standard_charges":[{"gross_charge":4086.0,"discounted_cash":2247.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Drain Bl W Suprapubic Cath Ins","code_information":[{"code":"813654","type":"CDM"},{"code":"361","type":"RC"},{"code":"51102","type":"HCPCS"}],"standard_charges":[{"gross_charge":5398.0,"discounted_cash":2968.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Insert Tunneled Pleural Cath","code_information":[{"code":"813702","type":"CDM"},{"code":"361","type":"RC"},{"code":"32550","type":"HCPCS"}],"standard_charges":[{"gross_charge":8632.0,"discounted_cash":4747.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Us Aaa Screening","code_information":[{"code":"813718","type":"CDM"},{"code":"402","type":"RC"},{"code":"76706","type":"HCPCS"}],"standard_charges":[{"gross_charge":744.0,"discounted_cash":409.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Inj Aa Strd Brachial Plexus Cont Infus W Img","code_information":[{"code":"813767","type":"CDM"},{"code":"361","type":"RC"},{"code":"64416","type":"HCPCS"}],"standard_charges":[{"gross_charge":2375.0,"discounted_cash":1306.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Inj Aa Strd Sciatic Nerve Cont Inf W Img","code_information":[{"code":"813768","type":"CDM"},{"code":"361","type":"RC"},{"code":"64446","type":"HCPCS"}],"standard_charges":[{"gross_charge":2929.0,"discounted_cash":1610.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Inj Aa Strd Femoral Nerve Cont Infus W Img","code_information":[{"code":"813769","type":"CDM"},{"code":"361","type":"RC"},{"code":"64448","type":"HCPCS"}],"standard_charges":[{"gross_charge":2387.0,"discounted_cash":1312.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Thumb Spica Support","code_information":[{"code":"813913","type":"CDM"},{"code":"274","type":"RC"},{"code":"L3807","type":"HCPCS"}],"standard_charges":[{"gross_charge":473.44,"discounted_cash":260.39,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Bipap Disposable Full Face Mask","code_information":[{"code":"813919","type":"CDM"},{"code":"271","type":"RC"}],"standard_charges":[{"gross_charge":161.22,"discounted_cash":88.67,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Infrared Therapy Pt","code_information":[{"code":"813988","type":"CDM"},{"code":"420","type":"RC"},{"code":"97026","type":"HCPCS"}],"standard_charges":[{"gross_charge":68.0,"discounted_cash":37.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Botox Inj Mscle Facial Nrve","code_information":[{"code":"813991","type":"CDM"},{"code":"361","type":"RC"},{"code":"64612","type":"HCPCS"}],"standard_charges":[{"gross_charge":1465.0,"discounted_cash":805.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Noncdm Charge Record","code_information":[{"code":"813996","type":"CDM"},{"code":"402","type":"RC"},{"code":"76819","type":"HCPCS"}],"standard_charges":[{"gross_charge":687.0,"discounted_cash":377.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Hc Op Family Psychotherapy W Pt 50 Min","code_information":[{"code":"814010","type":"CDM"},{"code":"916","type":"RC"},{"code":"90847","type":"HCPCS"}],"standard_charges":[{"gross_charge":238.0,"discounted_cash":130.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Venipuncture >=3Yrs Non Routine","code_information":[{"code":"814020","type":"CDM"},{"code":"761","type":"RC"},{"code":"36410","type":"HCPCS"}],"standard_charges":[{"gross_charge":298.0,"discounted_cash":163.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Treat Pleurodesis W Agent","code_information":[{"code":"814021","type":"CDM"},{"code":"361","type":"RC"},{"code":"32560","type":"HCPCS"}],"standard_charges":[{"gross_charge":2867.0,"discounted_cash":1576.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Refill Implnt Pump Spine Brain By Hc Pro","code_information":[{"code":"814031","type":"CDM"},{"code":"761","type":"RC"},{"code":"95991","type":"HCPCS"}],"standard_charges":[{"gross_charge":926.0,"discounted_cash":509.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Inj Ans Superior Hypogast Plexus","code_information":[{"code":"814058","type":"CDM"},{"code":"361","type":"RC"},{"code":"64517","type":"HCPCS"}],"standard_charges":[{"gross_charge":1938.0,"discounted_cash":1065.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Replace Cath Only Of Vad","code_information":[{"code":"814088","type":"CDM"},{"code":"361","type":"RC"},{"code":"36578","type":"HCPCS"}],"standard_charges":[{"gross_charge":5326.0,"discounted_cash":2929.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Fine Needle Aspir Wo Imaging 1St Lesn","code_information":[{"code":"814090","type":"CDM"},{"code":"361","type":"RC"},{"code":"10021","type":"HCPCS"}],"standard_charges":[{"gross_charge":1157.0,"discounted_cash":636.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Revasc Iliac Uni W Stnt+Pta Init","code_information":[{"code":"814137","type":"CDM"},{"code":"361","type":"RC"},{"code":"37221","type":"HCPCS"}],"standard_charges":[{"gross_charge":19186.0,"discounted_cash":10552.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Revasc Fem Pop Uni W Pta","code_information":[{"code":"814140","type":"CDM"},{"code":"361","type":"RC"},{"code":"37224","type":"HCPCS"}],"standard_charges":[{"gross_charge":12876.0,"discounted_cash":7081.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Revasc Fem Pop Uni W Ath+Pta","code_information":[{"code":"814141","type":"CDM"},{"code":"361","type":"RC"},{"code":"37225","type":"HCPCS"}],"standard_charges":[{"gross_charge":24053.0,"discounted_cash":13229.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Revasc Fem Pop Uni W Stnt+Pta","code_information":[{"code":"814142","type":"CDM"},{"code":"361","type":"RC"},{"code":"37226","type":"HCPCS"}],"standard_charges":[{"gross_charge":19532.0,"discounted_cash":10742.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Revasc Fem Pop Uni W Stnt+Ath+Pta","code_information":[{"code":"814143","type":"CDM"},{"code":"361","type":"RC"},{"code":"37227","type":"HCPCS"}],"standard_charges":[{"gross_charge":37530.0,"discounted_cash":20641.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Revasc Tib Per Uni W Pta Init","code_information":[{"code":"814144","type":"CDM"},{"code":"361","type":"RC"},{"code":"37228","type":"HCPCS"}],"standard_charges":[{"gross_charge":14787.0,"discounted_cash":8132.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Revasc Tib Per Uni Ath+Pta Init","code_information":[{"code":"814145","type":"CDM"},{"code":"361","type":"RC"},{"code":"37229","type":"HCPCS"}],"standard_charges":[{"gross_charge":22880.0,"discounted_cash":12584.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Revasc Tib Per Uni Stnt+Pta Init","code_information":[{"code":"814146","type":"CDM"},{"code":"361","type":"RC"},{"code":"37230","type":"HCPCS"}],"standard_charges":[{"gross_charge":20047.0,"discounted_cash":11025.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Revasc Tib Per Uni Stnt+Ath Init","code_information":[{"code":"814147","type":"CDM"},{"code":"361","type":"RC"},{"code":"37231","type":"HCPCS"}],"standard_charges":[{"gross_charge":30820.0,"discounted_cash":16951.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Revasc Iliac Uni W Pta Init","code_information":[{"code":"814153","type":"CDM"},{"code":"361","type":"RC"},{"code":"37220","type":"HCPCS"}],"standard_charges":[{"gross_charge":12913.0,"discounted_cash":7102.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Inj Lt Vent Atrl Angio Dur Cath","code_information":[{"code":"814155","type":"CDM"},{"code":"481","type":"RC"},{"code":"93565","type":"HCPCS"}],"standard_charges":[{"gross_charge":1950.0,"discounted_cash":1072.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Inj Nonselect Pulm Art Angio Dur Cath","code_information":[{"code":"814157","type":"CDM"},{"code":"481","type":"RC"},{"code":"93568","type":"HCPCS"}],"standard_charges":[{"gross_charge":2618.0,"discounted_cash":1439.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Rhc W O2 Sat And Cardiac Output","code_information":[{"code":"814158","type":"CDM"},{"code":"481","type":"RC"},{"code":"93451","type":"HCPCS"}],"standard_charges":[{"gross_charge":5749.0,"discounted_cash":3161.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Rlhc W Lt Vent W S+I","code_information":[{"code":"814160","type":"CDM"},{"code":"481","type":"RC"},{"code":"93453","type":"HCPCS"}],"standard_charges":[{"gross_charge":15860.0,"discounted_cash":8723.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Plcmt Cath Cor Angio Inj W S+I","code_information":[{"code":"814161","type":"CDM"},{"code":"481","type":"RC"},{"code":"93454","type":"HCPCS"}],"standard_charges":[{"gross_charge":11773.0,"discounted_cash":6475.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Plcmt Cath Cor Ang W S+I Bypass","code_information":[{"code":"814162","type":"CDM"},{"code":"481","type":"RC"},{"code":"93455","type":"HCPCS"}],"standard_charges":[{"gross_charge":10941.0,"discounted_cash":6017.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Rhc W Cor Angio W S+I","code_information":[{"code":"814163","type":"CDM"},{"code":"481","type":"RC"},{"code":"93456","type":"HCPCS"}],"standard_charges":[{"gross_charge":16038.0,"discounted_cash":8820.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Lhc W Cor Angio Lt Vent W S+I","code_information":[{"code":"814165","type":"CDM"},{"code":"481","type":"RC"},{"code":"93458","type":"HCPCS"}],"standard_charges":[{"gross_charge":14466.0,"discounted_cash":7956.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Lhc W Cor Ang Lt Vent S+I Bypass","code_information":[{"code":"814166","type":"CDM"},{"code":"481","type":"RC"},{"code":"93459","type":"HCPCS"}],"standard_charges":[{"gross_charge":15876.0,"discounted_cash":8731.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Rlhc W Cor Angio Lt Vent W S+I","code_information":[{"code":"814167","type":"CDM"},{"code":"481","type":"RC"},{"code":"93460","type":"HCPCS"}],"standard_charges":[{"gross_charge":14713.0,"discounted_cash":8092.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Rlhc Cor Ang Lt Vent W S+I Bypass","code_information":[{"code":"814168","type":"CDM"},{"code":"481","type":"RC"},{"code":"93461","type":"HCPCS"}],"standard_charges":[{"gross_charge":10836.0,"discounted_cash":5959.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Lhc Transpunc Via Intact Septum","code_information":[{"code":"814169","type":"CDM"},{"code":"481","type":"RC"},{"code":"93462","type":"HCPCS"}],"standard_charges":[{"gross_charge":8030.0,"discounted_cash":4416.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Drug Admin & Hemodynamic Meas","code_information":[{"code":"814177","type":"CDM"},{"code":"481","type":"RC"},{"code":"93463","type":"HCPCS"}],"standard_charges":[{"gross_charge":595.0,"discounted_cash":327.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Us Joint Or Nonvasc Ext Limited","code_information":[{"code":"814179","type":"CDM"},{"code":"402","type":"RC"},{"code":"76882","type":"HCPCS"}],"standard_charges":[{"gross_charge":744.0,"discounted_cash":409.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Insert Cath Tunneld Intraperiton Cmplt","code_information":[{"code":"814201","type":"CDM"},{"code":"360","type":"RC"},{"code":"49418","type":"HCPCS"}],"standard_charges":[{"gross_charge":5878.0,"discounted_cash":3232.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Inj Tndn Ligmnt Sngl Apnuros","code_information":[{"code":"814203","type":"CDM"},{"code":"361","type":"RC"},{"code":"20550","type":"HCPCS"}],"standard_charges":[{"gross_charge":1705.0,"discounted_cash":937.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Iliac Ipsi Stnt Pta Ea Add","code_information":[{"code":"814204","type":"CDM"},{"code":"361","type":"RC"},{"code":"37223","type":"HCPCS"}],"standard_charges":[{"gross_charge":17790.0,"discounted_cash":9784.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Iliac Ipsi W Pta Ea Add","code_information":[{"code":"814205","type":"CDM"},{"code":"361","type":"RC"},{"code":"37222","type":"HCPCS"}],"standard_charges":[{"gross_charge":10933.0,"discounted_cash":6013.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Revasc Tib Per Uni W Pta Ea Addl Vsl","code_information":[{"code":"814207","type":"CDM"},{"code":"361","type":"RC"},{"code":"37232","type":"HCPCS"}],"standard_charges":[{"gross_charge":10875.0,"discounted_cash":5981.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Revasc Tib Per Uni Stnt+Pta Ea Addl Vsl","code_information":[{"code":"814209","type":"CDM"},{"code":"361","type":"RC"},{"code":"37234","type":"HCPCS"}],"standard_charges":[{"gross_charge":16721.0,"discounted_cash":9196.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Debrid Subq Ea Add 20 Cm","code_information":[{"code":"814210","type":"CDM"},{"code":"361","type":"RC"},{"code":"11045","type":"HCPCS"}],"standard_charges":[{"gross_charge":1381.0,"discounted_cash":759.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Debrid Muscle Ea Add 20 Cm","code_information":[{"code":"814211","type":"CDM"},{"code":"361","type":"RC"},{"code":"11046","type":"HCPCS"}],"standard_charges":[{"gross_charge":1381.0,"discounted_cash":759.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Debrid Bone Ea Add 20 Cm","code_information":[{"code":"814212","type":"CDM"},{"code":"361","type":"RC"},{"code":"11047","type":"HCPCS"}],"standard_charges":[{"gross_charge":2178.0,"discounted_cash":1197.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Inj Supravalv Aogrphy Dur Cath","code_information":[{"code":"814241","type":"CDM"},{"code":"481","type":"RC"},{"code":"93567","type":"HCPCS"}],"standard_charges":[{"gross_charge":3087.0,"discounted_cash":1697.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Inj Facet Jnt L/S 2Nd Lvl Bilat","code_information":[{"code":"814263","type":"CDM"},{"code":"361","type":"RC"},{"code":"64494","type":"HCPCS"}],"standard_charges":[{"gross_charge":7191.0,"discounted_cash":3955.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Inj Facet Jnt L/S 3Rd Lvl Bilat","code_information":[{"code":"814264","type":"CDM"},{"code":"361","type":"RC"},{"code":"64495","type":"HCPCS"}],"standard_charges":[{"gross_charge":7191.0,"discounted_cash":3955.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Skin Tissue Procedure Unlisted","code_information":[{"code":"814281","type":"CDM"},{"code":"360","type":"RC"},{"code":"17999","type":"HCPCS"}],"standard_charges":[{"gross_charge":178.0,"discounted_cash":97.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Rmvl Lesn Benign Tk/Extrm 2.1-3Cm","code_information":[{"code":"814288","type":"CDM"},{"code":"361","type":"RC"},{"code":"11403","type":"HCPCS"}],"standard_charges":[{"gross_charge":4292.0,"discounted_cash":2360.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Remv Nail Plate Ea Addl","code_information":[{"code":"814292","type":"CDM"},{"code":"361","type":"RC"},{"code":"11732","type":"HCPCS"}],"standard_charges":[{"gross_charge":444.0,"discounted_cash":244.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Canalith Repositioning Per Day Pt","code_information":[{"code":"814443","type":"CDM"},{"code":"420","type":"RC"},{"code":"95992","type":"HCPCS"}],"standard_charges":[{"gross_charge":217.0,"discounted_cash":119.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Wnd Tx Super Deh W/Pack","code_information":[{"code":"814448","type":"CDM"},{"code":"361","type":"RC"},{"code":"12021","type":"HCPCS"}],"standard_charges":[{"gross_charge":1505.0,"discounted_cash":827.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Rb Residential Room Daily","code_information":[{"code":"814455","type":"CDM"},{"code":"169","type":"RC"}],"standard_charges":[{"gross_charge":1072.0,"discounted_cash":589.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Laryngoscopy Flex Diagnostic","code_information":[{"code":"814469","type":"CDM"},{"code":"361","type":"RC"},{"code":"31575","type":"HCPCS"}],"standard_charges":[{"gross_charge":372.0,"discounted_cash":204.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Eval Speech Gen Device Addl 30Min","code_information":[{"code":"814475","type":"CDM"},{"code":"444","type":"RC"},{"code":"92608","type":"HCPCS"}],"standard_charges":[{"gross_charge":222.0,"discounted_cash":122.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ob Outpatient/Observ (0 - < 4Hrs)","code_information":[{"code":"814513","type":"CDM"},{"code":"514","type":"RC"},{"code":"99211","type":"HCPCS"}],"standard_charges":[{"gross_charge":695.0,"discounted_cash":382.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ob Outpatient/Observ (4 - < 8Hrs)","code_information":[{"code":"814514","type":"CDM"},{"code":"514","type":"RC"},{"code":"99211","type":"HCPCS"}],"standard_charges":[{"gross_charge":2155.0,"discounted_cash":1185.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ob Outpatient/Observ (8 - < 12Hrs)","code_information":[{"code":"814515","type":"CDM"},{"code":"514","type":"RC"},{"code":"99211","type":"HCPCS"}],"standard_charges":[{"gross_charge":4288.0,"discounted_cash":2358.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ob Outpatient/Observ (12 - < 16Hrs)","code_information":[{"code":"814516","type":"CDM"},{"code":"514","type":"RC"},{"code":"99211","type":"HCPCS"}],"standard_charges":[{"gross_charge":5181.0,"discounted_cash":2849.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ob Outpatient/Observ (16 - < 20Hrs)","code_information":[{"code":"814517","type":"CDM"},{"code":"514","type":"RC"},{"code":"99211","type":"HCPCS"}],"standard_charges":[{"gross_charge":6789.0,"discounted_cash":3733.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ob Outpatient/Observ (20 - 24Hrs)","code_information":[{"code":"814518","type":"CDM"},{"code":"514","type":"RC"},{"code":"99211","type":"HCPCS"}],"standard_charges":[{"gross_charge":9738.0,"discounted_cash":5355.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Repr Bl Ves Direct Low Extrem","code_information":[{"code":"814530","type":"CDM"},{"code":"361","type":"RC"},{"code":"35226","type":"HCPCS"}],"standard_charges":[{"gross_charge":882.0,"discounted_cash":485.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Esophageal Function Test","code_information":[{"code":"814549","type":"CDM"},{"code":"750","type":"RC"},{"code":"91037","type":"HCPCS"}],"standard_charges":[{"gross_charge":745.0,"discounted_cash":409.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Counsel Smoking/Tobacco Intensive >10Min","code_information":[{"code":"814667","type":"CDM"},{"code":"942","type":"RC"},{"code":"99407","type":"HCPCS"}],"standard_charges":[{"gross_charge":84.0,"discounted_cash":46.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Duplex Vein Extrem Unilat","code_information":[{"code":"814680","type":"CDM"},{"code":"450","type":"RC"},{"code":"93971","type":"HCPCS"}],"standard_charges":[{"gross_charge":1423.0,"discounted_cash":782.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Us Abdomen Limited","code_information":[{"code":"814681","type":"CDM"},{"code":"450","type":"RC"},{"code":"76705","type":"HCPCS"}],"standard_charges":[{"gross_charge":1120.0,"discounted_cash":616.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Interview Psych Dx","code_information":[{"code":"814704","type":"CDM"},{"code":"900","type":"RC"},{"code":"90791","type":"HCPCS"}],"standard_charges":[{"gross_charge":388.0,"discounted_cash":213.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Cath Picc Powr Solo Sgl Lumn 4Fr","code_information":[{"code":"814730","type":"CDM"},{"code":"272","type":"RC"},{"code":"C1751","type":"HCPCS"}],"standard_charges":[{"gross_charge":805.24,"discounted_cash":442.88,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."},{"gross_charge":802.41,"discounted_cash":441.33,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Hc Tray Epidural Catheterization","code_information":[{"code":"814731","type":"CDM"},{"code":"272","type":"RC"}],"standard_charges":[{"gross_charge":292.93,"discounted_cash":161.11,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"},{"gross_charge":286.34,"discounted_cash":157.49,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."},{"gross_charge":292.93,"discounted_cash":161.11,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Hc Rb Private Med/Surg/Gyn","code_information":[{"code":"814735","type":"CDM"},{"code":"111","type":"RC"}],"standard_charges":[{"gross_charge":1505.0,"discounted_cash":827.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Rb Private Ob","code_information":[{"code":"814736","type":"CDM"},{"code":"112","type":"RC"}],"standard_charges":[{"gross_charge":1505.0,"discounted_cash":827.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Rb Private Psych","code_information":[{"code":"814737","type":"CDM"},{"code":"114","type":"RC"}],"standard_charges":[{"gross_charge":1935.0,"discounted_cash":1064.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Rb Newborn Level I","code_information":[{"code":"814743","type":"CDM"},{"code":"171","type":"RC"}],"standard_charges":[{"gross_charge":1208.0,"discounted_cash":664.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Rb Newborn Level Ii","code_information":[{"code":"814744","type":"CDM"},{"code":"172","type":"RC"}],"standard_charges":[{"gross_charge":2128.0,"discounted_cash":1170.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Rb Newborn Level Iii","code_information":[{"code":"814745","type":"CDM"},{"code":"173","type":"RC"}],"standard_charges":[{"gross_charge":2929.0,"discounted_cash":1610.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Rb Icu General","code_information":[{"code":"814747","type":"CDM"},{"code":"200","type":"RC"}],"standard_charges":[{"gross_charge":3209.0,"discounted_cash":1764.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Rb Ccu Intermediate","code_information":[{"code":"814750","type":"CDM"},{"code":"214","type":"RC"}],"standard_charges":[{"gross_charge":2937.0,"discounted_cash":1615.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Rb Observation Per Hr","code_information":[{"code":"814751","type":"CDM"},{"code":"762","type":"RC"},{"code":"G0378","type":"HCPCS"}],"standard_charges":[{"gross_charge":1.33,"discounted_cash":0.73,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Rb Mdb Extend Recovery Per Min","code_information":[{"code":"814968","type":"CDM"},{"code":"710","type":"RC"}],"standard_charges":[{"gross_charge":1.51,"discounted_cash":0.83,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Rmvl Lesn Benign Tk/Extrm 1.1-2Cm","code_information":[{"code":"814970","type":"CDM"},{"code":"361","type":"RC"},{"code":"11402","type":"HCPCS"}],"standard_charges":[{"gross_charge":2134.0,"discounted_cash":1173.7,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Rmvl Lesn Benign Tk/Extrm 3.1-4Cm","code_information":[{"code":"814971","type":"CDM"},{"code":"361","type":"RC"},{"code":"11404","type":"HCPCS"}],"standard_charges":[{"gross_charge":5986.0,"discounted_cash":3292.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Chng Tube Trach No Fistula Tract","code_information":[{"code":"814982","type":"CDM"},{"code":"361","type":"RC"},{"code":"31502","type":"HCPCS"}],"standard_charges":[{"gross_charge":580.0,"discounted_cash":319.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Pacemaker Upgrade Single To Dual","code_information":[{"code":"814983","type":"CDM"},{"code":"481","type":"RC"},{"code":"33214","type":"HCPCS"}],"standard_charges":[{"gross_charge":5701.0,"discounted_cash":3135.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Rpr Electrode Sngl Transvenous","code_information":[{"code":"814984","type":"CDM"},{"code":"481","type":"RC"},{"code":"33218","type":"HCPCS"}],"standard_charges":[{"gross_charge":5220.0,"discounted_cash":2871.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Primary Trombectmy Mech Artery Addl Vsls","code_information":[{"code":"814986","type":"CDM"},{"code":"361","type":"RC"},{"code":"37185","type":"HCPCS"}],"standard_charges":[{"gross_charge":2901.0,"discounted_cash":1595.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Secondary Thrombectmy Perc Artery Noncor","code_information":[{"code":"814987","type":"CDM"},{"code":"361","type":"RC"},{"code":"37186","type":"HCPCS"}],"standard_charges":[{"gross_charge":2729.0,"discounted_cash":1500.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Noncdm Charge Record","code_information":[{"code":"814988","type":"CDM"},{"code":"361","type":"RC"},{"code":"51797","type":"HCPCS"}],"standard_charges":[{"gross_charge":730.8,"discounted_cash":401.94,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Noncdm Charge Record","code_information":[{"code":"814993","type":"CDM"},{"code":"361","type":"RC"},{"code":"58100","type":"HCPCS"}],"standard_charges":[{"gross_charge":385.0,"discounted_cash":211.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Hc Inj Aa Strd Greater Occipital Nerve","code_information":[{"code":"814995","type":"CDM"},{"code":"361","type":"RC"},{"code":"64405","type":"HCPCS"}],"standard_charges":[{"gross_charge":1253.0,"discounted_cash":689.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Interrogate Icm In Person","code_information":[{"code":"814998","type":"CDM"},{"code":"480","type":"RC"},{"code":"93290","type":"HCPCS"}],"standard_charges":[{"gross_charge":262.0,"discounted_cash":144.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Analysis Of Impl Pacer W Induc","code_information":[{"code":"815001","type":"CDM"},{"code":"480","type":"RC"},{"code":"93724","type":"HCPCS"}],"standard_charges":[{"gross_charge":1285.0,"discounted_cash":706.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Refill And Maintain Impl Pump/Resvr","code_information":[{"code":"815014","type":"CDM"},{"code":"260","type":"RC"},{"code":"96522","type":"HCPCS"}],"standard_charges":[{"gross_charge":561.0,"discounted_cash":308.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Tte 2D W/ Contrast Limited","code_information":[{"code":"815034","type":"CDM"},{"code":"483","type":"RC"},{"code":"C8924","type":"HCPCS"}],"standard_charges":[{"gross_charge":920.0,"discounted_cash":506.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Tee 2D W/ Contrast","code_information":[{"code":"815035","type":"CDM"},{"code":"483","type":"RC"},{"code":"C8925","type":"HCPCS"}],"standard_charges":[{"gross_charge":2180.0,"discounted_cash":1199.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Noncdm Charge Record","code_information":[{"code":"815039","type":"CDM"},{"code":"770","type":"RC"},{"code":"G0402","type":"HCPCS"}],"standard_charges":[{"gross_charge":319.54,"discounted_cash":175.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Noncdm Charge Record","code_information":[{"code":"815042","type":"CDM"},{"code":"311","type":"RC"},{"code":"Q0091","type":"HCPCS"}],"standard_charges":[{"gross_charge":36.8,"discounted_cash":20.24,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Hc Cognitive Test By Hc Pro Per Hr St","code_information":[{"code":"815070","type":"CDM"},{"code":"440","type":"RC"},{"code":"96125","type":"HCPCS"}],"standard_charges":[{"gross_charge":899.0,"discounted_cash":494.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Noncdm Charge Record","code_information":[{"code":"815113","type":"CDM"},{"code":"770","type":"RC"},{"code":"G0101","type":"HCPCS"}],"standard_charges":[{"gross_charge":87.15,"discounted_cash":47.93,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Hc Or Surgery Level 6","code_information":[{"code":"815115","type":"CDM"},{"code":"360","type":"RC"}],"standard_charges":[{"gross_charge":8585.0,"discounted_cash":4721.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"},{"gross_charge":3708.0,"discounted_cash":2039.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Saf Surgery Ctr Fsc 3053"}]},{"description":"Hc Or Surgery Level 5","code_information":[{"code":"815123","type":"CDM"},{"code":"360","type":"RC"}],"standard_charges":[{"gross_charge":7616.0,"discounted_cash":4188.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"},{"gross_charge":3399.0,"discounted_cash":1869.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Saf Surgery Ctr Fsc 3053"}]},{"description":"Hc Inj Trigger Points >=3 Muscles","code_information":[{"code":"815163","type":"CDM"},{"code":"361","type":"RC"},{"code":"20553","type":"HCPCS"}],"standard_charges":[{"gross_charge":1284.0,"discounted_cash":706.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Biopsy Bone Open Superficial","code_information":[{"code":"815168","type":"CDM"},{"code":"361","type":"RC"},{"code":"20240","type":"HCPCS"}],"standard_charges":[{"gross_charge":11825.0,"discounted_cash":6503.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Tenotomy Shld Area Single Tendon","code_information":[{"code":"815204","type":"CDM"},{"code":"360","type":"RC"},{"code":"23405","type":"HCPCS"}],"standard_charges":[{"gross_charge":7541.0,"discounted_cash":4147.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Tenotomy Shoulder Multiple Areas","code_information":[{"code":"815205","type":"CDM"},{"code":"360","type":"RC"},{"code":"23406","type":"HCPCS"}],"standard_charges":[{"gross_charge":8771.0,"discounted_cash":4824.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc I&D Abscess Hematom Humerus","code_information":[{"code":"815229","type":"CDM"},{"code":"360","type":"RC"},{"code":"23930","type":"HCPCS"}],"standard_charges":[{"gross_charge":3663.0,"discounted_cash":2014.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Tenotomy Elbow Lat Or Med Perc","code_information":[{"code":"815258","type":"CDM"},{"code":"361","type":"RC"},{"code":"24357","type":"HCPCS"}],"standard_charges":[{"gross_charge":6512.0,"discounted_cash":3581.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Incise Finger Tendon Sheath","code_information":[{"code":"815349","type":"CDM"},{"code":"360","type":"RC"},{"code":"26055","type":"HCPCS"}],"standard_charges":[{"gross_charge":5183.0,"discounted_cash":2850.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Tenotomy Hip Abductors Extensors","code_information":[{"code":"815423","type":"CDM"},{"code":"360","type":"RC"},{"code":"27006","type":"HCPCS"}],"standard_charges":[{"gross_charge":7029.0,"discounted_cash":3865.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Repair Blood Vessel Upper Extremi","code_information":[{"code":"815674","type":"CDM"},{"code":"360","type":"RC"},{"code":"35206","type":"HCPCS"}],"standard_charges":[{"gross_charge":5961.0,"discounted_cash":3278.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Carpal Tunnel Release Bilat","code_information":[{"code":"815707","type":"CDM"},{"code":"360","type":"RC"},{"code":"64721","type":"HCPCS"}],"standard_charges":[{"gross_charge":12517.0,"discounted_cash":6884.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Therapy Serv For Speech Gener Dev St","code_information":[{"code":"815730","type":"CDM"},{"code":"444","type":"RC"},{"code":"92609","type":"HCPCS"}],"standard_charges":[{"gross_charge":282.0,"discounted_cash":155.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Eval Swallow Func Cine/Video Recrd St","code_information":[{"code":"815732","type":"CDM"},{"code":"440","type":"RC"},{"code":"92611","type":"HCPCS"}],"standard_charges":[{"gross_charge":920.0,"discounted_cash":506.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Whirlpool Ot","code_information":[{"code":"815739","type":"CDM"},{"code":"430","type":"RC"},{"code":"97022","type":"HCPCS"}],"standard_charges":[{"gross_charge":85.0,"discounted_cash":46.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Whirlpool Pt","code_information":[{"code":"815740","type":"CDM"},{"code":"420","type":"RC"},{"code":"97022","type":"HCPCS"}],"standard_charges":[{"gross_charge":85.0,"discounted_cash":46.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Electrical Stimulation Ea 15 Min Ot","code_information":[{"code":"815741","type":"CDM"},{"code":"430","type":"RC"},{"code":"97032","type":"HCPCS"}],"standard_charges":[{"gross_charge":99.0,"discounted_cash":54.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Electrical Stimulation Ea 15 Min Pt","code_information":[{"code":"815742","type":"CDM"},{"code":"420","type":"RC"},{"code":"97032","type":"HCPCS"}],"standard_charges":[{"gross_charge":99.0,"discounted_cash":54.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Iontophoresis Ea 15 Min Ot","code_information":[{"code":"815743","type":"CDM"},{"code":"430","type":"RC"},{"code":"97033","type":"HCPCS"}],"standard_charges":[{"gross_charge":120.0,"discounted_cash":66.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Iontophoresis Ea 15 Min Pt","code_information":[{"code":"815744","type":"CDM"},{"code":"420","type":"RC"},{"code":"97033","type":"HCPCS"}],"standard_charges":[{"gross_charge":120.0,"discounted_cash":66.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ultrasound Therapy Ea 15 Min Ot","code_information":[{"code":"815745","type":"CDM"},{"code":"430","type":"RC"},{"code":"97035","type":"HCPCS"}],"standard_charges":[{"gross_charge":96.0,"discounted_cash":52.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ultrasound Therapy Ea 15 Min Pt","code_information":[{"code":"815746","type":"CDM"},{"code":"420","type":"RC"},{"code":"97035","type":"HCPCS"}],"standard_charges":[{"gross_charge":96.0,"discounted_cash":52.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ther Exercise Ea 15 Min Ot","code_information":[{"code":"815747","type":"CDM"},{"code":"430","type":"RC"},{"code":"97110","type":"HCPCS"}],"standard_charges":[{"gross_charge":125.0,"discounted_cash":68.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ther Exercise Ea 15 Min","code_information":[{"code":"815748","type":"CDM"},{"code":"951","type":"RC"},{"code":"97110","type":"HCPCS"}],"standard_charges":[{"gross_charge":125.0,"discounted_cash":68.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Neuromusc Reeducat 1+ Areas Ea 15 Min Ot","code_information":[{"code":"815749","type":"CDM"},{"code":"430","type":"RC"},{"code":"97112","type":"HCPCS"}],"standard_charges":[{"gross_charge":121.0,"discounted_cash":66.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Neuromusc Reeducat 1+ Areas Ea 15 Min Pt","code_information":[{"code":"815750","type":"CDM"},{"code":"420","type":"RC"},{"code":"97112","type":"HCPCS"}],"standard_charges":[{"gross_charge":121.0,"discounted_cash":66.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Aquatic Therapy/Exercise Ea 15Min  Pt","code_information":[{"code":"815751","type":"CDM"},{"code":"420","type":"RC"},{"code":"97113","type":"HCPCS"}],"standard_charges":[{"gross_charge":162.0,"discounted_cash":89.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Gait Training Ea 15 Min Pt","code_information":[{"code":"815752","type":"CDM"},{"code":"420","type":"RC"},{"code":"97116","type":"HCPCS"}],"standard_charges":[{"gross_charge":99.0,"discounted_cash":54.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Massage Therapy Ea 15 Min Ot","code_information":[{"code":"815753","type":"CDM"},{"code":"430","type":"RC"},{"code":"97124","type":"HCPCS"}],"standard_charges":[{"gross_charge":99.0,"discounted_cash":54.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Massage Therapy Ea 15 Min Pt","code_information":[{"code":"815754","type":"CDM"},{"code":"420","type":"RC"},{"code":"97124","type":"HCPCS"}],"standard_charges":[{"gross_charge":99.0,"discounted_cash":54.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Manual Ther Tech 1+Regions Ea 15 Min Ot","code_information":[{"code":"815755","type":"CDM"},{"code":"430","type":"RC"},{"code":"97140","type":"HCPCS"}],"standard_charges":[{"gross_charge":124.0,"discounted_cash":68.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Manual Ther Tech 1+Regions Ea 15 Min Pt","code_information":[{"code":"815756","type":"CDM"},{"code":"420","type":"RC"},{"code":"97140","type":"HCPCS"}],"standard_charges":[{"gross_charge":124.0,"discounted_cash":68.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ther Activities Ea 15 Min Ot","code_information":[{"code":"815759","type":"CDM"},{"code":"430","type":"RC"},{"code":"97530","type":"HCPCS"}],"standard_charges":[{"gross_charge":112.0,"discounted_cash":61.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ther Activities Ea 15 Min Pt","code_information":[{"code":"815760","type":"CDM"},{"code":"420","type":"RC"},{"code":"97530","type":"HCPCS"}],"standard_charges":[{"gross_charge":112.0,"discounted_cash":61.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Train Self Care Ea 15 Min Ot","code_information":[{"code":"815763","type":"CDM"},{"code":"430","type":"RC"},{"code":"97535","type":"HCPCS"}],"standard_charges":[{"gross_charge":88.0,"discounted_cash":48.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Debrid Selective 1St 20Sq Cm Or < Ot","code_information":[{"code":"815766","type":"CDM"},{"code":"430","type":"RC"},{"code":"97597","type":"HCPCS"}],"standard_charges":[{"gross_charge":443.0,"discounted_cash":243.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Debrid Selective 1St 20Sq Cm Or < Pt","code_information":[{"code":"815767","type":"CDM"},{"code":"420","type":"RC"},{"code":"97597","type":"HCPCS"}],"standard_charges":[{"gross_charge":443.0,"discounted_cash":243.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Debrid Selective Ea Addl 20Sq Cm  Pt","code_information":[{"code":"815768","type":"CDM"},{"code":"420","type":"RC"},{"code":"97598","type":"HCPCS"}],"standard_charges":[{"gross_charge":446.0,"discounted_cash":245.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Debridement Non Selective Pt","code_information":[{"code":"815769","type":"CDM"},{"code":"420","type":"RC"},{"code":"97602","type":"HCPCS"}],"standard_charges":[{"gross_charge":310.0,"discounted_cash":170.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Orthotic Mgmt And Training Ea 15 Min Ot","code_information":[{"code":"815770","type":"CDM"},{"code":"430","type":"RC"},{"code":"97760","type":"HCPCS"}],"standard_charges":[{"gross_charge":122.0,"discounted_cash":67.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Sputum Mobilization Initial","code_information":[{"code":"815774","type":"CDM"},{"code":"300","type":"RC"},{"code":"89220","type":"HCPCS"}],"standard_charges":[{"gross_charge":449.0,"discounted_cash":246.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Applic Unna Boot Bilat","code_information":[{"code":"815782","type":"CDM"},{"code":"361","type":"RC"},{"code":"29580","type":"HCPCS"}],"standard_charges":[{"gross_charge":1300.0,"discounted_cash":715.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Apply Multlay Comprs Leg Bilat","code_information":[{"code":"815783","type":"CDM"},{"code":"361","type":"RC"},{"code":"29581","type":"HCPCS"}],"standard_charges":[{"gross_charge":1278.0,"discounted_cash":702.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Patient Education","code_information":[{"code":"815836","type":"CDM"},{"code":"942","type":"RC"}],"standard_charges":[{"gross_charge":52.0,"discounted_cash":28.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Electrode Stim Brain Md 1St Hr","code_information":[{"code":"816017","type":"CDM"},{"code":"740","type":"RC"},{"code":"95961","type":"HCPCS"}],"standard_charges":[{"gross_charge":905.0,"discounted_cash":497.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Whfo Rigid W/O Joints","code_information":[{"code":"816050","type":"CDM"},{"code":"274","type":"RC"},{"code":"L3808","type":"HCPCS"}],"standard_charges":[{"gross_charge":580.17,"discounted_cash":319.09,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"},{"gross_charge":568.06,"discounted_cash":312.43,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."},{"gross_charge":567.13,"discounted_cash":311.92,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Hc Fo W/O Joints Cf","code_information":[{"code":"816052","type":"CDM"},{"code":"274","type":"RC"},{"code":"L3933","type":"HCPCS"}],"standard_charges":[{"gross_charge":325.18,"discounted_cash":178.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Hc Whfo W/Joint(S) Custom Fab","code_information":[{"code":"816053","type":"CDM"},{"code":"274","type":"RC"},{"code":"L3806","type":"HCPCS"}],"standard_charges":[{"gross_charge":793.62,"discounted_cash":436.49,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Hfo W/O Joints Cf","code_information":[{"code":"816054","type":"CDM"},{"code":"274","type":"RC"},{"code":"L3913","type":"HCPCS"}],"standard_charges":[{"gross_charge":381.79,"discounted_cash":209.98,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."},{"gross_charge":383.04,"discounted_cash":210.67,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Hc Hfo W/Joint(S) Cust Fab","code_information":[{"code":"816055","type":"CDM"},{"code":"274","type":"RC"},{"code":"L3921","type":"HCPCS"}],"standard_charges":[{"gross_charge":488.2,"discounted_cash":268.51,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Hfo W/O Joints Prefab","code_information":[{"code":"816056","type":"CDM"},{"code":"274","type":"RC"},{"code":"L3923","type":"HCPCS"}],"standard_charges":[{"gross_charge":132.84,"discounted_cash":73.06,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"},{"gross_charge":129.85,"discounted_cash":71.42,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Hc Appl Cast Total Contact Leg","code_information":[{"code":"816069","type":"CDM"},{"code":"361","type":"RC"},{"code":"29445","type":"HCPCS"}],"standard_charges":[{"gross_charge":842.0,"discounted_cash":463.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Aspiration Via Nasotracheal Catheter","code_information":[{"code":"816071","type":"CDM"},{"code":"410","type":"RC"},{"code":"31720","type":"HCPCS"}],"standard_charges":[{"gross_charge":221.0,"discounted_cash":121.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Noncdm Charge Record","code_information":[{"code":"816074","type":"CDM"},{"code":"361","type":"RC"},{"code":"36471","type":"HCPCS"}],"standard_charges":[{"gross_charge":727.2,"discounted_cash":399.96,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Noncdm Charge Record","code_information":[{"code":"816078","type":"CDM"},{"code":"360","type":"RC"},{"code":"37765","type":"HCPCS"}],"standard_charges":[{"gross_charge":2223.0,"discounted_cash":1222.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Hc Stab Phlebect Vn >20 Stab Inc","code_information":[{"code":"816079","type":"CDM"},{"code":"360","type":"RC"},{"code":"37766","type":"HCPCS"}],"standard_charges":[{"gross_charge":2698.0,"discounted_cash":1483.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Cysto W Remv Fb Smpl","code_information":[{"code":"816083","type":"CDM"},{"code":"361","type":"RC"},{"code":"52310","type":"HCPCS"}],"standard_charges":[{"gross_charge":5214.0,"discounted_cash":2867.7,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Rb Pvt Rehab","code_information":[{"code":"816103","type":"CDM"},{"code":"118","type":"RC"}],"standard_charges":[{"gross_charge":1668.0,"discounted_cash":917.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Us Measure Bladder Capacity","code_information":[{"code":"816106","type":"CDM"},{"code":"450","type":"RC"},{"code":"51798","type":"HCPCS"}],"standard_charges":[{"gross_charge":184.0,"discounted_cash":101.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Arthrocentesis Joint Major Wo Us","code_information":[{"code":"816108","type":"CDM"},{"code":"450","type":"RC"},{"code":"20610","type":"HCPCS"}],"standard_charges":[{"gross_charge":1786.0,"discounted_cash":982.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Aspiration Punc Absc Hem Cyst","code_information":[{"code":"816109","type":"CDM"},{"code":"450","type":"RC"},{"code":"10160","type":"HCPCS"}],"standard_charges":[{"gross_charge":1153.0,"discounted_cash":634.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Lumbar Puncture Dx Wo Ct Fl","code_information":[{"code":"816114","type":"CDM"},{"code":"450","type":"RC"},{"code":"62270","type":"HCPCS"}],"standard_charges":[{"gross_charge":2940.0,"discounted_cash":1617.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Us Remove Intrauterine Device","code_information":[{"code":"816118","type":"CDM"},{"code":"450","type":"RC"},{"code":"58301","type":"HCPCS"}],"standard_charges":[{"gross_charge":775.0,"discounted_cash":426.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Cystostomy Tube Change Simple","code_information":[{"code":"816120","type":"CDM"},{"code":"450","type":"RC"},{"code":"51705","type":"HCPCS"}],"standard_charges":[{"gross_charge":1343.0,"discounted_cash":738.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Thoracostomy W Tube Open","code_information":[{"code":"816122","type":"CDM"},{"code":"450","type":"RC"},{"code":"32551","type":"HCPCS"}],"standard_charges":[{"gross_charge":2417.0,"discounted_cash":1329.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Debride Subq Tissue 1St 20 Cm Or Less","code_information":[{"code":"816127","type":"CDM"},{"code":"450","type":"RC"},{"code":"11042","type":"HCPCS"}],"standard_charges":[{"gross_charge":1728.0,"discounted_cash":950.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed I&D Hematoma Seroma Fluid","code_information":[{"code":"816129","type":"CDM"},{"code":"450","type":"RC"},{"code":"10140","type":"HCPCS"}],"standard_charges":[{"gross_charge":6173.0,"discounted_cash":3395.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Iv Inf Hydration Init 31 Min To 1Hr","code_information":[{"code":"816130","type":"CDM"},{"code":"450","type":"RC"},{"code":"96360","type":"HCPCS"}],"standard_charges":[{"gross_charge":534.0,"discounted_cash":293.7,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Iv Inf Hydration Ea Addl Hr","code_information":[{"code":"816131","type":"CDM"},{"code":"450","type":"RC"},{"code":"96361","type":"HCPCS"}],"standard_charges":[{"gross_charge":263.0,"discounted_cash":144.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Iv Inf Ther/Proph/Diag 1St Hr","code_information":[{"code":"816132","type":"CDM"},{"code":"450","type":"RC"},{"code":"96365","type":"HCPCS"}],"standard_charges":[{"gross_charge":547.0,"discounted_cash":300.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Iv Inf Ther/Proph/Diag Ea Addl Hr","code_information":[{"code":"816133","type":"CDM"},{"code":"450","type":"RC"},{"code":"96366","type":"HCPCS"}],"standard_charges":[{"gross_charge":276.0,"discounted_cash":151.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Remv Fb Foot Subq","code_information":[{"code":"816134","type":"CDM"},{"code":"450","type":"RC"},{"code":"28190","type":"HCPCS"}],"standard_charges":[{"gross_charge":2462.0,"discounted_cash":1354.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Remv Nail Plate Part Or Cmplt Sngl","code_information":[{"code":"816135","type":"CDM"},{"code":"450","type":"RC"},{"code":"11730","type":"HCPCS"}],"standard_charges":[{"gross_charge":501.0,"discounted_cash":275.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Rpr Sclp/Trnk/Extrm Intrmd 2.6-7.5 Cm","code_information":[{"code":"816136","type":"CDM"},{"code":"450","type":"RC"},{"code":"12032","type":"HCPCS"}],"standard_charges":[{"gross_charge":1341.0,"discounted_cash":737.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Place Needle In Vein","code_information":[{"code":"816137","type":"CDM"},{"code":"450","type":"RC"},{"code":"36000","type":"HCPCS"}],"standard_charges":[{"gross_charge":154.0,"discounted_cash":84.7,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Cardiopulmonary Resuscitation","code_information":[{"code":"816138","type":"CDM"},{"code":"450","type":"RC"},{"code":"92950","type":"HCPCS"}],"standard_charges":[{"gross_charge":1107.0,"discounted_cash":608.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Cardioversion Elective External","code_information":[{"code":"816139","type":"CDM"},{"code":"450","type":"RC"},{"code":"92960","type":"HCPCS"}],"standard_charges":[{"gross_charge":2651.0,"discounted_cash":1458.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Applic Splint Long Leg","code_information":[{"code":"816142","type":"CDM"},{"code":"450","type":"RC"},{"code":"29505","type":"HCPCS"}],"standard_charges":[{"gross_charge":572.0,"discounted_cash":314.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Applic Splint Short Arm Static","code_information":[{"code":"816143","type":"CDM"},{"code":"450","type":"RC"},{"code":"29125","type":"HCPCS"}],"standard_charges":[{"gross_charge":519.0,"discounted_cash":285.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Applic Splint Short Leg","code_information":[{"code":"816144","type":"CDM"},{"code":"450","type":"RC"},{"code":"29515","type":"HCPCS"}],"standard_charges":[{"gross_charge":572.0,"discounted_cash":314.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Blood Transfusion Service","code_information":[{"code":"816145","type":"CDM"},{"code":"450","type":"RC"},{"code":"36430","type":"HCPCS"}],"standard_charges":[{"gross_charge":1265.0,"discounted_cash":695.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Control Epistaxis Ant Complx","code_information":[{"code":"816146","type":"CDM"},{"code":"450","type":"RC"},{"code":"30903","type":"HCPCS"}],"standard_charges":[{"gross_charge":497.0,"discounted_cash":273.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Critical Care Addl 30 Min","code_information":[{"code":"816147","type":"CDM"},{"code":"450","type":"RC"},{"code":"99292","type":"HCPCS"}],"standard_charges":[{"gross_charge":1505.0,"discounted_cash":827.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Critical Care E/M 30-74 Min","code_information":[{"code":"816148","type":"CDM"},{"code":"450","type":"RC"},{"code":"99291","type":"HCPCS"}],"standard_charges":[{"gross_charge":3013.0,"discounted_cash":1657.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Delivery Vaginal","code_information":[{"code":"816149","type":"CDM"},{"code":"450","type":"RC"},{"code":"59409","type":"HCPCS"}],"standard_charges":[{"gross_charge":8154.0,"discounted_cash":4484.7,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Burn Dress Debrid No Anesthes Sm","code_information":[{"code":"816150","type":"CDM"},{"code":"450","type":"RC"},{"code":"16020","type":"HCPCS"}],"standard_charges":[{"gross_charge":1036.0,"discounted_cash":569.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Exc Wedge Skin Nail Fold","code_information":[{"code":"816151","type":"CDM"},{"code":"450","type":"RC"},{"code":"11765","type":"HCPCS"}],"standard_charges":[{"gross_charge":1500.0,"discounted_cash":825.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed I&D Abcess Cyst Hematoma Dentalvelar","code_information":[{"code":"816152","type":"CDM"},{"code":"450","type":"RC"},{"code":"41800","type":"HCPCS"}],"standard_charges":[{"gross_charge":497.0,"discounted_cash":273.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed I&D Abcess Finger Smpl","code_information":[{"code":"816153","type":"CDM"},{"code":"450","type":"RC"},{"code":"26010","type":"HCPCS"}],"standard_charges":[{"gross_charge":751.0,"discounted_cash":413.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed I&D Abscess Gland Bartholins","code_information":[{"code":"816154","type":"CDM"},{"code":"450","type":"RC"},{"code":"56420","type":"HCPCS"}],"standard_charges":[{"gross_charge":705.0,"discounted_cash":387.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed I&D Abscess Smpl Sngl","code_information":[{"code":"816155","type":"CDM"},{"code":"450","type":"RC"},{"code":"10060","type":"HCPCS"}],"standard_charges":[{"gross_charge":1024.0,"discounted_cash":563.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed I&D Pilonidal Cyst Cmplx","code_information":[{"code":"816156","type":"CDM"},{"code":"450","type":"RC"},{"code":"10081","type":"HCPCS"}],"standard_charges":[{"gross_charge":2462.0,"discounted_cash":1354.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Inj Lumb Epidur Blood/Clot Patch","code_information":[{"code":"816158","type":"CDM"},{"code":"450","type":"RC"},{"code":"62273","type":"HCPCS"}],"standard_charges":[{"gross_charge":2730.0,"discounted_cash":1501.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Insert Cath Temp Indwell Bladder Smpl","code_information":[{"code":"816159","type":"CDM"},{"code":"450","type":"RC"},{"code":"51702","type":"HCPCS"}],"standard_charges":[{"gross_charge":867.0,"discounted_cash":476.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Simple Bladder Irrig Lavage Instill","code_information":[{"code":"816160","type":"CDM"},{"code":"450","type":"RC"},{"code":"51700","type":"HCPCS"}],"standard_charges":[{"gross_charge":1141.0,"discounted_cash":627.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Remv Cerumen Impacted W Instrmnt Uni","code_information":[{"code":"816162","type":"CDM"},{"code":"450","type":"RC"},{"code":"69210","type":"HCPCS"}],"standard_charges":[{"gross_charge":382.0,"discounted_cash":210.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Remv Fb Auditory Canal Ext No Gen Ans","code_information":[{"code":"816163","type":"CDM"},{"code":"450","type":"RC"},{"code":"69200","type":"HCPCS"}],"standard_charges":[{"gross_charge":451.0,"discounted_cash":248.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Remv Fb Eye Conjunctival Superficial","code_information":[{"code":"816164","type":"CDM"},{"code":"450","type":"RC"},{"code":"65205","type":"HCPCS"}],"standard_charges":[{"gross_charge":379.0,"discounted_cash":208.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Remv Fb Eye Corneal W/O Lamp","code_information":[{"code":"816165","type":"CDM"},{"code":"450","type":"RC"},{"code":"65220","type":"HCPCS"}],"standard_charges":[{"gross_charge":900.0,"discounted_cash":495.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Remv Fb Nose","code_information":[{"code":"816166","type":"CDM"},{"code":"450","type":"RC"},{"code":"30300","type":"HCPCS"}],"standard_charges":[{"gross_charge":497.0,"discounted_cash":273.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Wnd Rpr Cmplx Face Ea Addl 5Cm","code_information":[{"code":"816168","type":"CDM"},{"code":"450","type":"RC"},{"code":"13153","type":"HCPCS"}],"standard_charges":[{"gross_charge":690.0,"discounted_cash":379.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Rpr Face Ear Intrmd <=2.5 Cm","code_information":[{"code":"816169","type":"CDM"},{"code":"450","type":"RC"},{"code":"12051","type":"HCPCS"}],"standard_charges":[{"gross_charge":1341.0,"discounted_cash":737.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Rpr Face Ear Intrmd 2.6-5.0 Cm","code_information":[{"code":"816170","type":"CDM"},{"code":"450","type":"RC"},{"code":"12052","type":"HCPCS"}],"standard_charges":[{"gross_charge":1341.0,"discounted_cash":737.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Rpr Face Ear Intrmd 5.1-7.5 Cm","code_information":[{"code":"816171","type":"CDM"},{"code":"450","type":"RC"},{"code":"12053","type":"HCPCS"}],"standard_charges":[{"gross_charge":1341.0,"discounted_cash":737.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Rpr Nail Bed","code_information":[{"code":"816172","type":"CDM"},{"code":"450","type":"RC"},{"code":"11760","type":"HCPCS"}],"standard_charges":[{"gross_charge":2052.0,"discounted_cash":1128.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Rpr Face Ear Smpl <=2.5Cm","code_information":[{"code":"816173","type":"CDM"},{"code":"450","type":"RC"},{"code":"12011","type":"HCPCS"}],"standard_charges":[{"gross_charge":752.0,"discounted_cash":413.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Rpr Face Ear Smpl 2.6-5 Cm","code_information":[{"code":"816174","type":"CDM"},{"code":"450","type":"RC"},{"code":"12013","type":"HCPCS"}],"standard_charges":[{"gross_charge":752.0,"discounted_cash":413.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Rpr Face Ear Smpl 5.1-7.5 Cm","code_information":[{"code":"816175","type":"CDM"},{"code":"450","type":"RC"},{"code":"12014","type":"HCPCS"}],"standard_charges":[{"gross_charge":752.0,"discounted_cash":413.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Rpr Face Ear Smpl 7.6-12.5 Cm","code_information":[{"code":"816176","type":"CDM"},{"code":"450","type":"RC"},{"code":"12015","type":"HCPCS"}],"standard_charges":[{"gross_charge":752.0,"discounted_cash":413.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Rpr Face/Nk/Hd/Ft Cmp 1.1Cm-2.5 Cm","code_information":[{"code":"816177","type":"CDM"},{"code":"450","type":"RC"},{"code":"13131","type":"HCPCS"}],"standard_charges":[{"gross_charge":1464.0,"discounted_cash":805.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Rpr Face/Nk/Hd/Ft Cmplx 2.6-7.5 Cm","code_information":[{"code":"816178","type":"CDM"},{"code":"450","type":"RC"},{"code":"13132","type":"HCPCS"}],"standard_charges":[{"gross_charge":2269.0,"discounted_cash":1247.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Rpr Wnd Cmplx Face/Nk/Hd/Ft Addl 5Cm","code_information":[{"code":"816179","type":"CDM"},{"code":"450","type":"RC"},{"code":"13133","type":"HCPCS"}],"standard_charges":[{"gross_charge":1072.0,"discounted_cash":589.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Wnd Rpr  Intermd Nk Hd Ft Gen <=2.5Cm","code_information":[{"code":"816180","type":"CDM"},{"code":"450","type":"RC"},{"code":"12041","type":"HCPCS"}],"standard_charges":[{"gross_charge":1341.0,"discounted_cash":737.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Rpr Nk/Hd/Ft/Gen Intrmd 2.6-7.5 Cm","code_information":[{"code":"816181","type":"CDM"},{"code":"450","type":"RC"},{"code":"12042","type":"HCPCS"}],"standard_charges":[{"gross_charge":1438.0,"discounted_cash":790.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Rpr Sclp Extrm Cmplx 1.1-2.5 Cm","code_information":[{"code":"816182","type":"CDM"},{"code":"450","type":"RC"},{"code":"13120","type":"HCPCS"}],"standard_charges":[{"gross_charge":2269.0,"discounted_cash":1247.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Rpr Sclp Extrm Cmplx 2.6-7.5 Cm","code_information":[{"code":"816183","type":"CDM"},{"code":"450","type":"RC"},{"code":"13121","type":"HCPCS"}],"standard_charges":[{"gross_charge":2280.0,"discounted_cash":1254.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Rpr Sclp Extrm Cmplx Ea Addl 5 Cm","code_information":[{"code":"816184","type":"CDM"},{"code":"450","type":"RC"},{"code":"13122","type":"HCPCS"}],"standard_charges":[{"gross_charge":1134.0,"discounted_cash":623.7,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Rpr Sclp/Trnk/Extrm Intrmd 12.6-20 Cm","code_information":[{"code":"816185","type":"CDM"},{"code":"450","type":"RC"},{"code":"12035","type":"HCPCS"}],"standard_charges":[{"gross_charge":1449.0,"discounted_cash":796.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Rpr Sclp/Trnk/Extrm Intmd 7.6-12.5 Cm","code_information":[{"code":"816186","type":"CDM"},{"code":"450","type":"RC"},{"code":"12034","type":"HCPCS"}],"standard_charges":[{"gross_charge":1341.0,"discounted_cash":737.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Rpr Sclp/Trnk/Extrm Smpl <= 2.5Cm","code_information":[{"code":"816187","type":"CDM"},{"code":"450","type":"RC"},{"code":"12001","type":"HCPCS"}],"standard_charges":[{"gross_charge":895.0,"discounted_cash":492.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Rpr Sclp/Trnk/Extrm Smpl 12.6-20 Cm","code_information":[{"code":"816188","type":"CDM"},{"code":"450","type":"RC"},{"code":"12005","type":"HCPCS"}],"standard_charges":[{"gross_charge":1204.0,"discounted_cash":662.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Rpr Sclp/Trnk/Extrm Smpl 2.6-7.5 Cm","code_information":[{"code":"816189","type":"CDM"},{"code":"450","type":"RC"},{"code":"12002","type":"HCPCS"}],"standard_charges":[{"gross_charge":1024.0,"discounted_cash":563.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Rpr Sclp/Trnk/Extrm Smpl 7.6-12.5 Cm","code_information":[{"code":"816190","type":"CDM"},{"code":"450","type":"RC"},{"code":"12004","type":"HCPCS"}],"standard_charges":[{"gross_charge":1110.0,"discounted_cash":610.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Rpr Tndn Extensor Finger Ea","code_information":[{"code":"816191","type":"CDM"},{"code":"450","type":"RC"},{"code":"26418","type":"HCPCS"}],"standard_charges":[{"gross_charge":5731.0,"discounted_cash":3152.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Rpr Tndn/Musc Flex Forearm Wrist Ea","code_information":[{"code":"816192","type":"CDM"},{"code":"450","type":"RC"},{"code":"25260","type":"HCPCS"}],"standard_charges":[{"gross_charge":11356.0,"discounted_cash":6245.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Strapping Hip","code_information":[{"code":"816197","type":"CDM"},{"code":"450","type":"RC"},{"code":"29520","type":"HCPCS"}],"standard_charges":[{"gross_charge":252.0,"discounted_cash":138.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Strapping Knee","code_information":[{"code":"816198","type":"CDM"},{"code":"450","type":"RC"},{"code":"29530","type":"HCPCS"}],"standard_charges":[{"gross_charge":559.0,"discounted_cash":307.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Strapping Shoulder","code_information":[{"code":"816199","type":"CDM"},{"code":"450","type":"RC"},{"code":"29240","type":"HCPCS"}],"standard_charges":[{"gross_charge":437.0,"discounted_cash":240.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Tx Disloc Elbow Clsd W/O Ans","code_information":[{"code":"816201","type":"CDM"},{"code":"450","type":"RC"},{"code":"24600","type":"HCPCS"}],"standard_charges":[{"gross_charge":957.0,"discounted_cash":526.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Tx Disloc Finger W/ Manip","code_information":[{"code":"816202","type":"CDM"},{"code":"450","type":"RC"},{"code":"26670","type":"HCPCS"}],"standard_charges":[{"gross_charge":816.0,"discounted_cash":448.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Bronchoscopy","code_information":[{"code":"816203","type":"CDM"},{"code":"450","type":"RC"},{"code":"31622","type":"HCPCS"}],"standard_charges":[{"gross_charge":3420.0,"discounted_cash":1881.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Tx Disloc Knee W/O Ans","code_information":[{"code":"816204","type":"CDM"},{"code":"450","type":"RC"},{"code":"27550","type":"HCPCS"}],"standard_charges":[{"gross_charge":1058.0,"discounted_cash":581.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Tx Disloc Patellar W/O Ans","code_information":[{"code":"816205","type":"CDM"},{"code":"450","type":"RC"},{"code":"27560","type":"HCPCS"}],"standard_charges":[{"gross_charge":951.0,"discounted_cash":523.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Tx Disloc Shldr Clsd W Manip Wo Anes","code_information":[{"code":"816206","type":"CDM"},{"code":"450","type":"RC"},{"code":"23650","type":"HCPCS"}],"standard_charges":[{"gross_charge":957.0,"discounted_cash":526.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Tx Disloc Thumb W/ Manip","code_information":[{"code":"816207","type":"CDM"},{"code":"450","type":"RC"},{"code":"26641","type":"HCPCS"}],"standard_charges":[{"gross_charge":895.0,"discounted_cash":492.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Tx Fx Calcaneal W/O Manip","code_information":[{"code":"816210","type":"CDM"},{"code":"450","type":"RC"},{"code":"28400","type":"HCPCS"}],"standard_charges":[{"gross_charge":907.0,"discounted_cash":498.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Tx Fx Fibula Distal Clsd W/ Manip","code_information":[{"code":"816211","type":"CDM"},{"code":"450","type":"RC"},{"code":"27788","type":"HCPCS"}],"standard_charges":[{"gross_charge":1148.0,"discounted_cash":631.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Tx Fx Humerus Shft Clsd W/ Manip","code_information":[{"code":"816214","type":"CDM"},{"code":"450","type":"RC"},{"code":"24505","type":"HCPCS"}],"standard_charges":[{"gross_charge":1461.0,"discounted_cash":803.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Tx Fx Metacarpal Clsd Ea W/ Manip","code_information":[{"code":"816216","type":"CDM"},{"code":"450","type":"RC"},{"code":"26605","type":"HCPCS"}],"standard_charges":[{"gross_charge":957.0,"discounted_cash":526.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Tx Fx Metacarpal Clsd Ea W/O Manip","code_information":[{"code":"816217","type":"CDM"},{"code":"450","type":"RC"},{"code":"26600","type":"HCPCS"}],"standard_charges":[{"gross_charge":907.0,"discounted_cash":498.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Tx Fx Nasal Clsd Wo Stabilization","code_information":[{"code":"816218","type":"CDM"},{"code":"450","type":"RC"},{"code":"21315","type":"HCPCS"}],"standard_charges":[{"gross_charge":8161.0,"discounted_cash":4488.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Tx Fx Phalanx Distal Clsd W/ Manip","code_information":[{"code":"816219","type":"CDM"},{"code":"450","type":"RC"},{"code":"26755","type":"HCPCS"}],"standard_charges":[{"gross_charge":957.0,"discounted_cash":526.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Tx Fx Phalanx Distal Open Ea","code_information":[{"code":"816220","type":"CDM"},{"code":"450","type":"RC"},{"code":"26765","type":"HCPCS"}],"standard_charges":[{"gross_charge":5195.0,"discounted_cash":2857.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Tx Fx Radial Distal Clsd W/O Manip","code_information":[{"code":"816221","type":"CDM"},{"code":"450","type":"RC"},{"code":"25600","type":"HCPCS"}],"standard_charges":[{"gross_charge":711.0,"discounted_cash":391.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Tx Fx Radial Ulnar Shft Clsd W/ Manip","code_information":[{"code":"816223","type":"CDM"},{"code":"450","type":"RC"},{"code":"25565","type":"HCPCS"}],"standard_charges":[{"gross_charge":5622.0,"discounted_cash":3092.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Tx Nursemaid Elbow W/ Manip","code_information":[{"code":"816230","type":"CDM"},{"code":"450","type":"RC"},{"code":"24640","type":"HCPCS"}],"standard_charges":[{"gross_charge":957.0,"discounted_cash":526.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Tx Wound Dehiscence Smpl Closure","code_information":[{"code":"816232","type":"CDM"},{"code":"450","type":"RC"},{"code":"12020","type":"HCPCS"}],"standard_charges":[{"gross_charge":2269.0,"discounted_cash":1247.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Inj Ther/Diag Ivp Ea Addl New Drug","code_information":[{"code":"816245","type":"CDM"},{"code":"450","type":"RC"},{"code":"96375","type":"HCPCS"}],"standard_charges":[{"gross_charge":388.0,"discounted_cash":213.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Inj Ther/Proph/Diag Ivp Sngl Or Init","code_information":[{"code":"816246","type":"CDM"},{"code":"450","type":"RC"},{"code":"96374","type":"HCPCS"}],"standard_charges":[{"gross_charge":388.0,"discounted_cash":213.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Inj Ther/Proph/Diag Subq/Im","code_information":[{"code":"816247","type":"CDM"},{"code":"450","type":"RC"},{"code":"96372","type":"HCPCS"}],"standard_charges":[{"gross_charge":108.0,"discounted_cash":59.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Iv Inf Ther/Proph/Diag Concurrent","code_information":[{"code":"816251","type":"CDM"},{"code":"450","type":"RC"},{"code":"96368","type":"HCPCS"}],"standard_charges":[{"gross_charge":276.0,"discounted_cash":151.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Iv Inf Ther/Proph/Diag Seq Inf 1St Hr","code_information":[{"code":"816252","type":"CDM"},{"code":"450","type":"RC"},{"code":"96367","type":"HCPCS"}],"standard_charges":[{"gross_charge":276.0,"discounted_cash":151.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Debrid Selective 1St 20Sq Cm Or <","code_information":[{"code":"816253","type":"CDM"},{"code":"450","type":"RC"},{"code":"97597","type":"HCPCS"}],"standard_charges":[{"gross_charge":507.0,"discounted_cash":278.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Exc Skin Benign Trnk/Extrm 0.6-1.0Cm","code_information":[{"code":"816254","type":"CDM"},{"code":"450","type":"RC"},{"code":"11401","type":"HCPCS"}],"standard_charges":[{"gross_charge":1735.0,"discounted_cash":954.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Intubation Endotracheal Emergent","code_information":[{"code":"816255","type":"CDM"},{"code":"450","type":"RC"},{"code":"31500","type":"HCPCS"}],"standard_charges":[{"gross_charge":1609.0,"discounted_cash":884.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Rpr Flexor Tendn Prim/Sec W/O Grft Ea","code_information":[{"code":"816256","type":"CDM"},{"code":"450","type":"RC"},{"code":"26350","type":"HCPCS"}],"standard_charges":[{"gross_charge":7644.0,"discounted_cash":4204.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Tx Disloc Metacarpophalang  W/O Ans","code_information":[{"code":"816257","type":"CDM"},{"code":"450","type":"RC"},{"code":"26700","type":"HCPCS"}],"standard_charges":[{"gross_charge":957.0,"discounted_cash":526.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Tx Disloc Metatarsophalng Jnt W/O Ans","code_information":[{"code":"816258","type":"CDM"},{"code":"450","type":"RC"},{"code":"28630","type":"HCPCS"}],"standard_charges":[{"gross_charge":957.0,"discounted_cash":526.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Tx Disloc Shldr Clsd W Man W Fx Neck","code_information":[{"code":"816259","type":"CDM"},{"code":"450","type":"RC"},{"code":"23675","type":"HCPCS"}],"standard_charges":[{"gross_charge":5731.0,"discounted_cash":3152.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Tx Disloc Tmj Closed","code_information":[{"code":"816260","type":"CDM"},{"code":"450","type":"RC"},{"code":"21480","type":"HCPCS"}],"standard_charges":[{"gross_charge":1053.0,"discounted_cash":579.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Declot By Thrombolytic Agent Vad Cath","code_information":[{"code":"816261","type":"CDM"},{"code":"450","type":"RC"},{"code":"36593","type":"HCPCS"}],"standard_charges":[{"gross_charge":929.0,"discounted_cash":510.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Tx Disloc Shldr Clsd W Man W Fx Tubr","code_information":[{"code":"816262","type":"CDM"},{"code":"450","type":"RC"},{"code":"23665","type":"HCPCS"}],"standard_charges":[{"gross_charge":5580.0,"discounted_cash":3069.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Chemical Cautery Granulation Tissue","code_information":[{"code":"816266","type":"CDM"},{"code":"450","type":"RC"},{"code":"17250","type":"HCPCS"}],"standard_charges":[{"gross_charge":1027.0,"discounted_cash":564.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Burn Dress Debrid No Anesthes Lg","code_information":[{"code":"816271","type":"CDM"},{"code":"450","type":"RC"},{"code":"16030","type":"HCPCS"}],"standard_charges":[{"gross_charge":1139.0,"discounted_cash":626.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Burn Dress Debrid No Anesthes Med","code_information":[{"code":"816272","type":"CDM"},{"code":"450","type":"RC"},{"code":"16025","type":"HCPCS"}],"standard_charges":[{"gross_charge":1101.0,"discounted_cash":605.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Burn Treatment Init First Degree","code_information":[{"code":"816273","type":"CDM"},{"code":"450","type":"RC"},{"code":"16000","type":"HCPCS"}],"standard_charges":[{"gross_charge":388.0,"discounted_cash":213.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Insert Cath Temp Indwell Bladdr Cmplx","code_information":[{"code":"816274","type":"CDM"},{"code":"450","type":"RC"},{"code":"51703","type":"HCPCS"}],"standard_charges":[{"gross_charge":975.0,"discounted_cash":536.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Disloc Ankle Closed Tx No Anesth","code_information":[{"code":"816275","type":"CDM"},{"code":"450","type":"RC"},{"code":"27840","type":"HCPCS"}],"standard_charges":[{"gross_charge":1053.0,"discounted_cash":579.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Tx Disloc Interphal Closed Wo Anes","code_information":[{"code":"816277","type":"CDM"},{"code":"450","type":"RC"},{"code":"28660","type":"HCPCS"}],"standard_charges":[{"gross_charge":922.0,"discounted_cash":507.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Epistaxis Contrl Anterior Simple","code_information":[{"code":"816278","type":"CDM"},{"code":"450","type":"RC"},{"code":"30901","type":"HCPCS"}],"standard_charges":[{"gross_charge":497.0,"discounted_cash":273.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Epistaxis Contrl Post & Pack Init","code_information":[{"code":"816279","type":"CDM"},{"code":"450","type":"RC"},{"code":"30905","type":"HCPCS"}],"standard_charges":[{"gross_charge":497.0,"discounted_cash":273.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed For Body Remov Eyelid Embedded","code_information":[{"code":"816280","type":"CDM"},{"code":"450","type":"RC"},{"code":"67938","type":"HCPCS"}],"standard_charges":[{"gross_charge":1057.0,"discounted_cash":581.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Removal Foreign Body Subq Simple","code_information":[{"code":"816282","type":"CDM"},{"code":"450","type":"RC"},{"code":"10120","type":"HCPCS"}],"standard_charges":[{"gross_charge":1334.0,"discounted_cash":733.7,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Fx Talus Closed Tx & Manip","code_information":[{"code":"816286","type":"CDM"},{"code":"450","type":"RC"},{"code":"28435","type":"HCPCS"}],"standard_charges":[{"gross_charge":5731.0,"discounted_cash":3152.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed I&D Abscess Perirectal","code_information":[{"code":"816288","type":"CDM"},{"code":"450","type":"RC"},{"code":"46040","type":"HCPCS"}],"standard_charges":[{"gross_charge":4578.0,"discounted_cash":2517.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed I&D Abscess Peritonsillar","code_information":[{"code":"816289","type":"CDM"},{"code":"450","type":"RC"},{"code":"42700","type":"HCPCS"}],"standard_charges":[{"gross_charge":876.0,"discounted_cash":481.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed I&D Bursa Elbow Infected","code_information":[{"code":"816290","type":"CDM"},{"code":"450","type":"RC"},{"code":"23931","type":"HCPCS"}],"standard_charges":[{"gross_charge":4726.0,"discounted_cash":2599.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Tracheostomy Emergency Cricothyrd","code_information":[{"code":"816291","type":"CDM"},{"code":"450","type":"RC"},{"code":"31605","type":"HCPCS"}],"standard_charges":[{"gross_charge":2512.0,"discounted_cash":1381.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Wnd Rpr Intermed Face 12.6-00Cm","code_information":[{"code":"816293","type":"CDM"},{"code":"450","type":"RC"},{"code":"12055","type":"HCPCS"}],"standard_charges":[{"gross_charge":3035.0,"discounted_cash":1669.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Wnd Rpr Interm Nk Hn Ft Gn 12.6-20Cm","code_information":[{"code":"816297","type":"CDM"},{"code":"450","type":"RC"},{"code":"12045","type":"HCPCS"}],"standard_charges":[{"gross_charge":2153.0,"discounted_cash":1184.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Wnd Rpr Interm Nk Hn Ft Gn 20.1-30Cm","code_information":[{"code":"816298","type":"CDM"},{"code":"450","type":"RC"},{"code":"12046","type":"HCPCS"}],"standard_charges":[{"gross_charge":2285.0,"discounted_cash":1256.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Wnd Rpr Int Sc Ax Tk Xt 20.1-30.0Cm","code_information":[{"code":"816300","type":"CDM"},{"code":"450","type":"RC"},{"code":"12036","type":"HCPCS"}],"standard_charges":[{"gross_charge":2062.0,"discounted_cash":1134.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Wnd Rpr Sim Face 20.1-30Cm","code_information":[{"code":"816302","type":"CDM"},{"code":"450","type":"RC"},{"code":"12017","type":"HCPCS"}],"standard_charges":[{"gross_charge":1341.0,"discounted_cash":737.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Insert Cath Straight","code_information":[{"code":"816306","type":"CDM"},{"code":"450","type":"RC"},{"code":"51701","type":"HCPCS"}],"standard_charges":[{"gross_charge":562.0,"discounted_cash":309.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Arthrocentesis Joint Intermed Wo Us","code_information":[{"code":"816309","type":"CDM"},{"code":"450","type":"RC"},{"code":"20605","type":"HCPCS"}],"standard_charges":[{"gross_charge":1743.0,"discounted_cash":958.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Clsd Tx Hip Arthr Disl W/O Anesth","code_information":[{"code":"816310","type":"CDM"},{"code":"450","type":"RC"},{"code":"27265","type":"HCPCS"}],"standard_charges":[{"gross_charge":1053.0,"discounted_cash":579.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Disloc Hip Closed Tx No Anes","code_information":[{"code":"816311","type":"CDM"},{"code":"450","type":"RC"},{"code":"27250","type":"HCPCS"}],"standard_charges":[{"gross_charge":1053.0,"discounted_cash":579.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Evacuation Subungal Hematoma","code_information":[{"code":"816312","type":"CDM"},{"code":"450","type":"RC"},{"code":"11740","type":"HCPCS"}],"standard_charges":[{"gross_charge":451.0,"discounted_cash":248.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed For Body Remov Cornea With Lamp","code_information":[{"code":"816313","type":"CDM"},{"code":"450","type":"RC"},{"code":"65222","type":"HCPCS"}],"standard_charges":[{"gross_charge":1320.0,"discounted_cash":726.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Fx Ankle Bimall Clsd Tx & Manip","code_information":[{"code":"816314","type":"CDM"},{"code":"450","type":"RC"},{"code":"27810","type":"HCPCS"}],"standard_charges":[{"gross_charge":6252.0,"discounted_cash":3438.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Fx Ankle Trimall Clsd Tx & Manip","code_information":[{"code":"816315","type":"CDM"},{"code":"450","type":"RC"},{"code":"27818","type":"HCPCS"}],"standard_charges":[{"gross_charge":5622.0,"discounted_cash":3092.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Fx Med Malleolus Clsd Tx & Manip","code_information":[{"code":"816316","type":"CDM"},{"code":"450","type":"RC"},{"code":"27762","type":"HCPCS"}],"standard_charges":[{"gross_charge":5622.0,"discounted_cash":3092.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Fx Phalanx Shaft Clsd Tx & Manip","code_information":[{"code":"816317","type":"CDM"},{"code":"450","type":"RC"},{"code":"26725","type":"HCPCS"}],"standard_charges":[{"gross_charge":957.0,"discounted_cash":526.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Fx Radius Distal Clsd Tx & Manip","code_information":[{"code":"816319","type":"CDM"},{"code":"450","type":"RC"},{"code":"25605","type":"HCPCS"}],"standard_charges":[{"gross_charge":5580.0,"discounted_cash":3069.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Tx Fx Toe Other Closed W Manip Ea","code_information":[{"code":"816320","type":"CDM"},{"code":"450","type":"RC"},{"code":"28515","type":"HCPCS"}],"standard_charges":[{"gross_charge":957.0,"discounted_cash":526.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed I&D Abscess Complex Or Multiple","code_information":[{"code":"816322","type":"CDM"},{"code":"450","type":"RC"},{"code":"10061","type":"HCPCS"}],"standard_charges":[{"gross_charge":1219.0,"discounted_cash":670.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed I&D Cyst Pilonidal Simple","code_information":[{"code":"816323","type":"CDM"},{"code":"450","type":"RC"},{"code":"10080","type":"HCPCS"}],"standard_charges":[{"gross_charge":2462.0,"discounted_cash":1354.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed I&D Hemorrhoid Thrombosed Externl","code_information":[{"code":"816324","type":"CDM"},{"code":"450","type":"RC"},{"code":"46083","type":"HCPCS"}],"standard_charges":[{"gross_charge":982.0,"discounted_cash":540.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Inj Aa Strd Peripheral Nerve","code_information":[{"code":"816325","type":"CDM"},{"code":"450","type":"RC"},{"code":"64450","type":"HCPCS"}],"standard_charges":[{"gross_charge":1636.0,"discounted_cash":899.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Insert Non Tun Cvc >=5 Yrs","code_information":[{"code":"816326","type":"CDM"},{"code":"450","type":"RC"},{"code":"36556","type":"HCPCS"}],"standard_charges":[{"gross_charge":2343.0,"discounted_cash":1288.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Applic Splint Arm Long","code_information":[{"code":"816329","type":"CDM"},{"code":"450","type":"RC"},{"code":"29105","type":"HCPCS"}],"standard_charges":[{"gross_charge":572.0,"discounted_cash":314.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Applic Splint Finger Static","code_information":[{"code":"816330","type":"CDM"},{"code":"450","type":"RC"},{"code":"29130","type":"HCPCS"}],"standard_charges":[{"gross_charge":326.0,"discounted_cash":179.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Wnd Rpr Cmp Eyld Ns Er Lp 1.1-2.5Cm","code_information":[{"code":"816331","type":"CDM"},{"code":"450","type":"RC"},{"code":"13151","type":"HCPCS"}],"standard_charges":[{"gross_charge":2269.0,"discounted_cash":1247.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Wnd Rpr Cmp Eyld Ns Er Lp 2.6-7.5Cm","code_information":[{"code":"816332","type":"CDM"},{"code":"450","type":"RC"},{"code":"13152","type":"HCPCS"}],"standard_charges":[{"gross_charge":2278.0,"discounted_cash":1252.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Wnd Rpr Intermed Face 7.6-12.5Cm","code_information":[{"code":"816333","type":"CDM"},{"code":"450","type":"RC"},{"code":"12054","type":"HCPCS"}],"standard_charges":[{"gross_charge":1341.0,"discounted_cash":737.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Wnd Rpr Interm Nk Hn Ft Gn 7.6-12.5Cm","code_information":[{"code":"816334","type":"CDM"},{"code":"450","type":"RC"},{"code":"12044","type":"HCPCS"}],"standard_charges":[{"gross_charge":2062.0,"discounted_cash":1134.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Rpr Face Ear Smpl 12.6-20 Cm","code_information":[{"code":"816335","type":"CDM"},{"code":"450","type":"RC"},{"code":"12016","type":"HCPCS"}],"standard_charges":[{"gross_charge":1341.0,"discounted_cash":737.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Rpr Sclp/Trnk/Extrm Smpl >30 Cm","code_information":[{"code":"816336","type":"CDM"},{"code":"450","type":"RC"},{"code":"12007","type":"HCPCS"}],"standard_charges":[{"gross_charge":1341.0,"discounted_cash":737.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Rpr Sclp/Trnk/Extrm Smpl 20.1-30 Cm","code_information":[{"code":"816337","type":"CDM"},{"code":"450","type":"RC"},{"code":"12006","type":"HCPCS"}],"standard_charges":[{"gross_charge":1272.0,"discounted_cash":699.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Rmvl Bivlv Cast Gaunt Bdy Boot","code_information":[{"code":"816338","type":"CDM"},{"code":"450","type":"RC"},{"code":"29700","type":"HCPCS"}],"standard_charges":[{"gross_charge":1001.0,"discounted_cash":550.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Ivp Tpd Ea Add Push Same Drug","code_information":[{"code":"816342","type":"CDM"},{"code":"450","type":"RC"},{"code":"96376","type":"HCPCS"}],"standard_charges":[{"gross_charge":388.0,"discounted_cash":213.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed I&D Abscess Vulva Perineal","code_information":[{"code":"816344","type":"CDM"},{"code":"450","type":"RC"},{"code":"56405","type":"HCPCS"}],"standard_charges":[{"gross_charge":1161.0,"discounted_cash":638.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Exc Nail Permanent","code_information":[{"code":"816345","type":"CDM"},{"code":"450","type":"RC"},{"code":"11750","type":"HCPCS"}],"standard_charges":[{"gross_charge":2123.0,"discounted_cash":1167.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Explore Wound Extremity","code_information":[{"code":"816346","type":"CDM"},{"code":"450","type":"RC"},{"code":"20103","type":"HCPCS"}],"standard_charges":[{"gross_charge":2784.0,"discounted_cash":1531.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed I And D Complex Post Op Wound","code_information":[{"code":"816347","type":"CDM"},{"code":"450","type":"RC"},{"code":"10180","type":"HCPCS"}],"standard_charges":[{"gross_charge":10688.0,"discounted_cash":5878.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Tx Fx Radial Shft Clsd W Manip","code_information":[{"code":"816349","type":"CDM"},{"code":"450","type":"RC"},{"code":"25505","type":"HCPCS"}],"standard_charges":[{"gross_charge":5432.0,"discounted_cash":2987.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Drain Bl W Suprapubic Cath Ins","code_information":[{"code":"816353","type":"CDM"},{"code":"450","type":"RC"},{"code":"51102","type":"HCPCS"}],"standard_charges":[{"gross_charge":6207.0,"discounted_cash":3413.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Removal Implant Superficial","code_information":[{"code":"816354","type":"CDM"},{"code":"450","type":"RC"},{"code":"20670","type":"HCPCS"}],"standard_charges":[{"gross_charge":6429.0,"discounted_cash":3535.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Inj Trigger Point 1 Or 2 Musc","code_information":[{"code":"816356","type":"CDM"},{"code":"450","type":"RC"},{"code":"20552","type":"HCPCS"}],"standard_charges":[{"gross_charge":1305.0,"discounted_cash":717.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Tx Disloc Shldr Clsd W Manip W Anes","code_information":[{"code":"816358","type":"CDM"},{"code":"450","type":"RC"},{"code":"23655","type":"HCPCS"}],"standard_charges":[{"gross_charge":5580.0,"discounted_cash":3069.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Clsd Tx Supra-Transconylar Humeral","code_information":[{"code":"816359","type":"CDM"},{"code":"450","type":"RC"},{"code":"24535","type":"HCPCS"}],"standard_charges":[{"gross_charge":6172.0,"discounted_cash":3394.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Clsd Tx Rad Head Fx W/Manip","code_information":[{"code":"816360","type":"CDM"},{"code":"450","type":"RC"},{"code":"24655","type":"HCPCS"}],"standard_charges":[{"gross_charge":5731.0,"discounted_cash":3152.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Clsd Tx Articular Fx Mcp Ip W Manip","code_information":[{"code":"816364","type":"CDM"},{"code":"450","type":"RC"},{"code":"26742","type":"HCPCS"}],"standard_charges":[{"gross_charge":5622.0,"discounted_cash":3092.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Closure Lac Vestibule Mouth <=2.5Cm","code_information":[{"code":"816368","type":"CDM"},{"code":"450","type":"RC"},{"code":"40830","type":"HCPCS"}],"standard_charges":[{"gross_charge":876.0,"discounted_cash":481.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Rpr Of Lac 2.5Cm Or < Fl Mth 2/3 To","code_information":[{"code":"816369","type":"CDM"},{"code":"450","type":"RC"},{"code":"41250","type":"HCPCS"}],"standard_charges":[{"gross_charge":454.0,"discounted_cash":249.7,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Rpr Tongue Laceration >2.6Cm","code_information":[{"code":"816370","type":"CDM"},{"code":"450","type":"RC"},{"code":"41252","type":"HCPCS"}],"standard_charges":[{"gross_charge":712.0,"discounted_cash":391.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Drainage Abscess Palate Or Uvula","code_information":[{"code":"816371","type":"CDM"},{"code":"450","type":"RC"},{"code":"42000","type":"HCPCS"}],"standard_charges":[{"gross_charge":876.0,"discounted_cash":481.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Drainage Scrotal Wall Abscess","code_information":[{"code":"816372","type":"CDM"},{"code":"450","type":"RC"},{"code":"55100","type":"HCPCS"}],"standard_charges":[{"gross_charge":5694.0,"discounted_cash":3131.7,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Blepharotomy","code_information":[{"code":"816373","type":"CDM"},{"code":"450","type":"RC"},{"code":"67700","type":"HCPCS"}],"standard_charges":[{"gross_charge":1583.0,"discounted_cash":870.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Drainage Ext Ear Abscess Simple","code_information":[{"code":"816374","type":"CDM"},{"code":"450","type":"RC"},{"code":"69000","type":"HCPCS"}],"standard_charges":[{"gross_charge":2708.0,"discounted_cash":1489.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Rpr Sclp/Trnk/Extrem Intermed <=2.5Cm","code_information":[{"code":"816377","type":"CDM"},{"code":"450","type":"RC"},{"code":"12031","type":"HCPCS"}],"standard_charges":[{"gross_charge":1341.0,"discounted_cash":737.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Wnd Tx Super Deh W/Pack","code_information":[{"code":"816380","type":"CDM"},{"code":"450","type":"RC"},{"code":"12021","type":"HCPCS"}],"standard_charges":[{"gross_charge":1731.0,"discounted_cash":952.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Remv Fb Arm/Elbow Subq","code_information":[{"code":"816381","type":"CDM"},{"code":"450","type":"RC"},{"code":"24200","type":"HCPCS"}],"standard_charges":[{"gross_charge":5501.0,"discounted_cash":3025.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Remv Fb Anoscopy","code_information":[{"code":"816383","type":"CDM"},{"code":"450","type":"RC"},{"code":"46608","type":"HCPCS"}],"standard_charges":[{"gross_charge":2197.0,"discounted_cash":1208.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Repr Bl Ves Direct,Low Extrem","code_information":[{"code":"816385","type":"CDM"},{"code":"450","type":"RC"},{"code":"35226","type":"HCPCS"}],"standard_charges":[{"gross_charge":1014.0,"discounted_cash":557.7,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Tx Fx Metatarsal Clsd W/Manip Ea","code_information":[{"code":"816390","type":"CDM"},{"code":"450","type":"RC"},{"code":"28475","type":"HCPCS"}],"standard_charges":[{"gross_charge":680.0,"discounted_cash":374.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Clsd Tmt Fac Dist Tib W Skel Trac","code_information":[{"code":"816405","type":"CDM"},{"code":"450","type":"RC"},{"code":"27825","type":"HCPCS"}],"standard_charges":[{"gross_charge":5622.0,"discounted_cash":3092.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Tx Disloc Acromioclav Closed W Manip","code_information":[{"code":"816413","type":"CDM"},{"code":"450","type":"RC"},{"code":"23545","type":"HCPCS"}],"standard_charges":[{"gross_charge":984.0,"discounted_cash":541.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Cl Rdl Shft Fx&Cltx Dis Dis Rad/Ul Jt","code_information":[{"code":"816414","type":"CDM"},{"code":"450","type":"RC"},{"code":"25520","type":"HCPCS"}],"standard_charges":[{"gross_charge":4394.0,"discounted_cash":2416.7,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Drain Abscess/Hematoma Nasal Int Appr","code_information":[{"code":"816418","type":"CDM"},{"code":"450","type":"RC"},{"code":"30000","type":"HCPCS"}],"standard_charges":[{"gross_charge":820.0,"discounted_cash":451.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Rmvl Embedded Fb Vestibule Mouth Smpl","code_information":[{"code":"816422","type":"CDM"},{"code":"450","type":"RC"},{"code":"40804","type":"HCPCS"}],"standard_charges":[{"gross_charge":3261.0,"discounted_cash":1793.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Irrigation Corpora Cavernosa Priapism","code_information":[{"code":"816428","type":"CDM"},{"code":"450","type":"RC"},{"code":"54220","type":"HCPCS"}],"standard_charges":[{"gross_charge":1151.0,"discounted_cash":633.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Recovery Phase Ii Per Min Optime","code_information":[{"code":"816433","type":"CDM"},{"code":"710","type":"RC"}],"standard_charges":[{"gross_charge":70.0,"discounted_cash":38.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Or Surgery Level 1 Per Min","code_information":[{"code":"816438","type":"CDM"},{"code":"360","type":"RC"}],"standard_charges":[{"gross_charge":42.0,"discounted_cash":23.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"},{"gross_charge":23.69,"discounted_cash":13.03,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Saf Surgery Ctr Fsc 3053"}]},{"description":"Hc Or Surgery Level 2 Per Min","code_information":[{"code":"816439","type":"CDM"},{"code":"360","type":"RC"}],"standard_charges":[{"gross_charge":48.0,"discounted_cash":26.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"},{"gross_charge":26.78,"discounted_cash":14.73,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Saf Surgery Ctr Fsc 3053"}]},{"description":"Hc Or Surgery Level 3 Per Min","code_information":[{"code":"816440","type":"CDM"},{"code":"360","type":"RC"}],"standard_charges":[{"gross_charge":56.0,"discounted_cash":30.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"},{"gross_charge":29.87,"discounted_cash":16.43,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Saf Surgery Ctr Fsc 3053"}]},{"description":"Hc Or Surgery Level 4 Per Min","code_information":[{"code":"816441","type":"CDM"},{"code":"360","type":"RC"}],"standard_charges":[{"gross_charge":61.0,"discounted_cash":33.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"},{"gross_charge":33.99,"discounted_cash":18.69,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Saf Surgery Ctr Fsc 3053"}]},{"description":"Hc Or Surgery Level 6 Per Min","code_information":[{"code":"816442","type":"CDM"},{"code":"360","type":"RC"}],"standard_charges":[{"gross_charge":77.0,"discounted_cash":42.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"},{"gross_charge":40.17,"discounted_cash":22.09,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Saf Surgery Ctr Fsc 3053"}]},{"description":"Hc Or Surgery Level 5 Per Min","code_information":[{"code":"816443","type":"CDM"},{"code":"360","type":"RC"}],"standard_charges":[{"gross_charge":67.0,"discounted_cash":36.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"},{"gross_charge":37.08,"discounted_cash":20.39,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Saf Surgery Ctr Fsc 3053"}]},{"description":"Hc Ans General Per Min","code_information":[{"code":"816444","type":"CDM"},{"code":"370","type":"RC"}],"standard_charges":[{"gross_charge":60.0,"discounted_cash":33.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"},{"gross_charge":43.26,"discounted_cash":23.79,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Saf Surgery Ctr Fsc 3053"}]},{"description":"Hc Hot Or Cold Pack Therapy Pt","code_information":[{"code":"816448","type":"CDM"},{"code":"420","type":"RC"},{"code":"97010","type":"HCPCS"}],"standard_charges":[{"gross_charge":22.0,"discounted_cash":12.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Train Self Care Ea 15 Min Pt","code_information":[{"code":"816451","type":"CDM"},{"code":"420","type":"RC"},{"code":"97535","type":"HCPCS"}],"standard_charges":[{"gross_charge":88.0,"discounted_cash":48.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Atherectomy Brachioceph Trunk Branch","code_information":[{"code":"816465","type":"CDM"},{"code":"481","type":"RC"},{"code":"0237T","type":"HCPCS"}],"standard_charges":[{"gross_charge":20988.0,"discounted_cash":11543.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Disloc Finger Ip Closed Tx No Anesth","code_information":[{"code":"816466","type":"CDM"},{"code":"450","type":"RC"},{"code":"26770","type":"HCPCS"}],"standard_charges":[{"gross_charge":957.0,"discounted_cash":526.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Group Psychotherapy Iop Php 45-50 Min","code_information":[{"code":"816471","type":"CDM"},{"code":"915","type":"RC"},{"code":"G0410","type":"HCPCS"}],"standard_charges":[{"gross_charge":239.0,"discounted_cash":131.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Whfo Cust Flx Hinge Wr/Fng Driven","code_information":[{"code":"816539","type":"CDM"},{"code":"274","type":"RC"},{"code":"L3900","type":"HCPCS"}],"standard_charges":[{"gross_charge":2563.64,"discounted_cash":1410.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Who Wrist Gauntlet Custom","code_information":[{"code":"816541","type":"CDM"},{"code":"274","type":"RC"},{"code":"L3906","type":"HCPCS"}],"standard_charges":[{"gross_charge":628.98,"discounted_cash":345.94,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"},{"gross_charge":628.98,"discounted_cash":345.94,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."},{"gross_charge":614.85,"discounted_cash":338.17,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Hc Who Wrist Ext Control Cock Up","code_information":[{"code":"816542","type":"CDM"},{"code":"274","type":"RC"},{"code":"L3908","type":"HCPCS"}],"standard_charges":[{"gross_charge":120.35,"discounted_cash":66.19,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"},{"gross_charge":117.64,"discounted_cash":64.7,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Hc Eo Wo Joints Cust Fab","code_information":[{"code":"816548","type":"CDM"},{"code":"274","type":"RC"},{"code":"L3702","type":"HCPCS"}],"standard_charges":[{"gross_charge":451.88,"discounted_cash":248.53,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ewho Rigid Wo Jnts Cust Fab","code_information":[{"code":"816550","type":"CDM"},{"code":"274","type":"RC"},{"code":"L3763","type":"HCPCS"}],"standard_charges":[{"gross_charge":1068.37,"discounted_cash":587.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"},{"gross_charge":1044.35,"discounted_cash":574.39,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Hc Paraffin Bath Pt","code_information":[{"code":"816558","type":"CDM"},{"code":"420","type":"RC"},{"code":"97018","type":"HCPCS"}],"standard_charges":[{"gross_charge":70.0,"discounted_cash":38.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Paraffin Bath Ot","code_information":[{"code":"816567","type":"CDM"},{"code":"430","type":"RC"},{"code":"97018","type":"HCPCS"}],"standard_charges":[{"gross_charge":70.0,"discounted_cash":38.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Trihexyphenidyl HCl Tab 2 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"8166","type":"CDM"},{"code":"591533501","type":"NDC"}],"standard_charges":[{"gross_charge":8.81,"discounted_cash":4.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Hc Treatment Dysphagia 15 Min St","code_information":[{"code":"816633","type":"CDM"},{"code":"440","type":"RC"},{"code":"92526","type":"HCPCS"}],"standard_charges":[{"gross_charge":660.0,"discounted_cash":363.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Treatment Dysphagia 30 Min St","code_information":[{"code":"816634","type":"CDM"},{"code":"440","type":"RC"},{"code":"92526","type":"HCPCS"}],"standard_charges":[{"gross_charge":660.0,"discounted_cash":363.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Treatment Dysphagia 45 Min St","code_information":[{"code":"816635","type":"CDM"},{"code":"440","type":"RC"},{"code":"92526","type":"HCPCS"}],"standard_charges":[{"gross_charge":660.0,"discounted_cash":363.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Treatment Dysphagia 60 Min St","code_information":[{"code":"816636","type":"CDM"},{"code":"440","type":"RC"},{"code":"92526","type":"HCPCS"}],"standard_charges":[{"gross_charge":660.0,"discounted_cash":363.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Tx Speech Disorder Individ 15 Min St","code_information":[{"code":"816641","type":"CDM"},{"code":"440","type":"RC"},{"code":"92507","type":"HCPCS"}],"standard_charges":[{"gross_charge":298.0,"discounted_cash":163.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Tx Speech Disorder Individ 30 Min St","code_information":[{"code":"816642","type":"CDM"},{"code":"440","type":"RC"},{"code":"92507","type":"HCPCS"}],"standard_charges":[{"gross_charge":298.0,"discounted_cash":163.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Tx Speech Disorder Individ 45 Min St","code_information":[{"code":"816643","type":"CDM"},{"code":"440","type":"RC"},{"code":"92507","type":"HCPCS"}],"standard_charges":[{"gross_charge":298.0,"discounted_cash":163.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Tx Speech Disorder Individ 60 Min St","code_information":[{"code":"816644","type":"CDM"},{"code":"440","type":"RC"},{"code":"92507","type":"HCPCS"}],"standard_charges":[{"gross_charge":298.0,"discounted_cash":163.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Therapeutic Procedures Group 15 Min Pt","code_information":[{"code":"816755","type":"CDM"},{"code":"423","type":"RC"},{"code":"97150","type":"HCPCS"}],"standard_charges":[{"gross_charge":91.0,"discounted_cash":50.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Therapeutic Procedures Group 30 Min Pt","code_information":[{"code":"816756","type":"CDM"},{"code":"423","type":"RC"},{"code":"97150","type":"HCPCS"}],"standard_charges":[{"gross_charge":91.0,"discounted_cash":50.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Therapeutic Procedures Group 45 Min Pt","code_information":[{"code":"816757","type":"CDM"},{"code":"423","type":"RC"},{"code":"97150","type":"HCPCS"}],"standard_charges":[{"gross_charge":91.0,"discounted_cash":50.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Therapeutic Procedures Group 60 Min Pt","code_information":[{"code":"816758","type":"CDM"},{"code":"423","type":"RC"},{"code":"97150","type":"HCPCS"}],"standard_charges":[{"gross_charge":91.0,"discounted_cash":50.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Rem Repl Pm Gen Sgl","code_information":[{"code":"816789","type":"CDM"},{"code":"481","type":"RC"},{"code":"33227","type":"HCPCS"}],"standard_charges":[{"gross_charge":9220.0,"discounted_cash":5071.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Rem Repl Pm Gen Dual Lead","code_information":[{"code":"816790","type":"CDM"},{"code":"481","type":"RC"},{"code":"33228","type":"HCPCS"}],"standard_charges":[{"gross_charge":10800.0,"discounted_cash":5940.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Rem Repl Pm Gen Mult Leads","code_information":[{"code":"816791","type":"CDM"},{"code":"481","type":"RC"},{"code":"33229","type":"HCPCS"}],"standard_charges":[{"gross_charge":11912.0,"discounted_cash":6551.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Insert Pulse Gen W/Mult Leads","code_information":[{"code":"816793","type":"CDM"},{"code":"481","type":"RC"},{"code":"33231","type":"HCPCS"}],"standard_charges":[{"gross_charge":37202.0,"discounted_cash":20461.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Rmvl Defib Gen W Rplcmt Sngl Ld","code_information":[{"code":"816794","type":"CDM"},{"code":"481","type":"RC"},{"code":"33262","type":"HCPCS"}],"standard_charges":[{"gross_charge":36635.0,"discounted_cash":20149.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Rmvl Defib Gen W Rplcmt Dual Ld","code_information":[{"code":"816795","type":"CDM"},{"code":"481","type":"RC"},{"code":"33263","type":"HCPCS"}],"standard_charges":[{"gross_charge":43553.0,"discounted_cash":23954.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Rmvl Defib Gen W Rplmct Mult Lds","code_information":[{"code":"816796","type":"CDM"},{"code":"481","type":"RC"},{"code":"33264","type":"HCPCS"}],"standard_charges":[{"gross_charge":38996.0,"discounted_cash":21447.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc App Skin Sub High T/A/L <100Cm 1St 25Cm","code_information":[{"code":"816802","type":"CDM"},{"code":"361","type":"RC"},{"code":"15271","type":"HCPCS"}],"standard_charges":[{"gross_charge":2122.0,"discounted_cash":1167.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc App Skin Sub High T/A/L <100Cm Addl 25Cm","code_information":[{"code":"816803","type":"CDM"},{"code":"361","type":"RC"},{"code":"15272","type":"HCPCS"}],"standard_charges":[{"gross_charge":407.0,"discounted_cash":223.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc App Skin Sub High F/S/H <100 Cm 1St 25","code_information":[{"code":"816806","type":"CDM"},{"code":"361","type":"RC"},{"code":"15275","type":"HCPCS"}],"standard_charges":[{"gross_charge":2019.0,"discounted_cash":1110.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc App Skin Sub High F/S/H <100Cm Add 25Cm","code_information":[{"code":"816807","type":"CDM"},{"code":"361","type":"RC"},{"code":"15276","type":"HCPCS"}],"standard_charges":[{"gross_charge":423.0,"discounted_cash":232.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Insert Pm Generator W Existing Leads","code_information":[{"code":"816813","type":"CDM"},{"code":"481","type":"RC"},{"code":"33221","type":"HCPCS"}],"standard_charges":[{"gross_charge":6097.0,"discounted_cash":3353.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Plcmt Cath Selective Renal Angio Unilat","code_information":[{"code":"816814","type":"CDM"},{"code":"481","type":"RC"},{"code":"36251","type":"HCPCS"}],"standard_charges":[{"gross_charge":6018.0,"discounted_cash":3309.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Plcmt Cath Selective Renal Angio Bila","code_information":[{"code":"816815","type":"CDM"},{"code":"481","type":"RC"},{"code":"36252","type":"HCPCS"}],"standard_charges":[{"gross_charge":12032.0,"discounted_cash":6617.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Plcmt Cath Superselect Renal Angio Uni","code_information":[{"code":"816816","type":"CDM"},{"code":"481","type":"RC"},{"code":"36253","type":"HCPCS"}],"standard_charges":[{"gross_charge":8308.0,"discounted_cash":4569.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Plcmt Cath Superselect Renal Angio Bilat","code_information":[{"code":"816817","type":"CDM"},{"code":"481","type":"RC"},{"code":"36254","type":"HCPCS"}],"standard_charges":[{"gross_charge":16532.0,"discounted_cash":9092.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Insert Filter Vena Cava Endovascular","code_information":[{"code":"816818","type":"CDM"},{"code":"481","type":"RC"},{"code":"37191","type":"HCPCS"}],"standard_charges":[{"gross_charge":6120.0,"discounted_cash":3366.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Paracentesis Abd Wo Guidance","code_information":[{"code":"816820","type":"CDM"},{"code":"450","type":"RC"},{"code":"49082","type":"HCPCS"}],"standard_charges":[{"gross_charge":1911.0,"discounted_cash":1051.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Paracentesis Abd Wo Guidance","code_information":[{"code":"816821","type":"CDM"},{"code":"361","type":"RC"},{"code":"49082","type":"HCPCS"}],"standard_charges":[{"gross_charge":1662.0,"discounted_cash":914.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Paracentesis Abd W Guidance","code_information":[{"code":"816822","type":"CDM"},{"code":"450","type":"RC"},{"code":"49083","type":"HCPCS"}],"standard_charges":[{"gross_charge":2453.0,"discounted_cash":1349.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Paracentesis Abd W Guidance","code_information":[{"code":"816823","type":"CDM"},{"code":"361","type":"RC"},{"code":"49083","type":"HCPCS"}],"standard_charges":[{"gross_charge":2134.0,"discounted_cash":1173.7,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Destruct Facet Jnt W Img C/T Sngl Lvl","code_information":[{"code":"816826","type":"CDM"},{"code":"361","type":"RC"},{"code":"64633","type":"HCPCS"}],"standard_charges":[{"gross_charge":5178.0,"discounted_cash":2847.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Destruct Facet Jnt W Img C/T Addl Lvl","code_information":[{"code":"816827","type":"CDM"},{"code":"361","type":"RC"},{"code":"64634","type":"HCPCS"}],"standard_charges":[{"gross_charge":3166.0,"discounted_cash":1741.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Destruct Facet Jnt W Img L/S Sng Lvl","code_information":[{"code":"816828","type":"CDM"},{"code":"361","type":"RC"},{"code":"64635","type":"HCPCS"}],"standard_charges":[{"gross_charge":5178.0,"discounted_cash":2847.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Destruct Facet Jnt W Img L/S Addl Lvl","code_information":[{"code":"816829","type":"CDM"},{"code":"361","type":"RC"},{"code":"64636","type":"HCPCS"}],"standard_charges":[{"gross_charge":3166.0,"discounted_cash":1741.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Plethysmography For Lung Volumes","code_information":[{"code":"816830","type":"CDM"},{"code":"460","type":"RC"},{"code":"94726","type":"HCPCS"}],"standard_charges":[{"gross_charge":974.0,"discounted_cash":535.7,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Gas Dilution Washout For Lung Volume","code_information":[{"code":"816831","type":"CDM"},{"code":"460","type":"RC"},{"code":"94727","type":"HCPCS"}],"standard_charges":[{"gross_charge":967.0,"discounted_cash":531.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Diffusing Capacity","code_information":[{"code":"816833","type":"CDM"},{"code":"460","type":"RC"},{"code":"94729","type":"HCPCS"}],"standard_charges":[{"gross_charge":716.0,"discounted_cash":393.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Destruct Facet Jnt W Img L/S Sng Lvl Bil","code_information":[{"code":"816844","type":"CDM"},{"code":"361","type":"RC"},{"code":"64635","type":"HCPCS"}],"standard_charges":[{"gross_charge":10358.0,"discounted_cash":5696.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Destruct Facet Jnt W Img L/S Addl Lvl Bil","code_information":[{"code":"816845","type":"CDM"},{"code":"361","type":"RC"},{"code":"64636","type":"HCPCS"}],"standard_charges":[{"gross_charge":6334.0,"discounted_cash":3483.7,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Destruct Facet Jnt W Img C/T Sngl Lvl Bil","code_information":[{"code":"816846","type":"CDM"},{"code":"361","type":"RC"},{"code":"64633","type":"HCPCS"}],"standard_charges":[{"gross_charge":10358.0,"discounted_cash":5696.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Destruct Facet Jnt W Img C/T Addl Lvl Bil","code_information":[{"code":"816847","type":"CDM"},{"code":"361","type":"RC"},{"code":"64634","type":"HCPCS"}],"standard_charges":[{"gross_charge":6334.0,"discounted_cash":3483.7,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Hepatobiliary System Imaging","code_information":[{"code":"816848","type":"CDM"},{"code":"341","type":"RC"},{"code":"78226","type":"HCPCS"}],"standard_charges":[{"gross_charge":3520.0,"discounted_cash":1936.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Hepatobil Syst Image W/Drug","code_information":[{"code":"816849","type":"CDM"},{"code":"341","type":"RC"},{"code":"78227","type":"HCPCS"}],"standard_charges":[{"gross_charge":3520.0,"discounted_cash":1936.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Lung Ventilat&Perfus Imaging","code_information":[{"code":"816850","type":"CDM"},{"code":"341","type":"RC"},{"code":"78582","type":"HCPCS"}],"standard_charges":[{"gross_charge":3520.0,"discounted_cash":1936.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Lung Perf&Ventilat Diferentl","code_information":[{"code":"816851","type":"CDM"},{"code":"341","type":"RC"},{"code":"78598","type":"HCPCS"}],"standard_charges":[{"gross_charge":3520.0,"discounted_cash":1936.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Lung Ventilation Imaging","code_information":[{"code":"816852","type":"CDM"},{"code":"341","type":"RC"},{"code":"78579","type":"HCPCS"}],"standard_charges":[{"gross_charge":3520.0,"discounted_cash":1936.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Removal Foreign Body Subq Complex","code_information":[{"code":"816853","type":"CDM"},{"code":"450","type":"RC"},{"code":"10121","type":"HCPCS"}],"standard_charges":[{"gross_charge":6168.0,"discounted_cash":3392.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Debride Fx/Disloc Opn Skin Subq","code_information":[{"code":"816856","type":"CDM"},{"code":"450","type":"RC"},{"code":"11010","type":"HCPCS"}],"standard_charges":[{"gross_charge":2717.0,"discounted_cash":1494.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Debride Bone 1St 20 Cm Or Less","code_information":[{"code":"816860","type":"CDM"},{"code":"450","type":"RC"},{"code":"11044","type":"HCPCS"}],"standard_charges":[{"gross_charge":4104.0,"discounted_cash":2257.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Removal Skin Tags <= 15 Lesions","code_information":[{"code":"816866","type":"CDM"},{"code":"450","type":"RC"},{"code":"11200","type":"HCPCS"}],"standard_charges":[{"gross_charge":1617.0,"discounted_cash":889.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Exc Skin Benign <=0.5Cm Sclp/Nk/Hnd/Ft","code_information":[{"code":"816869","type":"CDM"},{"code":"450","type":"RC"},{"code":"11420","type":"HCPCS"}],"standard_charges":[{"gross_charge":6196.0,"discounted_cash":3407.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Destr Benign Lesion Other Skin Tag <14","code_information":[{"code":"816875","type":"CDM"},{"code":"450","type":"RC"},{"code":"17110","type":"HCPCS"}],"standard_charges":[{"gross_charge":739.0,"discounted_cash":406.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Explore Woundpenetrating Neck","code_information":[{"code":"816876","type":"CDM"},{"code":"450","type":"RC"},{"code":"20100","type":"HCPCS"}],"standard_charges":[{"gross_charge":1800.0,"discounted_cash":990.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Explore Wound Penetrating Chest","code_information":[{"code":"816877","type":"CDM"},{"code":"450","type":"RC"},{"code":"20101","type":"HCPCS"}],"standard_charges":[{"gross_charge":7403.0,"discounted_cash":4071.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Drain/Inject Small Joint/Bursa","code_information":[{"code":"816879","type":"CDM"},{"code":"450","type":"RC"},{"code":"20600","type":"HCPCS"}],"standard_charges":[{"gross_charge":1362.0,"discounted_cash":749.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Tx Fx Elbow Disl Clsd W Ans","code_information":[{"code":"816894","type":"CDM"},{"code":"450","type":"RC"},{"code":"24605","type":"HCPCS"}],"standard_charges":[{"gross_charge":5432.0,"discounted_cash":2987.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Tx Fx Elbow Disl Clsd W Manip","code_information":[{"code":"816895","type":"CDM"},{"code":"450","type":"RC"},{"code":"24620","type":"HCPCS"}],"standard_charges":[{"gross_charge":6172.0,"discounted_cash":3394.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Tx Fx Ulnar Prox W Manip","code_information":[{"code":"816896","type":"CDM"},{"code":"450","type":"RC"},{"code":"24675","type":"HCPCS"}],"standard_charges":[{"gross_charge":5654.0,"discounted_cash":3109.7,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Tx Fx Radial Shft Clsd W/O Manip","code_information":[{"code":"816897","type":"CDM"},{"code":"450","type":"RC"},{"code":"25500","type":"HCPCS"}],"standard_charges":[{"gross_charge":895.0,"discounted_cash":492.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Tx Raduln Distl Disl Clsd Manip","code_information":[{"code":"816903","type":"CDM"},{"code":"450","type":"RC"},{"code":"25675","type":"HCPCS"}],"standard_charges":[{"gross_charge":816.0,"discounted_cash":448.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Tx Fx Mcp Disl Clsd W Ans","code_information":[{"code":"816907","type":"CDM"},{"code":"450","type":"RC"},{"code":"26705","type":"HCPCS"}],"standard_charges":[{"gross_charge":6132.0,"discounted_cash":3372.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Tx Hip Disl Trauma Clsd W Ans","code_information":[{"code":"816916","type":"CDM"},{"code":"450","type":"RC"},{"code":"27252","type":"HCPCS"}],"standard_charges":[{"gross_charge":4658.0,"discounted_cash":2561.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Tx Hip Disl Post Surg W Ans","code_information":[{"code":"816918","type":"CDM"},{"code":"450","type":"RC"},{"code":"27266","type":"HCPCS"}],"standard_charges":[{"gross_charge":5580.0,"discounted_cash":3069.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Tx Fx Fem Shft Clsd W Manip","code_information":[{"code":"816921","type":"CDM"},{"code":"450","type":"RC"},{"code":"27502","type":"HCPCS"}],"standard_charges":[{"gross_charge":3851.0,"discounted_cash":2118.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Tx Knee Disl W Ans","code_information":[{"code":"816924","type":"CDM"},{"code":"450","type":"RC"},{"code":"27552","type":"HCPCS"}],"standard_charges":[{"gross_charge":4549.0,"discounted_cash":2501.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Tx Fx Tibia Shft Clsd W Manip","code_information":[{"code":"816925","type":"CDM"},{"code":"450","type":"RC"},{"code":"27752","type":"HCPCS"}],"standard_charges":[{"gross_charge":3924.0,"discounted_cash":2158.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Fb Remv Foot Subq Deep","code_information":[{"code":"816928","type":"CDM"},{"code":"450","type":"RC"},{"code":"28192","type":"HCPCS"}],"standard_charges":[{"gross_charge":6264.0,"discounted_cash":3445.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Tx Fx Toe Great Closed W Manip","code_information":[{"code":"816932","type":"CDM"},{"code":"450","type":"RC"},{"code":"28495","type":"HCPCS"}],"standard_charges":[{"gross_charge":900.0,"discounted_cash":495.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Tx Disloc Interphal Closed W Anes","code_information":[{"code":"816935","type":"CDM"},{"code":"450","type":"RC"},{"code":"28665","type":"HCPCS"}],"standard_charges":[{"gross_charge":957.0,"discounted_cash":526.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Applic Cast Long Leg","code_information":[{"code":"816940","type":"CDM"},{"code":"450","type":"RC"},{"code":"29345","type":"HCPCS"}],"standard_charges":[{"gross_charge":971.0,"discounted_cash":534.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Remv Cast Full Arm Leg","code_information":[{"code":"816944","type":"CDM"},{"code":"450","type":"RC"},{"code":"29705","type":"HCPCS"}],"standard_charges":[{"gross_charge":946.0,"discounted_cash":520.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Venipuncture Fm Jg < 3Yrs Non Routine","code_information":[{"code":"816950","type":"CDM"},{"code":"450","type":"RC"},{"code":"36400","type":"HCPCS"}],"standard_charges":[{"gross_charge":118.0,"discounted_cash":64.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Venipuncture  >=3Yrs Non Routine","code_information":[{"code":"816952","type":"CDM"},{"code":"450","type":"RC"},{"code":"36410","type":"HCPCS"}],"standard_charges":[{"gross_charge":343.0,"discounted_cash":188.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Insert Tunneled Cvc Wo Sq Port <5 Yr","code_information":[{"code":"816954","type":"CDM"},{"code":"450","type":"RC"},{"code":"36557","type":"HCPCS"}],"standard_charges":[{"gross_charge":20272.0,"discounted_cash":11149.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Insert Picc Wo Sq Pt < 5 Yrs Wo Img","code_information":[{"code":"816955","type":"CDM"},{"code":"450","type":"RC"},{"code":"36568","type":"HCPCS"}],"standard_charges":[{"gross_charge":3290.0,"discounted_cash":1809.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Interosseous Needle Placement","code_information":[{"code":"816960","type":"CDM"},{"code":"450","type":"RC"},{"code":"36680","type":"HCPCS"}],"standard_charges":[{"gross_charge":695.0,"discounted_cash":382.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Rpr Lip Full Thick Vermillion","code_information":[{"code":"816962","type":"CDM"},{"code":"450","type":"RC"},{"code":"40650","type":"HCPCS"}],"standard_charges":[{"gross_charge":2068.0,"discounted_cash":1137.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed I&D Abcess Vestibule Mouth Smpl","code_information":[{"code":"816963","type":"CDM"},{"code":"450","type":"RC"},{"code":"40800","type":"HCPCS"}],"standard_charges":[{"gross_charge":2462.0,"discounted_cash":1354.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Remv Fb Pharynx","code_information":[{"code":"816967","type":"CDM"},{"code":"450","type":"RC"},{"code":"42809","type":"HCPCS"}],"standard_charges":[{"gross_charge":1020.0,"discounted_cash":561.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Egd Flex Transoral Dx","code_information":[{"code":"816970","type":"CDM"},{"code":"450","type":"RC"},{"code":"43235","type":"HCPCS"}],"standard_charges":[{"gross_charge":657.0,"discounted_cash":361.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed I&D Abcess Perianal","code_information":[{"code":"816972","type":"CDM"},{"code":"450","type":"RC"},{"code":"46050","type":"HCPCS"}],"standard_charges":[{"gross_charge":3481.0,"discounted_cash":1914.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Manipulation Foreskin","code_information":[{"code":"816974","type":"CDM"},{"code":"450","type":"RC"},{"code":"54450","type":"HCPCS"}],"standard_charges":[{"gross_charge":1171.0,"discounted_cash":644.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed I&D Epididymis Testis Scrotum","code_information":[{"code":"816975","type":"CDM"},{"code":"450","type":"RC"},{"code":"54700","type":"HCPCS"}],"standard_charges":[{"gross_charge":8129.0,"discounted_cash":4470.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Coporrhaphy","code_information":[{"code":"816978","type":"CDM"},{"code":"450","type":"RC"},{"code":"57200","type":"HCPCS"}],"standard_charges":[{"gross_charge":8735.0,"discounted_cash":4804.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Delivery Placenta","code_information":[{"code":"816980","type":"CDM"},{"code":"450","type":"RC"},{"code":"59414","type":"HCPCS"}],"standard_charges":[{"gross_charge":6923.0,"discounted_cash":3807.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Remv Fb Embed Conjunctivia","code_information":[{"code":"816982","type":"CDM"},{"code":"450","type":"RC"},{"code":"65210","type":"HCPCS"}],"standard_charges":[{"gross_charge":396.0,"discounted_cash":217.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc I&D Abcess Hematoma Neck Thorax","code_information":[{"code":"817004","type":"CDM"},{"code":"361","type":"RC"},{"code":"21501","type":"HCPCS"}],"standard_charges":[{"gross_charge":3928.0,"discounted_cash":2160.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Lithotripsy Eswl","code_information":[{"code":"817014","type":"CDM"},{"code":"790","type":"RC"},{"code":"50590","type":"HCPCS"}],"standard_charges":[{"gross_charge":343.0,"discounted_cash":188.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Tenotomy Achilles Perc Local Ans","code_information":[{"code":"817015","type":"CDM"},{"code":"361","type":"RC"},{"code":"27605","type":"HCPCS"}],"standard_charges":[{"gross_charge":4730.0,"discounted_cash":2601.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Debridement Selective Ea Addl 20Cm Ot","code_information":[{"code":"817119","type":"CDM"},{"code":"430","type":"RC"},{"code":"97598","type":"HCPCS"}],"standard_charges":[{"gross_charge":446.0,"discounted_cash":245.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Prosthetic Train Extrem Ea 15 Min Ot","code_information":[{"code":"817120","type":"CDM"},{"code":"430","type":"RC"},{"code":"97761","type":"HCPCS"}],"standard_charges":[{"gross_charge":92.0,"discounted_cash":50.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Sensory Integrative Devel 15 Min Ot","code_information":[{"code":"817121","type":"CDM"},{"code":"430","type":"RC"},{"code":"97533","type":"HCPCS"}],"standard_charges":[{"gross_charge":96.0,"discounted_cash":52.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Work Hardening Ea Addl Hr Ot","code_information":[{"code":"817122","type":"CDM"},{"code":"430","type":"RC"},{"code":"97546","type":"HCPCS"}],"standard_charges":[{"gross_charge":189.0,"discounted_cash":103.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Insert Picc Per Wo Sq Pt >=5Yrs","code_information":[{"code":"817124","type":"CDM"},{"code":"450","type":"RC"},{"code":"36569","type":"HCPCS"}],"standard_charges":[{"gross_charge":2774.0,"discounted_cash":1525.7,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Repair Lip Over One Half Vert Ht","code_information":[{"code":"817125","type":"CDM"},{"code":"450","type":"RC"},{"code":"40654","type":"HCPCS"}],"standard_charges":[{"gross_charge":5475.0,"discounted_cash":3011.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Thrombolysis Cerebral Via Iv Inf","code_information":[{"code":"817126","type":"CDM"},{"code":"450","type":"RC"},{"code":"37195","type":"HCPCS"}],"standard_charges":[{"gross_charge":927.0,"discounted_cash":509.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Psychotherapy W Pt 45 Min","code_information":[{"code":"817149","type":"CDM"},{"code":"905","type":"RC"},{"code":"90834","type":"HCPCS"}],"standard_charges":[{"gross_charge":190.0,"discounted_cash":104.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Neurobehavioral Status Exam 1St Hr","code_information":[{"code":"817151","type":"CDM"},{"code":"918","type":"RC"},{"code":"96116","type":"HCPCS"}],"standard_charges":[{"gross_charge":162.0,"discounted_cash":89.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Cath Dual Pwr Pic Solo 5Fr","code_information":[{"code":"817209","type":"CDM"},{"code":"272","type":"RC"},{"code":"C1751","type":"HCPCS"}],"standard_charges":[{"gross_charge":840.86,"discounted_cash":462.47,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."},{"gross_charge":843.85,"discounted_cash":464.12,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."},{"gross_charge":839.03,"discounted_cash":461.47,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Hc Car Seat/Bed Test <=12 Mo Ea Addl 30Min","code_information":[{"code":"817344","type":"CDM"},{"code":"460","type":"RC"},{"code":"94781","type":"HCPCS"}],"standard_charges":[{"gross_charge":250.0,"discounted_cash":137.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Car Seat/Bed Test <=12 Mo 60Min","code_information":[{"code":"817345","type":"CDM"},{"code":"460","type":"RC"},{"code":"94780","type":"HCPCS"}],"standard_charges":[{"gross_charge":505.0,"discounted_cash":277.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Elec Stim Unattended Non Wound Ot","code_information":[{"code":"817349","type":"CDM"},{"code":"430","type":"RC"},{"code":"G0283","type":"HCPCS"}],"standard_charges":[{"gross_charge":124.0,"discounted_cash":68.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Fx Fibula Proxml Clsd Tx & Manip","code_information":[{"code":"817363","type":"CDM"},{"code":"450","type":"RC"},{"code":"27781","type":"HCPCS"}],"standard_charges":[{"gross_charge":6132.0,"discounted_cash":3372.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Applic Cast Short Leg","code_information":[{"code":"817367","type":"CDM"},{"code":"450","type":"RC"},{"code":"29405","type":"HCPCS"}],"standard_charges":[{"gross_charge":1101.0,"discounted_cash":605.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Rpr Lip Full Thick To Half Ht Vertcal","code_information":[{"code":"817371","type":"CDM"},{"code":"450","type":"RC"},{"code":"40652","type":"HCPCS"}],"standard_charges":[{"gross_charge":1862.0,"discounted_cash":1024.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Anoscopy Diagnostic","code_information":[{"code":"817375","type":"CDM"},{"code":"450","type":"RC"},{"code":"46600","type":"HCPCS"}],"standard_charges":[{"gross_charge":314.0,"discounted_cash":172.7,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Mra Spinal Canal W Contrast","code_information":[{"code":"817391","type":"CDM"},{"code":"618","type":"RC"},{"code":"C8931","type":"HCPCS"}],"standard_charges":[{"gross_charge":4412.0,"discounted_cash":2426.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Close Laa Perc Transcath W Implnt","code_information":[{"code":"817480","type":"CDM"},{"code":"481","type":"RC"},{"code":"33340","type":"HCPCS"}],"standard_charges":[{"gross_charge":37681.0,"discounted_cash":20724.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Carpal Tunnel Release Unilat","code_information":[{"code":"817524","type":"CDM"},{"code":"360","type":"RC"},{"code":"64721","type":"HCPCS"}],"standard_charges":[{"gross_charge":6258.0,"discounted_cash":3441.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Noncdm Charge Record","code_information":[{"code":"817593","type":"CDM"},{"code":"922","type":"RC"},{"code":"95885","type":"HCPCS"}],"standard_charges":[{"gross_charge":317.27,"discounted_cash":174.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Noncdm Charge Record","code_information":[{"code":"817594","type":"CDM"},{"code":"922","type":"RC"},{"code":"95886","type":"HCPCS"}],"standard_charges":[{"gross_charge":480.04,"discounted_cash":264.02,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Hc Fasciectomy Plantar Fascia Partial","code_information":[{"code":"817609","type":"CDM"},{"code":"360","type":"RC"},{"code":"28060","type":"HCPCS"}],"standard_charges":[{"gross_charge":5725.0,"discounted_cash":3148.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Heated High Flow O2 Subseq","code_information":[{"code":"817625","type":"CDM"},{"code":"410","type":"RC"},{"code":"94799","type":"HCPCS"}],"standard_charges":[{"gross_charge":596.0,"discounted_cash":327.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Trim Nails Nondystrophic","code_information":[{"code":"817655","type":"CDM"},{"code":"450","type":"RC"},{"code":"11719","type":"HCPCS"}],"standard_charges":[{"gross_charge":114.0,"discounted_cash":62.7,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Id Io Abscess Tng Floor Mth Submandib","code_information":[{"code":"817677","type":"CDM"},{"code":"450","type":"RC"},{"code":"41008","type":"HCPCS"}],"standard_charges":[{"gross_charge":11221.0,"discounted_cash":6171.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Inj Aa Strd Nerve Trigeminal","code_information":[{"code":"817689","type":"CDM"},{"code":"450","type":"RC"},{"code":"64400","type":"HCPCS"}],"standard_charges":[{"gross_charge":1162.0,"discounted_cash":639.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Id Abcess Auditory Canal Ext","code_information":[{"code":"817690","type":"CDM"},{"code":"450","type":"RC"},{"code":"69020","type":"HCPCS"}],"standard_charges":[{"gross_charge":2708.0,"discounted_cash":1489.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Lab Pt Poct Anticoag","code_information":[{"code":"817700","type":"CDM"},{"code":"305","type":"RC"},{"code":"85610","type":"HCPCS"}],"standard_charges":[{"gross_charge":57.0,"discounted_cash":31.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Removal Of Iab Assist Device","code_information":[{"code":"817705","type":"CDM"},{"code":"360","type":"RC"},{"code":"33968","type":"HCPCS"}],"standard_charges":[{"gross_charge":1968.0,"discounted_cash":1082.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Chest Drainage System Adult","code_information":[{"code":"817735","type":"CDM"},{"code":"272","type":"RC"},{"code":"C1729","type":"HCPCS"}],"standard_charges":[{"gross_charge":121.49,"discounted_cash":66.82,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Recovery Standard Post Op Per Min","code_information":[{"code":"817927","type":"CDM"},{"code":"710","type":"RC"}],"standard_charges":[{"gross_charge":3.88,"discounted_cash":2.13,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"},{"gross_charge":2.5,"discounted_cash":1.38,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Saf Surgery Ctr Fsc 3053"}]},{"description":"Hc Rb Semi Private Inpatient","code_information":[{"code":"817934","type":"CDM"},{"code":"121","type":"RC"}],"standard_charges":[{"gross_charge":1505.0,"discounted_cash":827.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Inj Trigger Pt >= 3 Muscles","code_information":[{"code":"817949","type":"CDM"},{"code":"450","type":"RC"},{"code":"20553","type":"HCPCS"}],"standard_charges":[{"gross_charge":1476.0,"discounted_cash":811.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Mon Interstit Fluid Pressure","code_information":[{"code":"817951","type":"CDM"},{"code":"450","type":"RC"},{"code":"20950","type":"HCPCS"}],"standard_charges":[{"gross_charge":973.0,"discounted_cash":535.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Bronchoscopy","code_information":[{"code":"817962","type":"CDM"},{"code":"360","type":"RC"},{"code":"31622","type":"HCPCS"}],"standard_charges":[{"gross_charge":2974.0,"discounted_cash":1635.7,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Tx Disloc Ipj Clsd W/Manip Ans","code_information":[{"code":"817964","type":"CDM"},{"code":"450","type":"RC"},{"code":"26775","type":"HCPCS"}],"standard_charges":[{"gross_charge":1142.0,"discounted_cash":628.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Tx Fx Tarsal W Manip Ea","code_information":[{"code":"817971","type":"CDM"},{"code":"450","type":"RC"},{"code":"28455","type":"HCPCS"}],"standard_charges":[{"gross_charge":4349.0,"discounted_cash":2391.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Tx Dislc Talotarsal Clsd W/O Ans","code_information":[{"code":"817972","type":"CDM"},{"code":"450","type":"RC"},{"code":"28570","type":"HCPCS"}],"standard_charges":[{"gross_charge":1288.0,"discounted_cash":708.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Laryngoscopy Direct W/ Remv Fb","code_information":[{"code":"817982","type":"CDM"},{"code":"450","type":"RC"},{"code":"31530","type":"HCPCS"}],"standard_charges":[{"gross_charge":5646.0,"discounted_cash":3105.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Laryngoscopy Flex Diagnostic","code_information":[{"code":"817983","type":"CDM"},{"code":"450","type":"RC"},{"code":"31575","type":"HCPCS"}],"standard_charges":[{"gross_charge":428.0,"discounted_cash":235.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed  Insert Repl Pm Temp Sngl Chmbr","code_information":[{"code":"817987","type":"CDM"},{"code":"450","type":"RC"},{"code":"33210","type":"HCPCS"}],"standard_charges":[{"gross_charge":10603.0,"discounted_cash":5831.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Venipuncture Other < 3Yrs Non Routine","code_information":[{"code":"817989","type":"CDM"},{"code":"450","type":"RC"},{"code":"36406","type":"HCPCS"}],"standard_charges":[{"gross_charge":171.0,"discounted_cash":94.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed  Unlisted Px Peritoneum Omentum","code_information":[{"code":"818006","type":"CDM"},{"code":"450","type":"RC"},{"code":"49999","type":"HCPCS"}],"standard_charges":[{"gross_charge":4246.0,"discounted_cash":2335.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed  Bx Endometrium W/Wo Endocerv Bx","code_information":[{"code":"818015","type":"CDM"},{"code":"450","type":"RC"},{"code":"58100","type":"HCPCS"}],"standard_charges":[{"gross_charge":472.0,"discounted_cash":259.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Inj  Aa Strd Axillary Nerve W Img","code_information":[{"code":"818020","type":"CDM"},{"code":"450","type":"RC"},{"code":"64417","type":"HCPCS"}],"standard_charges":[{"gross_charge":3147.0,"discounted_cash":1730.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Inj Thrpy Proph Diag Intra-Art","code_information":[{"code":"818028","type":"CDM"},{"code":"450","type":"RC"},{"code":"96373","type":"HCPCS"}],"standard_charges":[{"gross_charge":192.0,"discounted_cash":105.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ligation Of Arteriovenous Fistula","code_information":[{"code":"818041","type":"CDM"},{"code":"361","type":"RC"},{"code":"37607","type":"HCPCS"}],"standard_charges":[{"gross_charge":4756.0,"discounted_cash":2615.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Inj Aa Strd Ilioinguinal Nerve","code_information":[{"code":"818045","type":"CDM"},{"code":"361","type":"RC"},{"code":"64425","type":"HCPCS"}],"standard_charges":[{"gross_charge":1261.0,"discounted_cash":693.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ccpd Dialysis","code_information":[{"code":"818071","type":"CDM"},{"code":"851","type":"RC"},{"code":"90999","type":"HCPCS"}],"standard_charges":[{"gross_charge":1300.0,"discounted_cash":715.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Rb Mdb Extend Recovery Intermed Per Min","code_information":[{"code":"818127","type":"CDM"},{"code":"710","type":"RC"}],"standard_charges":[{"gross_charge":2.14,"discounted_cash":1.18,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Eval Device Periop Pm Or Leadls Pm","code_information":[{"code":"818129","type":"CDM"},{"code":"480","type":"RC"},{"code":"93286","type":"HCPCS"}],"standard_charges":[{"gross_charge":236.0,"discounted_cash":129.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Eval Device Periop Icd System","code_information":[{"code":"818130","type":"CDM"},{"code":"480","type":"RC"},{"code":"93287","type":"HCPCS"}],"standard_charges":[{"gross_charge":313.0,"discounted_cash":172.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Implantatn Prosth Valve Pulm Endovasc","code_information":[{"code":"818169","type":"CDM"},{"code":"481","type":"RC"},{"code":"33477","type":"HCPCS"}],"standard_charges":[{"gross_charge":36681.0,"discounted_cash":20174.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Lab Pt Poct Anticoag Stl","code_information":[{"code":"818173","type":"CDM"},{"code":"305","type":"RC"},{"code":"85610","type":"HCPCS"}],"standard_charges":[{"gross_charge":57.0,"discounted_cash":31.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Cysto W Dil Urethrl Stricture","code_information":[{"code":"818174","type":"CDM"},{"code":"361","type":"RC"},{"code":"52281","type":"HCPCS"}],"standard_charges":[{"gross_charge":4959.0,"discounted_cash":2727.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Somatosensory Stdy Ue And Le","code_information":[{"code":"818187","type":"CDM"},{"code":"920","type":"RC"},{"code":"95938","type":"HCPCS"}],"standard_charges":[{"gross_charge":2468.0,"discounted_cash":1357.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Stepdown Care Per Minute Op Time","code_information":[{"code":"818188","type":"CDM"},{"code":"710","type":"RC"}],"standard_charges":[{"gross_charge":8.0,"discounted_cash":4.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Lab Nitrozene Ph Poct (Ip) Beaker","code_information":[{"code":"818206","type":"CDM"},{"code":"301","type":"RC"},{"code":"83986","type":"HCPCS"}],"standard_charges":[{"gross_charge":91.0,"discounted_cash":50.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Atherectmy Perc W Stent Sng Maj Cor Art","code_information":[{"code":"818256","type":"CDM"},{"code":"481","type":"RC"},{"code":"92933","type":"HCPCS"}],"standard_charges":[{"gross_charge":19076.0,"discounted_cash":10491.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Revasc Perc Coron Bypass Graft Sngl Vssl","code_information":[{"code":"818258","type":"CDM"},{"code":"481","type":"RC"},{"code":"92937","type":"HCPCS"}],"standard_charges":[{"gross_charge":13236.0,"discounted_cash":7279.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Revasc Perc Cor Bypass Grft Ea Add Brnch","code_information":[{"code":"818259","type":"CDM"},{"code":"481","type":"RC"},{"code":"92938","type":"HCPCS"}],"standard_charges":[{"gross_charge":11821.0,"discounted_cash":6501.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Revasc Perc Ac Occ Cor Art W Mi Sngl Vsl","code_information":[{"code":"818260","type":"CDM"},{"code":"481","type":"RC"},{"code":"92941","type":"HCPCS"}],"standard_charges":[{"gross_charge":13697.0,"discounted_cash":7533.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Revasc Perc Ch Occ Cor Art Sngl Vessel","code_information":[{"code":"818261","type":"CDM"},{"code":"481","type":"RC"},{"code":"92943","type":"HCPCS"}],"standard_charges":[{"gross_charge":13897.0,"discounted_cash":7643.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ep & Ablate Supravent Arrhythmia","code_information":[{"code":"818263","type":"CDM"},{"code":"481","type":"RC"},{"code":"93653","type":"HCPCS"}],"standard_charges":[{"gross_charge":46413.0,"discounted_cash":25527.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ep & Ablate Ventricular Tachycardia","code_information":[{"code":"818264","type":"CDM"},{"code":"481","type":"RC"},{"code":"93654","type":"HCPCS"}],"standard_charges":[{"gross_charge":46413.0,"discounted_cash":25527.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ablation Arrhythmia Add On","code_information":[{"code":"818265","type":"CDM"},{"code":"481","type":"RC"},{"code":"93655","type":"HCPCS"}],"standard_charges":[{"gross_charge":590.0,"discounted_cash":324.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ep Eval Ablation Afib By Pulm Vein Iso","code_information":[{"code":"818266","type":"CDM"},{"code":"481","type":"RC"},{"code":"93656","type":"HCPCS"}],"standard_charges":[{"gross_charge":46413.0,"discounted_cash":25527.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ablate Atrium Afib Post Pulm Vein Isoltn","code_information":[{"code":"818267","type":"CDM"},{"code":"481","type":"RC"},{"code":"93657","type":"HCPCS"}],"standard_charges":[{"gross_charge":15053.0,"discounted_cash":8279.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Atherctmy Perc W De Stnt Sng Maj Cor Art","code_information":[{"code":"818268","type":"CDM"},{"code":"481","type":"RC"},{"code":"C9602","type":"HCPCS"}],"standard_charges":[{"gross_charge":19168.0,"discounted_cash":10542.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Atherctmy Perc W De Stnt Addl Brnch Cor","code_information":[{"code":"818269","type":"CDM"},{"code":"481","type":"RC"},{"code":"C9603","type":"HCPCS"}],"standard_charges":[{"gross_charge":19075.0,"discounted_cash":10491.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Revasc Cor Bypass Grft W De Stnt Sng Vsl","code_information":[{"code":"818270","type":"CDM"},{"code":"481","type":"RC"},{"code":"C9604","type":"HCPCS"}],"standard_charges":[{"gross_charge":13298.0,"discounted_cash":7313.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Revasc Cor Bypass W De Stnt Ea Add Brnch","code_information":[{"code":"818271","type":"CDM"},{"code":"481","type":"RC"},{"code":"C9605","type":"HCPCS"}],"standard_charges":[{"gross_charge":11877.0,"discounted_cash":6532.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Revasc Ac Occ Coron De Stnt W Mi Sng Vsl","code_information":[{"code":"818272","type":"CDM"},{"code":"481","type":"RC"},{"code":"C9606","type":"HCPCS"}],"standard_charges":[{"gross_charge":13763.0,"discounted_cash":7569.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Revasc Ch Occ Coron De Stnt Sngl Vessel","code_information":[{"code":"818273","type":"CDM"},{"code":"481","type":"RC"},{"code":"C9607","type":"HCPCS"}],"standard_charges":[{"gross_charge":13964.0,"discounted_cash":7680.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Revasc Ch Occ Coron W De Stnt Ea Add Vsl","code_information":[{"code":"818274","type":"CDM"},{"code":"481","type":"RC"},{"code":"C9608","type":"HCPCS"}],"standard_charges":[{"gross_charge":12052.0,"discounted_cash":6628.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Pl Cath Thor Aort Nonslct Angio W S&I","code_information":[{"code":"818275","type":"CDM"},{"code":"361","type":"RC"},{"code":"36221","type":"HCPCS"}],"standard_charges":[{"gross_charge":7194.0,"discounted_cash":3956.7,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Pl Cath Cartd Inom Uni Ang Excran W S&I","code_information":[{"code":"818276","type":"CDM"},{"code":"361","type":"RC"},{"code":"36222","type":"HCPCS"}],"standard_charges":[{"gross_charge":5870.0,"discounted_cash":3228.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Pl Cath Cartd Inom Bil Ang Excran W S&I","code_information":[{"code":"818277","type":"CDM"},{"code":"361","type":"RC"},{"code":"36222","type":"HCPCS"}],"standard_charges":[{"gross_charge":11742.0,"discounted_cash":6458.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Pl Cath Cartd Inom Uni Ang Intcran W S&I","code_information":[{"code":"818278","type":"CDM"},{"code":"361","type":"RC"},{"code":"36223","type":"HCPCS"}],"standard_charges":[{"gross_charge":7350.0,"discounted_cash":4042.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Pl Cath Cartd Inom Bil Ang Intcran W S&I","code_information":[{"code":"818279","type":"CDM"},{"code":"361","type":"RC"},{"code":"36223","type":"HCPCS"}],"standard_charges":[{"gross_charge":14701.0,"discounted_cash":8085.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Pl Cath Int Cartd Uni Ang Intcran W S&I","code_information":[{"code":"818280","type":"CDM"},{"code":"361","type":"RC"},{"code":"36224","type":"HCPCS"}],"standard_charges":[{"gross_charge":7314.0,"discounted_cash":4022.7,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Pl Cath Int Cartd Bil Ang Intcran W S&I","code_information":[{"code":"818281","type":"CDM"},{"code":"361","type":"RC"},{"code":"36224","type":"HCPCS"}],"standard_charges":[{"gross_charge":14629.0,"discounted_cash":8045.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Pl Cath Subclv Inom Uni Angio Vert W S&I","code_information":[{"code":"818282","type":"CDM"},{"code":"361","type":"RC"},{"code":"36225","type":"HCPCS"}],"standard_charges":[{"gross_charge":6019.0,"discounted_cash":3310.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Pl Cath Subclv Inom Bil Angio Vert W S&I","code_information":[{"code":"818283","type":"CDM"},{"code":"361","type":"RC"},{"code":"36225","type":"HCPCS"}],"standard_charges":[{"gross_charge":12038.0,"discounted_cash":6620.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Pl Cath Vertebral Artery Uni Angio W S&I","code_information":[{"code":"818284","type":"CDM"},{"code":"361","type":"RC"},{"code":"36226","type":"HCPCS"}],"standard_charges":[{"gross_charge":7457.0,"discounted_cash":4101.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Pl Cath Vertebral Artery Bil Angio W S&I","code_information":[{"code":"818285","type":"CDM"},{"code":"361","type":"RC"},{"code":"36226","type":"HCPCS"}],"standard_charges":[{"gross_charge":14914.0,"discounted_cash":8202.7,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Pl Cath External Carotid Uni Angio W S&I","code_information":[{"code":"818286","type":"CDM"},{"code":"361","type":"RC"},{"code":"36227","type":"HCPCS"}],"standard_charges":[{"gross_charge":3865.0,"discounted_cash":2125.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Pl Cath External Carotid Bil Angio W S&I","code_information":[{"code":"818287","type":"CDM"},{"code":"361","type":"RC"},{"code":"36227","type":"HCPCS"}],"standard_charges":[{"gross_charge":7732.0,"discounted_cash":4252.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Rmvl Intravasc Fb Transcath Percut W S&I","code_information":[{"code":"818289","type":"CDM"},{"code":"481","type":"RC"},{"code":"37197","type":"HCPCS"}],"standard_charges":[{"gross_charge":6591.0,"discounted_cash":3625.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Transcath Art Inf Thromb Noncor Init Day","code_information":[{"code":"818290","type":"CDM"},{"code":"361","type":"RC"},{"code":"37211","type":"HCPCS"}],"standard_charges":[{"gross_charge":5253.0,"discounted_cash":2889.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Transcath Ven Inf Thromb Noncor Init Day","code_information":[{"code":"818291","type":"CDM"},{"code":"361","type":"RC"},{"code":"37212","type":"HCPCS"}],"standard_charges":[{"gross_charge":3137.0,"discounted_cash":1725.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Transcath Inf Thromb Noncor Subsq Day","code_information":[{"code":"818292","type":"CDM"},{"code":"361","type":"RC"},{"code":"37213","type":"HCPCS"}],"standard_charges":[{"gross_charge":6040.0,"discounted_cash":3322.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Transcath Inf Thromb Noncor Last Day","code_information":[{"code":"818293","type":"CDM"},{"code":"361","type":"RC"},{"code":"37214","type":"HCPCS"}],"standard_charges":[{"gross_charge":5049.0,"discounted_cash":2776.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Thoracentesis Wo Imaging","code_information":[{"code":"818294","type":"CDM"},{"code":"361","type":"RC"},{"code":"32554","type":"HCPCS"}],"standard_charges":[{"gross_charge":1938.0,"discounted_cash":1065.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Thoracentesis W Imaging","code_information":[{"code":"818295","type":"CDM"},{"code":"361","type":"RC"},{"code":"32555","type":"HCPCS"}],"standard_charges":[{"gross_charge":2727.0,"discounted_cash":1499.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Drain Pleura W Cath Wo Imaging","code_information":[{"code":"818296","type":"CDM"},{"code":"361","type":"RC"},{"code":"32556","type":"HCPCS"}],"standard_charges":[{"gross_charge":2273.0,"discounted_cash":1250.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Drain Pleura W Cath W Imaging","code_information":[{"code":"818297","type":"CDM"},{"code":"361","type":"RC"},{"code":"32557","type":"HCPCS"}],"standard_charges":[{"gross_charge":2827.0,"discounted_cash":1554.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Chemodenerv Musc For Migraine","code_information":[{"code":"818298","type":"CDM"},{"code":"361","type":"RC"},{"code":"64615","type":"HCPCS"}],"standard_charges":[{"gross_charge":1513.0,"discounted_cash":832.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Tavr Prosthetic Perc Femoral","code_information":[{"code":"818332","type":"CDM"},{"code":"360","type":"RC"},{"code":"33361","type":"HCPCS"}],"standard_charges":[{"gross_charge":30000.0,"discounted_cash":16500.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Tavr Prosthetic Open Axillary","code_information":[{"code":"818334","type":"CDM"},{"code":"360","type":"RC"},{"code":"33363","type":"HCPCS"}],"standard_charges":[{"gross_charge":45950.0,"discounted_cash":25272.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Psych Diag Eval W Med Srvcs","code_information":[{"code":"818337","type":"CDM"},{"code":"900","type":"RC"},{"code":"90792","type":"HCPCS"}],"standard_charges":[{"gross_charge":356.0,"discounted_cash":195.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Psychotherapy W Pt 60 Min","code_information":[{"code":"818338","type":"CDM"},{"code":"905","type":"RC"},{"code":"90837","type":"HCPCS"}],"standard_charges":[{"gross_charge":238.0,"discounted_cash":130.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Interactive Complexity Add On","code_information":[{"code":"818417","type":"CDM"},{"code":"914","type":"RC"},{"code":"90785","type":"HCPCS"}],"standard_charges":[{"gross_charge":81.0,"discounted_cash":44.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Noncdm Charge Record","code_information":[{"code":"818419","type":"CDM"},{"code":"922","type":"RC"},{"code":"95908","type":"HCPCS"}],"standard_charges":[{"gross_charge":782.4,"discounted_cash":430.32,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Noncdm Charge Record","code_information":[{"code":"818420","type":"CDM"},{"code":"922","type":"RC"},{"code":"95909","type":"HCPCS"}],"standard_charges":[{"gross_charge":936.6,"discounted_cash":515.13,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Noncdm Charge Record","code_information":[{"code":"818421","type":"CDM"},{"code":"922","type":"RC"},{"code":"95910","type":"HCPCS"}],"standard_charges":[{"gross_charge":1384.5,"discounted_cash":761.48,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Noncdm Charge Record","code_information":[{"code":"818422","type":"CDM"},{"code":"922","type":"RC"},{"code":"95911","type":"HCPCS"}],"standard_charges":[{"gross_charge":1619.89,"discounted_cash":890.94,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Noncdm Charge Record","code_information":[{"code":"818423","type":"CDM"},{"code":"922","type":"RC"},{"code":"95912","type":"HCPCS"}],"standard_charges":[{"gross_charge":1876.72,"discounted_cash":1032.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Noncdm Charge Record","code_information":[{"code":"818424","type":"CDM"},{"code":"922","type":"RC"},{"code":"95913","type":"HCPCS"}],"standard_charges":[{"gross_charge":2413.43,"discounted_cash":1327.39,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Hc Parathyroid Planar W Spect","code_information":[{"code":"818425","type":"CDM"},{"code":"341","type":"RC"},{"code":"78071","type":"HCPCS"}],"standard_charges":[{"gross_charge":3520.0,"discounted_cash":1936.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Thoracentesis Wo Imaging","code_information":[{"code":"818431","type":"CDM"},{"code":"450","type":"RC"},{"code":"32554","type":"HCPCS"}],"standard_charges":[{"gross_charge":2229.0,"discounted_cash":1225.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Thoracentesis W Imaging","code_information":[{"code":"818432","type":"CDM"},{"code":"450","type":"RC"},{"code":"32555","type":"HCPCS"}],"standard_charges":[{"gross_charge":3135.0,"discounted_cash":1724.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Destrct Lesn Malig Tk Ext 0.6-1.0Cm","code_information":[{"code":"818440","type":"CDM"},{"code":"361","type":"RC"},{"code":"17261","type":"HCPCS"}],"standard_charges":[{"gross_charge":861.0,"discounted_cash":473.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc C Motor Evoked Upr And Lwr Limbs","code_information":[{"code":"818448","type":"CDM"},{"code":"922","type":"RC"},{"code":"95939","type":"HCPCS"}],"standard_charges":[{"gross_charge":2580.0,"discounted_cash":1419.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Noncdm Charge Record","code_information":[{"code":"818462","type":"CDM"},{"code":"361","type":"RC"},{"code":"64450","type":"HCPCS"}],"standard_charges":[{"gross_charge":2996.0,"discounted_cash":1647.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Hc Ligation Of Hemorrhoids","code_information":[{"code":"818480","type":"CDM"},{"code":"361","type":"RC"},{"code":"46221","type":"HCPCS"}],"standard_charges":[{"gross_charge":1937.0,"discounted_cash":1065.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Insert Vad Artery Access Left Heart","code_information":[{"code":"818506","type":"CDM"},{"code":"360","type":"RC"},{"code":"33990","type":"HCPCS"}],"standard_charges":[{"gross_charge":4927.0,"discounted_cash":2709.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Remove Vad Left Hrt Differnt Session","code_information":[{"code":"818508","type":"CDM"},{"code":"360","type":"RC"},{"code":"33992","type":"HCPCS"}],"standard_charges":[{"gross_charge":4623.0,"discounted_cash":2542.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Polysom <6Yrs 4 Or More Parameters","code_information":[{"code":"818509","type":"CDM"},{"code":"740","type":"RC"},{"code":"95782","type":"HCPCS"}],"standard_charges":[{"gross_charge":6888.0,"discounted_cash":3788.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Polysom <6Yrs 4 Param Cpap Bipap","code_information":[{"code":"818510","type":"CDM"},{"code":"740","type":"RC"},{"code":"95783","type":"HCPCS"}],"standard_charges":[{"gross_charge":7646.0,"discounted_cash":4205.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Bronch W Plcmt Fid Markers","code_information":[{"code":"818524","type":"CDM"},{"code":"360","type":"RC"},{"code":"31626","type":"HCPCS"}],"standard_charges":[{"gross_charge":7313.0,"discounted_cash":4022.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Canthotomy","code_information":[{"code":"818530","type":"CDM"},{"code":"450","type":"RC"},{"code":"67715","type":"HCPCS"}],"standard_charges":[{"gross_charge":6803.0,"discounted_cash":3741.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Noncdm Charge Record","code_information":[{"code":"818536","type":"CDM"},{"code":"361","type":"RC"},{"code":"57421","type":"HCPCS"}],"standard_charges":[{"gross_charge":676.0,"discounted_cash":371.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Hc Perfusion Standby Tavr/Mitraclip","code_information":[{"code":"818541","type":"CDM"},{"code":"480","type":"RC"}],"standard_charges":[{"gross_charge":4254.0,"discounted_cash":2339.7,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Reposition Vad Lt Or Rt Differnt Session","code_information":[{"code":"818542","type":"CDM"},{"code":"360","type":"RC"},{"code":"33993","type":"HCPCS"}],"standard_charges":[{"gross_charge":9822.0,"discounted_cash":5402.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Tte 2D W Stress Test Wo Contrast","code_information":[{"code":"818549","type":"CDM"},{"code":"483","type":"RC"},{"code":"93350","type":"HCPCS"}],"standard_charges":[{"gross_charge":1569.0,"discounted_cash":862.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Tx Fx Post Maleous Closed W Manip","code_information":[{"code":"818600","type":"CDM"},{"code":"450","type":"RC"},{"code":"27768","type":"HCPCS"}],"standard_charges":[{"gross_charge":5657.0,"discounted_cash":3111.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Remv Art Clot Iliac-Pop Leg Incis","code_information":[{"code":"818608","type":"CDM"},{"code":"361","type":"RC"},{"code":"34201","type":"HCPCS"}],"standard_charges":[{"gross_charge":6979.0,"discounted_cash":3838.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Psychother 30Min W Pt And Em Service","code_information":[{"code":"818609","type":"CDM"},{"code":"914","type":"RC"},{"code":"90833","type":"HCPCS"}],"standard_charges":[{"gross_charge":169.0,"discounted_cash":92.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Psychother 45Min W Pt And Em Service","code_information":[{"code":"818610","type":"CDM"},{"code":"914","type":"RC"},{"code":"90836","type":"HCPCS"}],"standard_charges":[{"gross_charge":173.0,"discounted_cash":95.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Psychother 60Min W Pt And Em Service","code_information":[{"code":"818611","type":"CDM"},{"code":"914","type":"RC"},{"code":"90838","type":"HCPCS"}],"standard_charges":[{"gross_charge":215.0,"discounted_cash":118.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Psychotherapy For Crisis Initial 60 Min","code_information":[{"code":"818612","type":"CDM"},{"code":"905","type":"RC"},{"code":"90839","type":"HCPCS"}],"standard_charges":[{"gross_charge":238.0,"discounted_cash":130.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Psychotherapy For Crisis Ea Addl 30 Min","code_information":[{"code":"818613","type":"CDM"},{"code":"905","type":"RC"},{"code":"90840","type":"HCPCS"}],"standard_charges":[{"gross_charge":169.0,"discounted_cash":92.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Multip Family-Group Psychotherapy","code_information":[{"code":"818615","type":"CDM"},{"code":"905","type":"RC"},{"code":"90849","type":"HCPCS"}],"standard_charges":[{"gross_charge":171.0,"discounted_cash":94.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Hyperbaric Oxygen Therapy Pr Session","code_information":[{"code":"818620","type":"CDM"},{"code":"413","type":"RC"},{"code":"99183","type":"HCPCS"}],"standard_charges":[{"gross_charge":2658.0,"discounted_cash":1461.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Cath Midline Basic Kit","code_information":[{"code":"818642","type":"CDM"},{"code":"278","type":"RC"},{"code":"C1751","type":"HCPCS"}],"standard_charges":[{"gross_charge":316.3,"discounted_cash":173.96,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."},{"gross_charge":316.81,"discounted_cash":174.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Hc Lens Iol Astigmatism Correcting","code_information":[{"code":"818645","type":"CDM"},{"code":"276","type":"RC"},{"code":"V2787","type":"HCPCS"}],"standard_charges":[{"gross_charge":589.25,"discounted_cash":324.09,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"},{"gross_charge":576.79,"discounted_cash":317.23,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Hc Lens Iol Tri Presbyopia Correcting","code_information":[{"code":"818646","type":"CDM"},{"code":"276","type":"RC"},{"code":"V2788","type":"HCPCS"}],"standard_charges":[{"gross_charge":1183.04,"discounted_cash":650.67,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"},{"gross_charge":1163.44,"discounted_cash":639.89,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Hc Lens Iol Presbyopia Correcting","code_information":[{"code":"818647","type":"CDM"},{"code":"276","type":"RC"},{"code":"V2788","type":"HCPCS"}],"standard_charges":[{"gross_charge":1088.8,"discounted_cash":598.84,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"},{"gross_charge":1064.33,"discounted_cash":585.38,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Hc Ko W Condyl Pads Jnts","code_information":[{"code":"818663","type":"CDM"},{"code":"274","type":"RC"},{"code":"L1820","type":"HCPCS"}],"standard_charges":[{"gross_charge":199.82,"discounted_cash":109.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"},{"gross_charge":195.33,"discounted_cash":107.43,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Hc Ko W Adj Flexext Rotator Cus","code_information":[{"code":"818666","type":"CDM"},{"code":"274","type":"RC"},{"code":"L1845","type":"HCPCS"}],"standard_charges":[{"gross_charge":1197.8,"discounted_cash":658.79,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"},{"gross_charge":1170.87,"discounted_cash":643.98,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Hc Thromboendartectmy Femoral Common","code_information":[{"code":"818705","type":"CDM"},{"code":"360","type":"RC"},{"code":"35371","type":"HCPCS"}],"standard_charges":[{"gross_charge":4940.0,"discounted_cash":2717.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Lab Cooximetry Arterial Poct (Ip) Beaker","code_information":[{"code":"818717","type":"CDM"},{"code":"301","type":"RC"},{"code":"82810","type":"HCPCS"}],"standard_charges":[{"gross_charge":99.0,"discounted_cash":54.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Cardiac Rehab Visit Level 2","code_information":[{"code":"818745","type":"CDM"},{"code":"510","type":"RC"},{"code":"99212","type":"HCPCS"}],"standard_charges":[{"gross_charge":165.0,"discounted_cash":90.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Cardiac Rehab Visit Level 3","code_information":[{"code":"818746","type":"CDM"},{"code":"510","type":"RC"},{"code":"99213","type":"HCPCS"}],"standard_charges":[{"gross_charge":219.0,"discounted_cash":120.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Cardiac Rehab Visit Level 4","code_information":[{"code":"818747","type":"CDM"},{"code":"510","type":"RC"},{"code":"99214","type":"HCPCS"}],"standard_charges":[{"gross_charge":328.0,"discounted_cash":180.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Cardiac Rehab Visit Level 5","code_information":[{"code":"818748","type":"CDM"},{"code":"510","type":"RC"},{"code":"99215","type":"HCPCS"}],"standard_charges":[{"gross_charge":486.0,"discounted_cash":267.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Insert Arterial Cath Cannul Percut","code_information":[{"code":"818765","type":"CDM"},{"code":"450","type":"RC"},{"code":"36620","type":"HCPCS"}],"standard_charges":[{"gross_charge":361.0,"discounted_cash":198.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Telemedicine Facility Fee","code_information":[{"code":"818766","type":"CDM"},{"code":"780","type":"RC"},{"code":"Q3014","type":"HCPCS"}],"standard_charges":[{"gross_charge":79.0,"discounted_cash":43.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Noncdm Charge Record","code_information":[{"code":"818772","type":"CDM"},{"code":"510","type":"RC"},{"code":"99495","type":"HCPCS"}],"standard_charges":[{"gross_charge":349.85,"discounted_cash":192.42,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Noncdm Charge Record","code_information":[{"code":"818773","type":"CDM"},{"code":"510","type":"RC"},{"code":"99496","type":"HCPCS"}],"standard_charges":[{"gross_charge":513.13,"discounted_cash":282.22,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Hc Cystourethroscopy","code_information":[{"code":"818849","type":"CDM"},{"code":"361","type":"RC"},{"code":"52000","type":"HCPCS"}],"standard_charges":[{"gross_charge":1548.0,"discounted_cash":851.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Zoledronic Acid IV Soln 5 MG/100ML","drug_information":{"unit":100.0,"type":"ML"},"code_information":[{"code":"81913","type":"CDM"},{"code":"72266015201","type":"NDC"}],"standard_charges":[{"gross_charge":543.82,"discounted_cash":299.10,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Hc Marker Rfid Tag Breast","code_information":[{"code":"819151","type":"CDM"},{"code":"278","type":"RC"},{"code":"C1819","type":"HCPCS"}],"standard_charges":[{"gross_charge":769.81,"discounted_cash":423.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"},{"gross_charge":758.27,"discounted_cash":417.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Hc Surgicel","code_information":[{"code":"819278","type":"CDM"},{"code":"272","type":"RC"}],"standard_charges":[{"gross_charge":531.34,"discounted_cash":292.24,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Eval Voice Prosth Device","code_information":[{"code":"819449","type":"CDM"},{"code":"444","type":"RC"},{"code":"92597","type":"HCPCS"}],"standard_charges":[{"gross_charge":680.0,"discounted_cash":374.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ot Srvcs W Php Iop Per Session >=45Min","code_information":[{"code":"819466","type":"CDM"},{"code":"430","type":"RC"},{"code":"G0129","type":"HCPCS"}],"standard_charges":[{"gross_charge":155.0,"discounted_cash":85.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Dil Ureth Strict Sound Male Initial","code_information":[{"code":"819483","type":"CDM"},{"code":"450","type":"RC"},{"code":"53600","type":"HCPCS"}],"standard_charges":[{"gross_charge":1153.0,"discounted_cash":634.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Tx Disloc Patella W Anes Closed","code_information":[{"code":"819484","type":"CDM"},{"code":"450","type":"RC"},{"code":"27562","type":"HCPCS"}],"standard_charges":[{"gross_charge":1053.0,"discounted_cash":579.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Interrogate Device  Pm Remote <=90Day","code_information":[{"code":"819485","type":"CDM"},{"code":"450","type":"RC"},{"code":"93294","type":"HCPCS"}],"standard_charges":[{"gross_charge":120.0,"discounted_cash":66.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Eval Device Program Pm Dual","code_information":[{"code":"819486","type":"CDM"},{"code":"450","type":"RC"},{"code":"93280","type":"HCPCS"}],"standard_charges":[{"gross_charge":239.0,"discounted_cash":131.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Interrogate Device Pm Or Leadls Pm","code_information":[{"code":"819487","type":"CDM"},{"code":"450","type":"RC"},{"code":"93288","type":"HCPCS"}],"standard_charges":[{"gross_charge":260.0,"discounted_cash":143.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Fine Needle Aspir Wo Imaging 1St Lesn","code_information":[{"code":"819492","type":"CDM"},{"code":"450","type":"RC"},{"code":"10021","type":"HCPCS"}],"standard_charges":[{"gross_charge":1332.0,"discounted_cash":732.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Inj Aa Strd Greater Occipital Nerve","code_information":[{"code":"819495","type":"CDM"},{"code":"450","type":"RC"},{"code":"64405","type":"HCPCS"}],"standard_charges":[{"gross_charge":1441.0,"discounted_cash":792.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Inject Tndn Origin Insert","code_information":[{"code":"819496","type":"CDM"},{"code":"450","type":"RC"},{"code":"20551","type":"HCPCS"}],"standard_charges":[{"gross_charge":1353.0,"discounted_cash":744.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Nasopharyngoscopy","code_information":[{"code":"819498","type":"CDM"},{"code":"450","type":"RC"},{"code":"92511","type":"HCPCS"}],"standard_charges":[{"gross_charge":418.0,"discounted_cash":229.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Proc Tongue Floor Mouth Unlisted","code_information":[{"code":"819506","type":"CDM"},{"code":"450","type":"RC"},{"code":"41599","type":"HCPCS"}],"standard_charges":[{"gross_charge":677.0,"discounted_cash":372.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Tx Miscarriage Incmplt Surg Any Tri","code_information":[{"code":"819507","type":"CDM"},{"code":"450","type":"RC"},{"code":"59812","type":"HCPCS"}],"standard_charges":[{"gross_charge":10797.0,"discounted_cash":5938.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ed Procedure Humerus Elbow Unlisted","code_information":[{"code":"819509","type":"CDM"},{"code":"450","type":"RC"},{"code":"24999","type":"HCPCS"}],"standard_charges":[{"gross_charge":724.0,"discounted_cash":398.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Bilirubin Total Transcut Poc (Ip) Beaker","code_information":[{"code":"819673","type":"CDM"},{"code":"301","type":"RC"},{"code":"88720","type":"HCPCS"}],"standard_charges":[{"gross_charge":21.0,"discounted_cash":11.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Recovery C Section","code_information":[{"code":"819683","type":"CDM"},{"code":"710","type":"RC"}],"standard_charges":[{"gross_charge":480.0,"discounted_cash":264.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Ekg Screening 12 Leads Tracing Only","code_information":[{"code":"819689","type":"CDM"},{"code":"730","type":"RC"},{"code":"G0404","type":"HCPCS"}],"standard_charges":[{"gross_charge":310.0,"discounted_cash":170.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Iodine Tincture","drug_information":{"unit":30.0,"type":"ML"},"code_information":[{"code":"82040","type":"CDM"},{"code":"87701040390","type":"NDC"}],"standard_charges":[{"gross_charge":25.86,"discounted_cash":14.22,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Fluorouracil IV Soln 2.5 GM/50ML (50 MG/ML)","drug_information":{"unit":50.0,"type":"ML"},"code_information":[{"code":"82269","type":"CDM"},{"code":"63323011758","type":"NDC"}],"standard_charges":[{"gross_charge":94.64,"discounted_cash":52.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Tropicamide Ophth Soln 1%","drug_information":{"unit":15.0,"type":"ML"},"code_information":[{"code":"8250","type":"CDM"},{"code":"70069012101","type":"NDC"}],"standard_charges":[{"gross_charge":154.16,"discounted_cash":84.79,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Tropicamide Ophth Soln 1%","drug_information":{"unit":3.0,"type":"ML"},"code_information":[{"code":"8250","type":"CDM"},{"code":"61314035501","type":"NDC"}],"standard_charges":[{"gross_charge":70.9,"discounted_cash":39.00,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Tuberculin PPD Inj 5 Unit/0.1ML","drug_information":{"unit":0.1,"type":"ML"},"code_information":[{"code":"8259","type":"CDM"},{"code":"49281075222","type":"NDC"}],"standard_charges":[{"gross_charge":52.11,"discounted_cash":28.66,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Tuberculin PPD Inj 5 Unit/0.1ML","drug_information":{"unit":0.1,"type":"ML"},"code_information":[{"code":"8259","type":"CDM"},{"code":"49281075221","type":"NDC"}],"standard_charges":[{"gross_charge":58.08,"discounted_cash":31.94,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Budesonide-Formoterol Fumarate Dihyd Aerosol 80-4.5 MCG/ACT","drug_information":{"unit":6.9,"type":"GM"},"code_information":[{"code":"82601","type":"CDM"},{"code":"186037228","type":"NDC"}],"standard_charges":[{"gross_charge":473.73,"discounted_cash":260.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Budesonide-Formoterol Fumarate Dihyd Aerosol 160-4.5 MCG/ACT","drug_information":{"unit":6.0,"type":"GM"},"code_information":[{"code":"82602","type":"CDM"},{"code":"186037028","type":"NDC"}],"standard_charges":[{"gross_charge":252.35,"discounted_cash":138.79,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Budesonide-Formoterol Fumarate Dihyd Aerosol 160-4.5 MCG/ACT","drug_information":{"unit":10.3,"type":"GM"},"code_information":[{"code":"82602","type":"CDM"},{"code":"378750332","type":"NDC"}],"standard_charges":[{"gross_charge":582.68,"discounted_cash":320.47,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Glucose Gel 40%","drug_information":{"unit":37.5,"type":"GM"},"code_information":[{"code":"82615","type":"CDM"},{"code":"574006930","type":"NDC"}],"standard_charges":[{"gross_charge":9.12,"discounted_cash":5.02,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Esmolol HCl Inj 100 MG/10ML","drug_information":{"unit":8.0,"type":"ML"},"code_information":[{"code":"82868","type":"CDM"},{"code":"67457018200","type":"NDC"}],"standard_charges":[{"gross_charge":25.3,"discounted_cash":13.92,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Esmolol HCl Inj 100 MG/10ML","drug_information":{"unit":8.0,"type":"ML"},"code_information":[{"code":"82868","type":"CDM"},{"code":"67457018210","type":"NDC"}],"standard_charges":[{"gross_charge":25.3,"discounted_cash":13.92,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Hp Applic Splint Long Arm","code_information":[{"code":"830013","type":"CDM"},{"code":"960","type":"RC"},{"code":"29105","type":"HCPCS"}],"standard_charges":[{"gross_charge":528.0,"discounted_cash":290.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hp Applic Splint Long Leg","code_information":[{"code":"830014","type":"CDM"},{"code":"960","type":"RC"},{"code":"29505","type":"HCPCS"}],"standard_charges":[{"gross_charge":480.0,"discounted_cash":264.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hp Applic Splint Short Arm Static","code_information":[{"code":"830015","type":"CDM"},{"code":"960","type":"RC"},{"code":"29125","type":"HCPCS"}],"standard_charges":[{"gross_charge":345.0,"discounted_cash":189.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hp Applic Splint Short Leg","code_information":[{"code":"830016","type":"CDM"},{"code":"960","type":"RC"},{"code":"29515","type":"HCPCS"}],"standard_charges":[{"gross_charge":392.0,"discounted_cash":215.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hp Cardiopulmonary Resuscitation","code_information":[{"code":"830019","type":"CDM"},{"code":"960","type":"RC"},{"code":"92950","type":"HCPCS"}],"standard_charges":[{"gross_charge":1218.0,"discounted_cash":669.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hp Control Epistaxis Ant Smpl","code_information":[{"code":"830024","type":"CDM"},{"code":"960","type":"RC"},{"code":"30901","type":"HCPCS"}],"standard_charges":[{"gross_charge":702.0,"discounted_cash":386.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hp Critical Care Addl 30 Min","code_information":[{"code":"830025","type":"CDM"},{"code":"960","type":"RC"},{"code":"99292","type":"HCPCS"}],"standard_charges":[{"gross_charge":522.0,"discounted_cash":287.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hp Critical Care E/M 30-74 Min","code_information":[{"code":"830026","type":"CDM"},{"code":"960","type":"RC"},{"code":"99291","type":"HCPCS"}],"standard_charges":[{"gross_charge":994.0,"discounted_cash":546.7,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hp Emergency Dept Visit Level 2","code_information":[{"code":"830031","type":"CDM"},{"code":"981","type":"RC"},{"code":"99282","type":"HCPCS"}],"standard_charges":[{"gross_charge":296.0,"discounted_cash":162.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hp Emergency Dept Visit Level 3","code_information":[{"code":"830033","type":"CDM"},{"code":"981","type":"RC"},{"code":"99283","type":"HCPCS"}],"standard_charges":[{"gross_charge":436.0,"discounted_cash":239.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hp Emergency Dept Visit Level 4","code_information":[{"code":"830035","type":"CDM"},{"code":"981","type":"RC"},{"code":"99284","type":"HCPCS"}],"standard_charges":[{"gross_charge":651.0,"discounted_cash":358.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hp Emergency Dept Visit Level 5","code_information":[{"code":"830037","type":"CDM"},{"code":"981","type":"RC"},{"code":"99285","type":"HCPCS"}],"standard_charges":[{"gross_charge":951.0,"discounted_cash":523.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hp Evac Subungal Hematoma","code_information":[{"code":"830040","type":"CDM"},{"code":"960","type":"RC"},{"code":"11740","type":"HCPCS"}],"standard_charges":[{"gross_charge":263.0,"discounted_cash":144.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hp Exc Wedge Skin Nail Fold","code_information":[{"code":"830041","type":"CDM"},{"code":"960","type":"RC"},{"code":"11765","type":"HCPCS"}],"standard_charges":[{"gross_charge":557.0,"discounted_cash":306.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hp Inj Aa Strd Peripheral Nerve Other","code_information":[{"code":"830052","type":"CDM"},{"code":"960","type":"RC"},{"code":"64450","type":"HCPCS"}],"standard_charges":[{"gross_charge":868.0,"discounted_cash":477.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hp Insert Non Tun Cvc >=5 Yrs","code_information":[{"code":"830054","type":"CDM"},{"code":"960","type":"RC"},{"code":"36556","type":"HCPCS"}],"standard_charges":[{"gross_charge":1841.0,"discounted_cash":1012.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hp Punc Asp Abcess Hematoma Cyst","code_information":[{"code":"830057","type":"CDM"},{"code":"960","type":"RC"},{"code":"10160","type":"HCPCS"}],"standard_charges":[{"gross_charge":727.0,"discounted_cash":399.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hp Remove Cerumen Impacted W Instrument Uni","code_information":[{"code":"830058","type":"CDM"},{"code":"960","type":"RC"},{"code":"69210","type":"HCPCS"}],"standard_charges":[{"gross_charge":252.0,"discounted_cash":138.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hp Rpr Face Ear Intrmd <=2.5 Cm","code_information":[{"code":"830068","type":"CDM"},{"code":"960","type":"RC"},{"code":"12051","type":"HCPCS"}],"standard_charges":[{"gross_charge":1130.0,"discounted_cash":621.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hp Rpr Face Ear Intrmd 2.6-5.0 Cm","code_information":[{"code":"830069","type":"CDM"},{"code":"960","type":"RC"},{"code":"12052","type":"HCPCS"}],"standard_charges":[{"gross_charge":557.0,"discounted_cash":306.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hp Rpr Face Ear Intrmd 7.6-12.5 Cm","code_information":[{"code":"830071","type":"CDM"},{"code":"960","type":"RC"},{"code":"12054","type":"HCPCS"}],"standard_charges":[{"gross_charge":1310.0,"discounted_cash":720.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hp Rpr Face Ear Smpl <=2.5Cm","code_information":[{"code":"830072","type":"CDM"},{"code":"960","type":"RC"},{"code":"12011","type":"HCPCS"}],"standard_charges":[{"gross_charge":939.0,"discounted_cash":516.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hp Rpr Face Ear Smpl 2.6-5 Cm","code_information":[{"code":"830074","type":"CDM"},{"code":"960","type":"RC"},{"code":"12013","type":"HCPCS"}],"standard_charges":[{"gross_charge":1089.0,"discounted_cash":598.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hp Rpr Face Ear Smpl 5.1-7.5 Cm","code_information":[{"code":"830075","type":"CDM"},{"code":"960","type":"RC"},{"code":"12014","type":"HCPCS"}],"standard_charges":[{"gross_charge":1193.0,"discounted_cash":656.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hp Rpr Face Ear Smpl 7.6-12.5 Cm","code_information":[{"code":"830076","type":"CDM"},{"code":"960","type":"RC"},{"code":"12015","type":"HCPCS"}],"standard_charges":[{"gross_charge":581.0,"discounted_cash":319.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hp Rpr Nk/Hd/Ft/Gen Intrmd 7.6-12.5 Cm","code_information":[{"code":"830083","type":"CDM"},{"code":"960","type":"RC"},{"code":"12044","type":"HCPCS"}],"standard_charges":[{"gross_charge":1511.0,"discounted_cash":831.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hp Rpr Sclp Extrm Cmplx 2.6-7.5 Cm","code_information":[{"code":"830084","type":"CDM"},{"code":"960","type":"RC"},{"code":"13121","type":"HCPCS"}],"standard_charges":[{"gross_charge":805.0,"discounted_cash":442.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hp Rpr Sclp Extrm Cmplx Ea Addl 5 Cm","code_information":[{"code":"830085","type":"CDM"},{"code":"960","type":"RC"},{"code":"13122","type":"HCPCS"}],"standard_charges":[{"gross_charge":2081.0,"discounted_cash":1144.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hp Rpr Sclp/Trnk/Extrem Intermed <=2.5 Cm","code_information":[{"code":"830086","type":"CDM"},{"code":"960","type":"RC"},{"code":"12031","type":"HCPCS"}],"standard_charges":[{"gross_charge":1166.0,"discounted_cash":641.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hp Rpr Sclp/Trnk/Extrm Intrmd 2.6-7.5 Cm","code_information":[{"code":"830088","type":"CDM"},{"code":"960","type":"RC"},{"code":"12032","type":"HCPCS"}],"standard_charges":[{"gross_charge":205.0,"discounted_cash":112.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hp Rpr Sclp/Trnk/Extrm Smpl <= 2.5Cm","code_information":[{"code":"830091","type":"CDM"},{"code":"960","type":"RC"},{"code":"12001","type":"HCPCS"}],"standard_charges":[{"gross_charge":783.0,"discounted_cash":430.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hp Rpr Sclp/Trnk/Extrm Smpl 12.6-20 Cm","code_information":[{"code":"830093","type":"CDM"},{"code":"960","type":"RC"},{"code":"12005","type":"HCPCS"}],"standard_charges":[{"gross_charge":177.0,"discounted_cash":97.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hp Rpr Sclp/Trnk/Extrm Smpl 2.6-7.5 Cm","code_information":[{"code":"830094","type":"CDM"},{"code":"960","type":"RC"},{"code":"12002","type":"HCPCS"}],"standard_charges":[{"gross_charge":939.0,"discounted_cash":516.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hp Rpr Sclp/Trnk/Extrm Smpl 20.1-30 Cm","code_information":[{"code":"830095","type":"CDM"},{"code":"960","type":"RC"},{"code":"12006","type":"HCPCS"}],"standard_charges":[{"gross_charge":1033.0,"discounted_cash":568.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hp Office/Outpt Visit Est Level Iv","code_information":[{"code":"830206","type":"CDM"},{"code":"960","type":"RC"},{"code":"99214","type":"HCPCS"}],"standard_charges":[{"gross_charge":332.0,"discounted_cash":182.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hp Id Abscess Smpl Sngl","code_information":[{"code":"830239","type":"CDM"},{"code":"960","type":"RC"},{"code":"10060","type":"HCPCS"}],"standard_charges":[{"gross_charge":572.0,"discounted_cash":314.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hp Id Abscess Complex Or Multiple","code_information":[{"code":"830241","type":"CDM"},{"code":"960","type":"RC"},{"code":"10061","type":"HCPCS"}],"standard_charges":[{"gross_charge":935.0,"discounted_cash":514.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hp Rpr Sclp/Trnk/Extrm Smp 7.6-12.5 Cm Cc","code_information":[{"code":"830247","type":"CDM"},{"code":"960","type":"RC"},{"code":"12004","type":"HCPCS"}],"standard_charges":[{"gross_charge":1020.0,"discounted_cash":561.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hp Insert Cath Temp Indwel Bladder Smpl","code_information":[{"code":"830289","type":"CDM"},{"code":"960","type":"RC"},{"code":"51702","type":"HCPCS"}],"standard_charges":[{"gross_charge":522.0,"discounted_cash":287.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hp Cardioversion Elective External Cc","code_information":[{"code":"830314","type":"CDM"},{"code":"960","type":"RC"},{"code":"92960","type":"HCPCS"}],"standard_charges":[{"gross_charge":1102.0,"discounted_cash":606.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hp I&D Of Vulva Or Perineal Abscess","code_information":[{"code":"830336","type":"CDM"},{"code":"960","type":"RC"},{"code":"56405","type":"HCPCS"}],"standard_charges":[{"gross_charge":868.0,"discounted_cash":477.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hp I&D Bartholin Gland Abscess","code_information":[{"code":"830366","type":"CDM"},{"code":"960","type":"RC"},{"code":"56420","type":"HCPCS"}],"standard_charges":[{"gross_charge":931.0,"discounted_cash":512.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hp Avulsion Nail Plate Sple Sgl","code_information":[{"code":"830396","type":"CDM"},{"code":"960","type":"RC"},{"code":"11730","type":"HCPCS"}],"standard_charges":[{"gross_charge":467.0,"discounted_cash":256.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hp Disloc Fngr Ip Cls Tx No Anes","code_information":[{"code":"830407","type":"CDM"},{"code":"960","type":"RC"},{"code":"26770","type":"HCPCS"}],"standard_charges":[{"gross_charge":1805.0,"discounted_cash":992.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hp Tx Disloc Shoulder Clsd W Manip Wo Anes","code_information":[{"code":"830408","type":"CDM"},{"code":"960","type":"RC"},{"code":"23650","type":"HCPCS"}],"standard_charges":[{"gross_charge":1866.0,"discounted_cash":1026.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hp For Body Remov Ear No Anes","code_information":[{"code":"830413","type":"CDM"},{"code":"960","type":"RC"},{"code":"69200","type":"HCPCS"}],"standard_charges":[{"gross_charge":501.0,"discounted_cash":275.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hp Interosseous Needle Placement","code_information":[{"code":"830432","type":"CDM"},{"code":"960","type":"RC"},{"code":"36680","type":"HCPCS"}],"standard_charges":[{"gross_charge":790.0,"discounted_cash":434.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hp Removal Nail Finger Or Toe","code_information":[{"code":"830437","type":"CDM"},{"code":"960","type":"RC"},{"code":"11750","type":"HCPCS"}],"standard_charges":[{"gross_charge":1032.0,"discounted_cash":567.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hp Wnd Rpr Intermed Nk Hn Ft Gn 12.6-20Cm","code_information":[{"code":"830451","type":"CDM"},{"code":"960","type":"RC"},{"code":"12045","type":"HCPCS"}],"standard_charges":[{"gross_charge":1760.0,"discounted_cash":968.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hp Wnd Rpr Int Nk Hn Ft Gn 2.6-7.5 Cm","code_information":[{"code":"830453","type":"CDM"},{"code":"960","type":"RC"},{"code":"12042","type":"HCPCS"}],"standard_charges":[{"gross_charge":1296.0,"discounted_cash":712.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hp Wnd Rpr Int Sc Ax Tk Xt <2.5Cm","code_information":[{"code":"830455","type":"CDM"},{"code":"960","type":"RC"},{"code":"12031","type":"HCPCS"}],"standard_charges":[{"gross_charge":1057.0,"discounted_cash":581.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hp Splint Arm Long","code_information":[{"code":"830468","type":"CDM"},{"code":"981","type":"RC"},{"code":"29105","type":"HCPCS"}],"standard_charges":[{"gross_charge":528.0,"discounted_cash":290.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hp Splint Leg Long","code_information":[{"code":"830471","type":"CDM"},{"code":"981","type":"RC"},{"code":"29505","type":"HCPCS"}],"standard_charges":[{"gross_charge":495.0,"discounted_cash":272.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hp Wnd Rpr Int Face <=2.5Cm","code_information":[{"code":"830479","type":"CDM"},{"code":"960","type":"RC"},{"code":"12051","type":"HCPCS"}],"standard_charges":[{"gross_charge":1271.0,"discounted_cash":699.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hp Inj Trigger Point 1 Or 2 Musc","code_information":[{"code":"830503","type":"CDM"},{"code":"960","type":"RC"},{"code":"20552","type":"HCPCS"}],"standard_charges":[{"gross_charge":472.0,"discounted_cash":259.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hp Inj Sngl/Mult Trgr Pt>3 Mscl","code_information":[{"code":"830504","type":"CDM"},{"code":"960","type":"RC"},{"code":"20553","type":"HCPCS"}],"standard_charges":[{"gross_charge":418.0,"discounted_cash":229.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hp Venipuncture >=3Yrs Non Routine","code_information":[{"code":"830511","type":"CDM"},{"code":"963","type":"RC"},{"code":"36410","type":"HCPCS"}],"standard_charges":[{"gross_charge":143.0,"discounted_cash":78.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hp Arthrocentesis Joint Intermed Wo Us","code_information":[{"code":"830526","type":"CDM"},{"code":"960","type":"RC"},{"code":"20605","type":"HCPCS"}],"standard_charges":[{"gross_charge":426.0,"discounted_cash":234.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hp Arthrocentesis Joint Major Wo Us","code_information":[{"code":"830527","type":"CDM"},{"code":"960","type":"RC"},{"code":"20610","type":"HCPCS"}],"standard_charges":[{"gross_charge":484.0,"discounted_cash":266.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hp Fb Remov Cornea No Lmp","code_information":[{"code":"830530","type":"CDM"},{"code":"960","type":"RC"},{"code":"65220","type":"HCPCS"}],"standard_charges":[{"gross_charge":436.0,"discounted_cash":239.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hp Fb Remov Eye Conj Surf","code_information":[{"code":"830532","type":"CDM"},{"code":"960","type":"RC"},{"code":"65205","type":"HCPCS"}],"standard_charges":[{"gross_charge":501.0,"discounted_cash":275.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hp Wnd Rpr  Inteermd Nk Hd Ft Gen <=2.5Cm","code_information":[{"code":"830535","type":"CDM"},{"code":"960","type":"RC"},{"code":"12041","type":"HCPCS"}],"standard_charges":[{"gross_charge":1073.0,"discounted_cash":590.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hp Clsd Tx Hip Arthr Disl W/O Ans","code_information":[{"code":"830555","type":"CDM"},{"code":"960","type":"RC"},{"code":"27265","type":"HCPCS"}],"standard_charges":[{"gross_charge":2376.0,"discounted_cash":1306.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hp Tx Disloc Elbow Cls No Anes","code_information":[{"code":"830558","type":"CDM"},{"code":"960","type":"RC"},{"code":"24600","type":"HCPCS"}],"standard_charges":[{"gross_charge":689.0,"discounted_cash":378.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hp Disloc Hip Clsd Tx No Anes","code_information":[{"code":"830559","type":"CDM"},{"code":"960","type":"RC"},{"code":"27250","type":"HCPCS"}],"standard_charges":[{"gross_charge":2743.0,"discounted_cash":1508.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hp Epistaxis Cntl Post&Pack Init","code_information":[{"code":"830565","type":"CDM"},{"code":"960","type":"RC"},{"code":"30905","type":"HCPCS"}],"standard_charges":[{"gross_charge":1277.0,"discounted_cash":702.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hp Epistaxis Cntrl Anter Cmplx","code_information":[{"code":"830566","type":"CDM"},{"code":"960","type":"RC"},{"code":"30903","type":"HCPCS"}],"standard_charges":[{"gross_charge":1010.0,"discounted_cash":555.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hp Fx Phalanx Shaft Cls Tx&Manip","code_information":[{"code":"830573","type":"CDM"},{"code":"960","type":"RC"},{"code":"26725","type":"HCPCS"}],"standard_charges":[{"gross_charge":474.0,"discounted_cash":260.7,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hp Intubation Endotracheal Emergent","code_information":[{"code":"830585","type":"CDM"},{"code":"960","type":"RC"},{"code":"31500","type":"HCPCS"}],"standard_charges":[{"gross_charge":971.0,"discounted_cash":534.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hp Tx Fx Ankle Trimall Clsd W Manip","code_information":[{"code":"830591","type":"CDM"},{"code":"960","type":"RC"},{"code":"27818","type":"HCPCS"}],"standard_charges":[{"gross_charge":1067.0,"discounted_cash":586.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hp Repair Of Nail Bed","code_information":[{"code":"830601","type":"CDM"},{"code":"960","type":"RC"},{"code":"11760","type":"HCPCS"}],"standard_charges":[{"gross_charge":1153.0,"discounted_cash":634.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hp Wnd Rpr Int Sc Ax Tk Xt 12.6-20.0Mm","code_information":[{"code":"830621","type":"CDM"},{"code":"981","type":"RC"},{"code":"12035","type":"HCPCS"}],"standard_charges":[{"gross_charge":1705.0,"discounted_cash":937.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hp Office Outpt Visit Est Levl Ii","code_information":[{"code":"830630","type":"CDM"},{"code":"960","type":"RC"},{"code":"99212","type":"HCPCS"}],"standard_charges":[{"gross_charge":177.0,"discounted_cash":97.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hp Office Outpt Visit Est Levl Iii","code_information":[{"code":"830631","type":"CDM"},{"code":"960","type":"RC"},{"code":"99213","type":"HCPCS"}],"standard_charges":[{"gross_charge":256.0,"discounted_cash":140.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hp I&D Abscess Simple","code_information":[{"code":"830665","type":"CDM"},{"code":"960","type":"RC"},{"code":"26010","type":"HCPCS"}],"standard_charges":[{"gross_charge":1029.0,"discounted_cash":565.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hp I&D Cyst Pilonidal Simple","code_information":[{"code":"830669","type":"CDM"},{"code":"960","type":"RC"},{"code":"10080","type":"HCPCS"}],"standard_charges":[{"gross_charge":354.0,"discounted_cash":194.7,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hp Thoracostomy W Tube Open","code_information":[{"code":"830671","type":"CDM"},{"code":"960","type":"RC"},{"code":"32551","type":"HCPCS"}],"standard_charges":[{"gross_charge":1950.0,"discounted_cash":1072.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hp Us Guided Needle Placement","code_information":[{"code":"830675","type":"CDM"},{"code":"972","type":"RC"},{"code":"76942","type":"HCPCS"}],"standard_charges":[{"gross_charge":416.0,"discounted_cash":228.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hp Inj Tndn Ligmnt Sngl Aponeurosis","code_information":[{"code":"830723","type":"CDM"},{"code":"960","type":"RC"},{"code":"20550","type":"HCPCS"}],"standard_charges":[{"gross_charge":388.0,"discounted_cash":213.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hp Inj Aa Strd Nerve Trigeminal","code_information":[{"code":"830735","type":"CDM"},{"code":"960","type":"RC"},{"code":"64400","type":"HCPCS"}],"standard_charges":[{"gross_charge":1518.0,"discounted_cash":834.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hp Inj Aa Strd Greater Occipitl Nrv","code_information":[{"code":"830737","type":"CDM"},{"code":"960","type":"RC"},{"code":"64405","type":"HCPCS"}],"standard_charges":[{"gross_charge":47.0,"discounted_cash":25.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hp Debride Subq Tissue 1St 20 Cm Or Less","code_information":[{"code":"831478","type":"CDM"},{"code":"960","type":"RC"},{"code":"11042","type":"HCPCS"}],"standard_charges":[{"gross_charge":161.0,"discounted_cash":88.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hp Repair Lip Full Thk Vermilion Only","code_information":[{"code":"831487","type":"CDM"},{"code":"960","type":"RC"},{"code":"40650","type":"HCPCS"}],"standard_charges":[{"gross_charge":2079.0,"discounted_cash":1143.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hp Rpr Of Lac 2.5Cm Or < Fl Mth 2/3 To","code_information":[{"code":"831492","type":"CDM"},{"code":"960","type":"RC"},{"code":"41250","type":"HCPCS"}],"standard_charges":[{"gross_charge":1141.0,"discounted_cash":627.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hp Drainage Ext Ear Abscess Simple","code_information":[{"code":"831506","type":"CDM"},{"code":"960","type":"RC"},{"code":"69000","type":"HCPCS"}],"standard_charges":[{"gross_charge":739.0,"discounted_cash":406.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hp Rpr Sclp/Trnk/Extrm Intrmd 7.6-12.5 Cm","code_information":[{"code":"831510","type":"CDM"},{"code":"960","type":"RC"},{"code":"12034","type":"HCPCS"}],"standard_charges":[{"gross_charge":1357.0,"discounted_cash":746.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hp Clsd Tx Articular Fx Mcp Ip W Mani","code_information":[{"code":"831546","type":"CDM"},{"code":"960","type":"RC"},{"code":"26742","type":"HCPCS"}],"standard_charges":[{"gross_charge":3040.0,"discounted_cash":1672.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hp Tx Fx Ulnar Prox W Manip","code_information":[{"code":"832330","type":"CDM"},{"code":"960","type":"RC"},{"code":"24675","type":"HCPCS"}],"standard_charges":[{"gross_charge":3204.0,"discounted_cash":1762.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hp Clsd Red Dislocated Hip Prosth","code_information":[{"code":"833002","type":"CDM"},{"code":"960","type":"RC"},{"code":"27266","type":"HCPCS"}],"standard_charges":[{"gross_charge":1597.0,"discounted_cash":878.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hp Closure Wound W Tissue Adhesive Only","code_information":[{"code":"833271","type":"CDM"},{"code":"960","type":"RC"},{"code":"G0168","type":"HCPCS"}],"standard_charges":[{"gross_charge":746.0,"discounted_cash":410.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hp Mod Sed Same Phys Ea Addl 15 Min","code_information":[{"code":"835454","type":"CDM"},{"code":"960","type":"RC"},{"code":"99153","type":"HCPCS"}],"standard_charges":[{"gross_charge":174.0,"discounted_cash":95.7,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hp Mod Sed Same Phys 5>=Yrs Init 15 Min","code_information":[{"code":"835458","type":"CDM"},{"code":"960","type":"RC"},{"code":"99152","type":"HCPCS"}],"standard_charges":[{"gross_charge":154.0,"discounted_cash":84.7,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hp Replc Gastro Tube Wo Img Wo Rev Gi Trct","code_information":[{"code":"835759","type":"CDM"},{"code":"960","type":"RC"},{"code":"43762","type":"HCPCS"}],"standard_charges":[{"gross_charge":791.0,"discounted_cash":435.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Valproic Acid Cap 250 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"8429","type":"CDM"},{"code":"69452015020","type":"NDC"}],"standard_charges":[{"gross_charge":11.74,"discounted_cash":6.46,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Vancomycin HCl For IV Soln 500 MG (Base Equivalent)","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"8443","type":"CDM"},{"code":"25021015010","type":"NDC"}],"standard_charges":[{"gross_charge":20.46,"discounted_cash":11.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Verapamil HCl IV Soln 2.5 MG/ML","drug_information":{"unit":1.0,"type":"ML"},"code_information":[{"code":"8527","type":"CDM"},{"code":"409114411","type":"NDC"}],"standard_charges":[{"gross_charge":79.48,"discounted_cash":43.71,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Verapamil HCl IV Soln 2.5 MG/ML","drug_information":{"unit":1.0,"type":"ML"},"code_information":[{"code":"8527","type":"CDM"},{"code":"409114405","type":"NDC"}],"standard_charges":[{"gross_charge":79.47,"discounted_cash":43.71,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Verapamil HCl Tab 40 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"8529","type":"CDM"},{"code":"591040401","type":"NDC"}],"standard_charges":[{"gross_charge":9.23,"discounted_cash":5.08,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Neomycin-Bacitracin-Polymyxin Oint","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"854","type":"CDM"},{"code":"45802014370","type":"NDC"}],"standard_charges":[{"gross_charge":4.36,"discounted_cash":2.40,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Neomycin-Bacitracin-Polymyxin Oint","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"854","type":"CDM"},{"code":"45802006170","type":"NDC"}],"standard_charges":[{"gross_charge":4.36,"discounted_cash":2.40,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Bacitracin-Polymyxin B Ophth Oint","drug_information":{"unit":3.5,"type":"GM"},"code_information":[{"code":"856","type":"CDM"},{"code":"574402135","type":"NDC"}],"standard_charges":[{"gross_charge":103.2,"discounted_cash":56.76,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Bacitracin-Polymyxin B Ophth Oint","drug_information":{"unit":3.5,"type":"GM"},"code_information":[{"code":"856","type":"CDM"},{"code":"24208055555","type":"NDC"}],"standard_charges":[{"gross_charge":111.55,"discounted_cash":61.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Baclofen Tab 10 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"860","type":"CDM"},{"code":"904647561","type":"NDC"}],"standard_charges":[{"gross_charge":10.23,"discounted_cash":5.63,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Baclofen Tab 10 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"860","type":"CDM"},{"code":"832105411","type":"NDC"}],"standard_charges":[{"gross_charge":17.51,"discounted_cash":9.63,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Vitamin A Cap 3 MG (10000 Unit)","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"8639","type":"CDM"},{"code":"11845005921","type":"NDC"}],"standard_charges":[{"gross_charge":8.29,"discounted_cash":4.56,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Cyanocobalamin Tab 500 MCG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"8657","type":"CDM"},{"code":"50268085415","type":"NDC"}],"standard_charges":[{"gross_charge":9.41,"discounted_cash":5.18,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Cyanocobalamin Tab 500 MCG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"8657","type":"CDM"},{"code":"50268085411","type":"NDC"}],"standard_charges":[{"gross_charge":9.41,"discounted_cash":5.18,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Pyridoxine HCl Tab 25 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"8665","type":"CDM"},{"code":"536440601","type":"NDC"}],"standard_charges":[{"gross_charge":8.15,"discounted_cash":4.48,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Ascorbic Acid Tab 500 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"8680","type":"CDM"},{"code":"904052361","type":"NDC"}],"standard_charges":[{"gross_charge":3.05,"discounted_cash":1.68,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Warfarin Sodium Tab 2 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"8749","type":"CDM"},{"code":"832121289","type":"NDC"}],"standard_charges":[{"gross_charge":10.85,"discounted_cash":5.97,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Warfarin Sodium Tab 2 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"8749","type":"CDM"},{"code":"832121201","type":"NDC"}],"standard_charges":[{"gross_charge":10.86,"discounted_cash":5.97,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Warfarin Sodium Tab 2.5 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"8750","type":"CDM"},{"code":"68084002711","type":"NDC"}],"standard_charges":[{"gross_charge":10.83,"discounted_cash":5.96,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Warfarin Sodium Tab 2.5 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"8750","type":"CDM"},{"code":"68084002701","type":"NDC"}],"standard_charges":[{"gross_charge":10.83,"discounted_cash":5.96,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Warfarin Sodium Tab 5 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"8751","type":"CDM"},{"code":"62584099411","type":"NDC"}],"standard_charges":[{"gross_charge":10.86,"discounted_cash":5.97,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Warfarin Sodium Tab 5 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"8751","type":"CDM"},{"code":"62584099401","type":"NDC"}],"standard_charges":[{"gross_charge":10.86,"discounted_cash":5.97,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Hc Angio Extermity Bilat","code_information":[{"code":"875716","type":"CDM"},{"code":"323","type":"RC"},{"code":"75716","type":"HCPCS"}],"standard_charges":[{"gross_charge":11387.0,"discounted_cash":6262.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Fetal Biophysical Profile W Nst","code_information":[{"code":"876818","type":"CDM"},{"code":"402","type":"RC"},{"code":"76818","type":"HCPCS"}],"standard_charges":[{"gross_charge":744.0,"discounted_cash":409.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Noncdm Charge Record Medical Supplies","code_information":[{"code":"880001","type":"CDM"},{"code":"278","type":"RC"},{"code":"C1876","type":"HCPCS"}],"standard_charges":[{"gross_charge":2486.31,"discounted_cash":1367.47,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Noncdm Charge Record Medical Supplies","code_information":[{"code":"880003","type":"CDM"},{"code":"278","type":"RC"},{"code":"C1880","type":"HCPCS"}],"standard_charges":[{"gross_charge":5220.94,"discounted_cash":2871.52,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Noncdm Charge Record Medical Supplies","code_information":[{"code":"880007","type":"CDM"},{"code":"272","type":"RC"},{"code":"C1884","type":"HCPCS"}],"standard_charges":[{"gross_charge":7484.26,"discounted_cash":4116.34,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Noncdm Charge Record Medical Supplies","code_information":[{"code":"880008","type":"CDM"},{"code":"272","type":"RC"},{"code":"C1887","type":"HCPCS"}],"standard_charges":[{"gross_charge":785.26,"discounted_cash":431.89,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Noncdm Charge Record Medical Supplies","code_information":[{"code":"880009","type":"CDM"},{"code":"272","type":"RC"},{"code":"C1888","type":"HCPCS"}],"standard_charges":[{"gross_charge":2209.85,"discounted_cash":1215.42,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Noncdm Charge Record Medical Supplies","code_information":[{"code":"880010","type":"CDM"},{"code":"272","type":"RC"},{"code":"C1892","type":"HCPCS"}],"standard_charges":[{"gross_charge":128.75,"discounted_cash":70.81,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Noncdm Charge Record Medical Supplies","code_information":[{"code":"880011","type":"CDM"},{"code":"272","type":"RC"},{"code":"C1893","type":"HCPCS"}],"standard_charges":[{"gross_charge":2098.61,"discounted_cash":1154.24,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Noncdm Charge Record Medical Supplies","code_information":[{"code":"880012","type":"CDM"},{"code":"272","type":"RC"},{"code":"C1894","type":"HCPCS"}],"standard_charges":[{"gross_charge":106.86,"discounted_cash":58.77,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."},{"gross_charge":477.73,"discounted_cash":262.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Noncdm Charge Record Medical Supplies","code_information":[{"code":"880014","type":"CDM"},{"code":"278","type":"RC"},{"code":"C1896","type":"HCPCS"}],"standard_charges":[{"gross_charge":12093.75,"discounted_cash":6651.56,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Noncdm Charge Record Medical Supplies","code_information":[{"code":"880018","type":"CDM"},{"code":"278","type":"RC"},{"code":"C1777","type":"HCPCS"}],"standard_charges":[{"gross_charge":5415.74,"discounted_cash":2978.66,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Noncdm Charge Record Medical Supplies","code_information":[{"code":"880019","type":"CDM"},{"code":"278","type":"RC"},{"code":"C2615","type":"HCPCS"}],"standard_charges":[{"gross_charge":2744.39,"discounted_cash":1509.41,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Noncdm Charge Record Medical Supplies","code_information":[{"code":"880020","type":"CDM"},{"code":"278","type":"RC"},{"code":"C2617","type":"HCPCS"}],"standard_charges":[{"gross_charge":540.58,"discounted_cash":297.32,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Noncdm Charge Record Medical Supplies","code_information":[{"code":"880021","type":"CDM"},{"code":"272","type":"RC"},{"code":"C2618","type":"HCPCS"}],"standard_charges":[{"gross_charge":5455.62,"discounted_cash":3000.59,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Noncdm Charge Record Medical Supplies","code_information":[{"code":"880022","type":"CDM"},{"code":"275","type":"RC"},{"code":"C2621","type":"HCPCS"}],"standard_charges":[{"gross_charge":18060.0,"discounted_cash":9933.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Noncdm Charge Record Medical Supplies","code_information":[{"code":"880026","type":"CDM"},{"code":"272","type":"RC"},{"code":"C2630","type":"HCPCS"}],"standard_charges":[{"gross_charge":10276.91,"discounted_cash":5652.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Noncdm Charge Record Medical Supplies","code_information":[{"code":"880027","type":"CDM"},{"code":"272","type":"RC"},{"code":"C2631","type":"HCPCS"}],"standard_charges":[{"gross_charge":1299.93,"discounted_cash":714.96,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Noncdm Charge Record Medical Supplies","code_information":[{"code":"880029","type":"CDM"},{"code":"278","type":"RC"},{"code":"L8600","type":"HCPCS"}],"standard_charges":[{"gross_charge":2972.38,"discounted_cash":1634.81,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Noncdm Charge Record Medical Supplies","code_information":[{"code":"880031","type":"CDM"},{"code":"278","type":"RC"},{"code":"L8610","type":"HCPCS"}],"standard_charges":[{"gross_charge":441.9,"discounted_cash":243.04,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."},{"gross_charge":631.01,"discounted_cash":347.06,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Noncdm Charge Record Medical Supplies","code_information":[{"code":"880032","type":"CDM"},{"code":"278","type":"RC"},{"code":"L8680","type":"HCPCS"}],"standard_charges":[{"gross_charge":8431.84,"discounted_cash":4637.51,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Noncdm Charge Record Medical Supplies","code_information":[{"code":"880035","type":"CDM"},{"code":"276","type":"RC"},{"code":"V2632","type":"HCPCS"}],"standard_charges":[{"gross_charge":447.2,"discounted_cash":245.96,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."},{"gross_charge":622.97,"discounted_cash":342.63,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Noncdm Charge Record Medical Supplies","code_information":[{"code":"880037","type":"CDM"},{"code":"270","type":"RC"}],"standard_charges":[{"gross_charge":390.69,"discounted_cash":214.88,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."},{"gross_charge":305.96,"discounted_cash":168.28,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."},{"gross_charge":200.93,"discounted_cash":110.51,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Noncdm Charge Record Medical Supplies","code_information":[{"code":"880038","type":"CDM"},{"code":"271","type":"RC"}],"standard_charges":[{"gross_charge":2117.75,"discounted_cash":1164.76,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."},{"gross_charge":209.62,"discounted_cash":115.29,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."},{"gross_charge":176.72,"discounted_cash":97.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Noncdm Charge Record Medical Supplies","code_information":[{"code":"880039","type":"CDM"},{"code":"272","type":"RC"}],"standard_charges":[{"gross_charge":544.1,"discounted_cash":299.26,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."},{"gross_charge":355.47,"discounted_cash":195.51,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."},{"gross_charge":411.69,"discounted_cash":226.43,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Noncdm Charge Record Medical Supplies","code_information":[{"code":"880045","type":"CDM"},{"code":"278","type":"RC"}],"standard_charges":[{"gross_charge":638.0,"discounted_cash":350.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."},{"gross_charge":522.92,"discounted_cash":287.61,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."},{"gross_charge":1728.53,"discounted_cash":950.69,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Noncdm Charge Record Medical Supplies","code_information":[{"code":"880048","type":"CDM"},{"code":"278","type":"RC"},{"code":"C2631","type":"HCPCS"}],"standard_charges":[{"gross_charge":1307.79,"discounted_cash":719.28,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Noncdm Charge Record Medical Supplies","code_information":[{"code":"880054","type":"CDM"},{"code":"272","type":"RC"},{"code":"C1782","type":"HCPCS"}],"standard_charges":[{"gross_charge":2028.71,"discounted_cash":1115.79,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."},{"gross_charge":2302.88,"discounted_cash":1266.58,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Noncdm Charge Record Medical Supplies","code_information":[{"code":"880055","type":"CDM"},{"code":"278","type":"RC"},{"code":"C1787","type":"HCPCS"}],"standard_charges":[{"gross_charge":12754.61,"discounted_cash":7015.04,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Noncdm Charge Record Medical Supplies","code_information":[{"code":"880056","type":"CDM"},{"code":"272","type":"RC"},{"code":"C1885","type":"HCPCS"}],"standard_charges":[{"gross_charge":6315.62,"discounted_cash":3473.59,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Noncdm Charge Record Medical Supplies","code_information":[{"code":"880058","type":"CDM"},{"code":"275","type":"RC"},{"code":"C1721","type":"HCPCS"}],"standard_charges":[{"gross_charge":29380.24,"discounted_cash":16159.13,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Noncdm Charge Record Medical Supplies","code_information":[{"code":"880059","type":"CDM"},{"code":"275","type":"RC"},{"code":"C1722","type":"HCPCS"}],"standard_charges":[{"gross_charge":45265.18,"discounted_cash":24895.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Noncdm Charge Record Medical Supplies","code_information":[{"code":"880061","type":"CDM"},{"code":"275","type":"RC"},{"code":"C1882","type":"HCPCS"}],"standard_charges":[{"gross_charge":39506.25,"discounted_cash":21728.44,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Noncdm Charge Record Medical Supplies","code_information":[{"code":"880062","type":"CDM"},{"code":"275","type":"RC"},{"code":"C1883","type":"HCPCS"}],"standard_charges":[{"gross_charge":1359.88,"discounted_cash":747.93,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Noncdm Charge Record Medical Supplies","code_information":[{"code":"880064","type":"CDM"},{"code":"278","type":"RC"},{"code":"C1713","type":"HCPCS"}],"standard_charges":[{"gross_charge":1014.26,"discounted_cash":557.84,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."},{"gross_charge":466.5,"discounted_cash":256.58,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."},{"gross_charge":1031.37,"discounted_cash":567.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Noncdm Charge Record Medical Supplies","code_information":[{"code":"880065","type":"CDM"},{"code":"272","type":"RC"},{"code":"C1714","type":"HCPCS"}],"standard_charges":[{"gross_charge":6011.43,"discounted_cash":3306.29,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."},{"gross_charge":1370.62,"discounted_cash":753.84,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Noncdm Charge Record Medical Supplies","code_information":[{"code":"880068","type":"CDM"},{"code":"272","type":"RC"},{"code":"C1724","type":"HCPCS"}],"standard_charges":[{"gross_charge":5657.22,"discounted_cash":3111.47,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Noncdm Charge Record Medical Supplies","code_information":[{"code":"880069","type":"CDM"},{"code":"272","type":"RC"},{"code":"C1725","type":"HCPCS"}],"standard_charges":[{"gross_charge":866.66,"discounted_cash":476.66,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Noncdm Charge Record Medical Supplies","code_information":[{"code":"880070","type":"CDM"},{"code":"272","type":"RC"},{"code":"C1726","type":"HCPCS"}],"standard_charges":[{"gross_charge":479.93,"discounted_cash":263.96,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."},{"gross_charge":529.47,"discounted_cash":291.21,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."},{"gross_charge":520.4,"discounted_cash":286.22,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Noncdm Charge Record Medical Supplies","code_information":[{"code":"880071","type":"CDM"},{"code":"272","type":"RC"},{"code":"C1729","type":"HCPCS"}],"standard_charges":[{"gross_charge":296.86,"discounted_cash":163.27,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Noncdm Charge Record Medical Supplies","code_information":[{"code":"880072","type":"CDM"},{"code":"272","type":"RC"},{"code":"C1730","type":"HCPCS"}],"standard_charges":[{"gross_charge":2003.16,"discounted_cash":1101.74,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Noncdm Charge Record Medical Supplies","code_information":[{"code":"880073","type":"CDM"},{"code":"272","type":"RC"},{"code":"C1731","type":"HCPCS"}],"standard_charges":[{"gross_charge":766.23,"discounted_cash":421.43,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Noncdm Charge Record Medical Supplies","code_information":[{"code":"880075","type":"CDM"},{"code":"272","type":"RC"},{"code":"C1733","type":"HCPCS"}],"standard_charges":[{"gross_charge":16133.46,"discounted_cash":8873.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Noncdm Charge Record Medical Supplies","code_information":[{"code":"880077","type":"CDM"},{"code":"278","type":"RC"},{"code":"C1750","type":"HCPCS"}],"standard_charges":[{"gross_charge":319.05,"discounted_cash":175.48,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."},{"gross_charge":1302.89,"discounted_cash":716.59,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Noncdm Charge Record Medical Supplies","code_information":[{"code":"880079","type":"CDM"},{"code":"272","type":"RC"},{"code":"C1753","type":"HCPCS"}],"standard_charges":[{"gross_charge":4718.73,"discounted_cash":2595.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Noncdm Charge Record Medical Supplies","code_information":[{"code":"880080","type":"CDM"},{"code":"272","type":"RC"},{"code":"C1757","type":"HCPCS"}],"standard_charges":[{"gross_charge":277.35,"discounted_cash":152.54,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."},{"gross_charge":9807.24,"discounted_cash":5393.98,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Noncdm Charge Record Medical Supplies","code_information":[{"code":"880081","type":"CDM"},{"code":"272","type":"RC"},{"code":"C1758","type":"HCPCS"}],"standard_charges":[{"gross_charge":210.9,"discounted_cash":116.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Noncdm Charge Record Medical Supplies","code_information":[{"code":"880082","type":"CDM"},{"code":"272","type":"RC"},{"code":"C1759","type":"HCPCS"}],"standard_charges":[{"gross_charge":4575.51,"discounted_cash":2516.53,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Noncdm Charge Record Medical Supplies","code_information":[{"code":"880086","type":"CDM"},{"code":"278","type":"RC"},{"code":"C1763","type":"HCPCS"}],"standard_charges":[{"gross_charge":2105.12,"discounted_cash":1157.82,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Noncdm Charge Record Medical Supplies","code_information":[{"code":"880087","type":"CDM"},{"code":"278","type":"RC"},{"code":"C1764","type":"HCPCS"}],"standard_charges":[{"gross_charge":10801.4,"discounted_cash":5940.77,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Noncdm Charge Record Medical Supplies","code_information":[{"code":"880088","type":"CDM"},{"code":"272","type":"RC"},{"code":"C1766","type":"HCPCS"}],"standard_charges":[{"gross_charge":3475.34,"discounted_cash":1911.44,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Noncdm Charge Record Medical Supplies","code_information":[{"code":"880089","type":"CDM"},{"code":"278","type":"RC"},{"code":"C1767","type":"HCPCS"}],"standard_charges":[{"gross_charge":24699.63,"discounted_cash":13584.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Noncdm Charge Record Medical Supplies","code_information":[{"code":"880091","type":"CDM"},{"code":"272","type":"RC"},{"code":"C1769","type":"HCPCS"}],"standard_charges":[{"gross_charge":326.01,"discounted_cash":179.31,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."},{"gross_charge":280.52,"discounted_cash":154.29,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."},{"gross_charge":208.22,"discounted_cash":114.52,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Noncdm Charge Record Medical Supplies","code_information":[{"code":"880093","type":"CDM"},{"code":"278","type":"RC"},{"code":"C1771","type":"HCPCS"}],"standard_charges":[{"gross_charge":2380.67,"discounted_cash":1309.37,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."},{"gross_charge":2437.85,"discounted_cash":1340.82,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Noncdm Charge Record Medical Supplies","code_information":[{"code":"880094","type":"CDM"},{"code":"272","type":"RC"},{"code":"C1773","type":"HCPCS"}],"standard_charges":[{"gross_charge":1857.84,"discounted_cash":1021.81,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Noncdm Charge Record Medical Supplies","code_information":[{"code":"880095","type":"CDM"},{"code":"278","type":"RC"},{"code":"C1776","type":"HCPCS"}],"standard_charges":[{"gross_charge":2342.42,"discounted_cash":1288.33,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."},{"gross_charge":2920.05,"discounted_cash":1606.03,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."},{"gross_charge":2206.11,"discounted_cash":1213.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Noncdm Charge Record Medical Supplies","code_information":[{"code":"880096","type":"CDM"},{"code":"278","type":"RC"},{"code":"C1777","type":"HCPCS"}],"standard_charges":[{"gross_charge":7826.0,"discounted_cash":4304.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Noncdm Charge Record Medical Supplies","code_information":[{"code":"880097","type":"CDM"},{"code":"278","type":"RC"},{"code":"C1778","type":"HCPCS"}],"standard_charges":[{"gross_charge":7196.26,"discounted_cash":3957.94,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Noncdm Charge Record Medical Supplies","code_information":[{"code":"880102","type":"CDM"},{"code":"278","type":"RC"},{"code":"C1781","type":"HCPCS"}],"standard_charges":[{"gross_charge":796.28,"discounted_cash":437.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."},{"gross_charge":1015.66,"discounted_cash":558.61,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."},{"gross_charge":1401.2,"discounted_cash":770.66,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Noncdm Charge Record Medical Supplies","code_information":[{"code":"880103","type":"CDM"},{"code":"275","type":"RC"},{"code":"C1785","type":"HCPCS"}],"standard_charges":[{"gross_charge":7600.64,"discounted_cash":4180.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Noncdm Charge Record Medical Supplies","code_information":[{"code":"880104","type":"CDM"},{"code":"275","type":"RC"},{"code":"C1786","type":"HCPCS"}],"standard_charges":[{"gross_charge":12478.55,"discounted_cash":6863.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Noncdm Charge Record Medical Supplies","code_information":[{"code":"880105","type":"CDM"},{"code":"278","type":"RC"},{"code":"C1789","type":"HCPCS"}],"standard_charges":[{"gross_charge":2789.09,"discounted_cash":1534.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."},{"gross_charge":2531.35,"discounted_cash":1392.24,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Noncdm Charge Record Medical Supplies","code_information":[{"code":"880110","type":"CDM"},{"code":"278","type":"RC"},{"code":"C1874","type":"HCPCS"}],"standard_charges":[{"gross_charge":2376.31,"discounted_cash":1306.97,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Noncdm Charge Record Medical Supplies","code_information":[{"code":"880112","type":"CDM"},{"code":"278","type":"RC"},{"code":"C1760","type":"HCPCS"}],"standard_charges":[{"gross_charge":892.5,"discounted_cash":490.88,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Noncdm Charge Record Medical Supplies","code_information":[{"code":"880115","type":"CDM"},{"code":"276","type":"RC"},{"code":"C1780","type":"HCPCS"}],"standard_charges":[{"gross_charge":1346.44,"discounted_cash":740.54,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Noncdm Charge Record Medical Supplies","code_information":[{"code":"880116","type":"CDM"},{"code":"276","type":"RC"},{"code":"V2787","type":"HCPCS"}],"standard_charges":[{"gross_charge":1473.82,"discounted_cash":810.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Noncdm Charge Record Medical Supplies","code_information":[{"code":"880119","type":"CDM"},{"code":"278","type":"RC"},{"code":"C1751","type":"HCPCS"}],"standard_charges":[{"gross_charge":1949.96,"discounted_cash":1072.48,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."},{"gross_charge":944.39,"discounted_cash":519.41,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."},{"gross_charge":515.7,"discounted_cash":283.64,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Noncdm Charge Record Medical Supplies","code_information":[{"code":"880120","type":"CDM"},{"code":"278","type":"RC"},{"code":"C1752","type":"HCPCS"}],"standard_charges":[{"gross_charge":446.3,"discounted_cash":245.46,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Noncdm Charge Record Medical Supplies","code_information":[{"code":"880122","type":"CDM"},{"code":"278","type":"RC"},{"code":"C1760","type":"HCPCS"}],"standard_charges":[{"gross_charge":826.5,"discounted_cash":454.58,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Noncdm Charge Record Medical Supplies","code_information":[{"code":"880123","type":"CDM"},{"code":"278","type":"RC"},{"code":"C1765","type":"HCPCS"}],"standard_charges":[{"gross_charge":624.96,"discounted_cash":343.73,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Noncdm Charge Record Medical Supplies","code_information":[{"code":"880124","type":"CDM"},{"code":"278","type":"RC"},{"code":"C1768","type":"HCPCS"}],"standard_charges":[{"gross_charge":3910.81,"discounted_cash":2150.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."},{"gross_charge":1403.82,"discounted_cash":772.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Noncdm Charge Record Medical Supplies","code_information":[{"code":"880127","type":"CDM"},{"code":"278","type":"RC"},{"code":"C1788","type":"HCPCS"}],"standard_charges":[{"gross_charge":795.5,"discounted_cash":437.52,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."},{"gross_charge":807.9,"discounted_cash":444.34,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."},{"gross_charge":977.47,"discounted_cash":537.61,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Noncdm Charge Record Medical Supplies","code_information":[{"code":"880130","type":"CDM"},{"code":"278","type":"RC"},{"code":"C1817","type":"HCPCS"}],"standard_charges":[{"gross_charge":36938.45,"discounted_cash":20316.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Noncdm Charge Record Medical Supplies","code_information":[{"code":"880132","type":"CDM"},{"code":"278","type":"RC"},{"code":"C1821","type":"HCPCS"}],"standard_charges":[{"gross_charge":94.6,"discounted_cash":52.03,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Noncdm Charge Record Medical Supplies","code_information":[{"code":"880134","type":"CDM"},{"code":"278","type":"RC"},{"code":"A4648","type":"HCPCS"}],"standard_charges":[{"gross_charge":320.29,"discounted_cash":176.16,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Noncdm Charge Record Medical Supplies","code_information":[{"code":"880137","type":"CDM"},{"code":"278","type":"RC"},{"code":"C1897","type":"HCPCS"}],"standard_charges":[{"gross_charge":1951.12,"discounted_cash":1073.12,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Noncdm Charge Record Medical Supplies","code_information":[{"code":"880138","type":"CDM"},{"code":"278","type":"RC"},{"code":"C2617","type":"HCPCS"}],"standard_charges":[{"gross_charge":370.39,"discounted_cash":203.71,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."},{"gross_charge":730.82,"discounted_cash":401.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Noncdm Charge Record Medical Supplies","code_information":[{"code":"880142","type":"CDM"},{"code":"278","type":"RC"},{"code":"L8606","type":"HCPCS"}],"standard_charges":[{"gross_charge":982.39,"discounted_cash":540.31,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Noncdm Charge Record Medical Supplies","code_information":[{"code":"880145","type":"CDM"},{"code":"278","type":"RC"},{"code":"L8670","type":"HCPCS"}],"standard_charges":[{"gross_charge":12033.28,"discounted_cash":6618.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Noncdm Charge Record Medical Supplies","code_information":[{"code":"880154","type":"CDM"},{"code":"276","type":"RC"},{"code":"V2630","type":"HCPCS"}],"standard_charges":[{"gross_charge":262.84,"discounted_cash":144.56,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Noncdm Charge Record Medical Supplies","code_information":[{"code":"880157","type":"CDM"},{"code":"278","type":"RC"},{"code":"C1898","type":"HCPCS"}],"standard_charges":[{"gross_charge":940.9,"discounted_cash":517.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Noncdm Charge Record Medical Supplies","code_information":[{"code":"880160","type":"CDM"},{"code":"278","type":"RC"},{"code":"C9363","type":"HCPCS"}],"standard_charges":[{"gross_charge":6012.6,"discounted_cash":3306.93,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Noncdm Charge Record Medical Supplies","code_information":[{"code":"880164","type":"CDM"},{"code":"278","type":"RC"},{"code":"C1884","type":"HCPCS"}],"standard_charges":[{"gross_charge":3660.38,"discounted_cash":2013.21,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Noncdm Charge Record Medical Supplies","code_information":[{"code":"880168","type":"CDM"},{"code":"278","type":"RC"},{"code":"L8699","type":"HCPCS"}],"standard_charges":[{"gross_charge":2558.5,"discounted_cash":1407.18,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Noncdm Charge Record Medical Supplies","code_information":[{"code":"880171","type":"CDM"},{"code":"278","type":"RC"},{"code":"Q4116","type":"HCPCS"}],"standard_charges":[{"gross_charge":22140.7,"discounted_cash":12177.38,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Noncdm Charge Record Medical Supplies","code_information":[{"code":"880185","type":"CDM"},{"code":"278","type":"RC"},{"code":"C1729","type":"HCPCS"}],"standard_charges":[{"gross_charge":402.44,"discounted_cash":221.34,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Noncdm Charge Record Medical Supplies","code_information":[{"code":"880208","type":"CDM"},{"code":"272","type":"RC"},{"code":"C2623","type":"HCPCS"}],"standard_charges":[{"gross_charge":4656.32,"discounted_cash":2560.98,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Noncdm Charge Record Medical Supplies","code_information":[{"code":"880224","type":"CDM"},{"code":"278","type":"RC"},{"code":"Q4125","type":"HCPCS"}],"standard_charges":[{"gross_charge":2712.22,"discounted_cash":1491.72,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."},{"gross_charge":6031.5,"discounted_cash":3317.32,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Noncdm Charge Record Medical Supplies","code_information":[{"code":"880225","type":"CDM"},{"code":"272","type":"RC"},{"code":"A4314","type":"HCPCS"}],"standard_charges":[{"gross_charge":111.36,"discounted_cash":61.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Noncdm Charge Record Medical Supplies","code_information":[{"code":"880235","type":"CDM"},{"code":"274","type":"RC"},{"code":"L8623","type":"HCPCS"}],"standard_charges":[{"gross_charge":44064.25,"discounted_cash":24235.34,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Noncdm Charge Record Medical Supplies","code_information":[{"code":"880253","type":"CDM"},{"code":"278","type":"RC"},{"code":"C1762","type":"HCPCS"}],"standard_charges":[{"gross_charge":16858.65,"discounted_cash":9272.26,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."},{"gross_charge":3232.69,"discounted_cash":1777.98,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."},{"gross_charge":4553.73,"discounted_cash":2504.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Noncdm Charge Record Medical Supplies","code_information":[{"code":"880324","type":"CDM"},{"code":"272","type":"RC"},{"code":"C1889","type":"HCPCS"}],"standard_charges":[{"gross_charge":864.24,"discounted_cash":475.33,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Noncdm Charge Record Medical Supplies","code_information":[{"code":"880325","type":"CDM"},{"code":"272","type":"RC"},{"code":"C1748","type":"HCPCS"}],"standard_charges":[{"gross_charge":9535.25,"discounted_cash":5244.39,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Noncdm Charge Record Medical Supplies","code_information":[{"code":"880327","type":"CDM"},{"code":"278","type":"RC"},{"code":"C2624","type":"HCPCS"}],"standard_charges":[{"gross_charge":57781.25,"discounted_cash":31779.69,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Noncdm Charge Record Medical Supplies","code_information":[{"code":"880328","type":"CDM"},{"code":"272","type":"RC"},{"code":"C1052","type":"HCPCS"}],"standard_charges":[{"gross_charge":5219.12,"discounted_cash":2870.52,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Noncdm Charge Record Medical Supplies","code_information":[{"code":"880331","type":"CDM"},{"code":"272","type":"RC"},{"code":"C1761","type":"HCPCS"}],"standard_charges":[{"gross_charge":12631.25,"discounted_cash":6947.19,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Noncdm Charge Record Medical Supplies","code_information":[{"code":"880346","type":"CDM"},{"code":"272","type":"RC"},{"code":"C1747","type":"HCPCS"}],"standard_charges":[{"gross_charge":3563.62,"discounted_cash":1959.99,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Noncdm Charge Record Medical Supplies","code_information":[{"code":"880374","type":"CDM"},{"code":"272","type":"RC"},{"code":"C9808","type":"HCPCS"}],"standard_charges":[{"gross_charge":5455.62,"discounted_cash":3000.59,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Zinc Oxide Oint 20%","drug_information":{"unit":57.0,"type":"GM"},"code_information":[{"code":"8874","type":"CDM"},{"code":"46122011846","type":"NDC"}],"standard_charges":[{"gross_charge":32.47,"discounted_cash":17.86,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Zinc Oxide Oint 20%","drug_information":{"unit":28.4,"type":"GM"},"code_information":[{"code":"8874","type":"CDM"},{"code":"75834017001","type":"NDC"}],"standard_charges":[{"gross_charge":46.19,"discounted_cash":25.40,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"NDC Description Not Available","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"890012","type":"CDM"},{"code":"272","type":"RC"},{"code":"64253011123","type":"NDC"}],"standard_charges":[{"gross_charge":31.91,"discounted_cash":17.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."},{"gross_charge":32.6,"discounted_cash":17.93,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."},{"gross_charge":32.84,"discounted_cash":18.06,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"NDC Description Not Available","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"890036","type":"CDM"},{"code":"343","type":"RC"},{"code":"A9570","type":"HCPCS"},{"code":"99990641500","type":"NDC"}],"standard_charges":[{"gross_charge":469.08,"discounted_cash":257.99,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."},{"gross_charge":501.67,"discounted_cash":275.92,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."},{"gross_charge":448.99,"discounted_cash":246.94,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Acetaminophen Susp 160 MG/5ML","drug_information":{"unit":5.0,"type":"ML"},"code_information":[{"code":"8943","type":"CDM"},{"code":"68094023162","type":"NDC"}],"standard_charges":[{"gross_charge":4.17,"discounted_cash":2.29,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Acetaminophen Susp 160 MG/5ML","drug_information":{"unit":5.0,"type":"ML"},"code_information":[{"code":"8943","type":"CDM"},{"code":"68094023159","type":"NDC"}],"standard_charges":[{"gross_charge":4.08,"discounted_cash":2.24,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Acetaminophen Susp 160 MG/5ML","drug_information":{"unit":1.25,"type":"ML"},"code_information":[{"code":"8943","type":"CDM"},{"code":"8888894301","type":"NDC"}],"standard_charges":[{"gross_charge":3.14,"discounted_cash":1.73,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Butalbital-Acetaminophen-Caffeine Tab 50-325-40 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"8958","type":"CDM"},{"code":"50268055311","type":"NDC"}],"standard_charges":[{"gross_charge":15.51,"discounted_cash":8.53,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Butalbital-Acetaminophen-Caffeine Tab 50-325-40 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"8958","type":"CDM"},{"code":"50268055313","type":"NDC"}],"standard_charges":[{"gross_charge":15.51,"discounted_cash":8.53,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Acetazolamide Cap ER 12HR 500 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"8962","type":"CDM"},{"code":"60687057811","type":"NDC"}],"standard_charges":[{"gross_charge":26.83,"discounted_cash":14.76,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Acetazolamide Cap ER 12HR 500 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"8962","type":"CDM"},{"code":"60687057821","type":"NDC"}],"standard_charges":[{"gross_charge":26.83,"discounted_cash":14.76,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Acyclovir Cap 200 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"8969","type":"CDM"},{"code":"72578000201","type":"NDC"}],"standard_charges":[{"gross_charge":9.34,"discounted_cash":5.14,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Albumin, Human Inj 25%","drug_information":{"unit":50.0,"type":"ML"},"code_information":[{"code":"8981","type":"CDM"},{"code":"68982064301","type":"NDC"}],"standard_charges":[{"gross_charge":111.96,"discounted_cash":61.58,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Albumin, Human Inj 25%","drug_information":{"unit":50.0,"type":"ML"},"code_information":[{"code":"8981","type":"CDM"},{"code":"68516521602","type":"NDC"}],"standard_charges":[{"gross_charge":93.69,"discounted_cash":51.53,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Albumin, Human Inj 5%","drug_information":{"unit":250.0,"type":"ML"},"code_information":[{"code":"8982","type":"CDM"},{"code":"68516521407","type":"NDC"}],"standard_charges":[{"gross_charge":93.55,"discounted_cash":51.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Alprostadil Inj 500 MCG/ML","drug_information":{"unit":1.0,"type":"ML"},"code_information":[{"code":"9001","type":"CDM"},{"code":"9316901","type":"NDC"}],"standard_charges":[{"gross_charge":376.46,"discounted_cash":207.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Phenylephrine-NaCl PF Pref Syr 1 MG/10ML-0.9% (100 MCG/ML),Phenylephrine-NaCl Pref Syr 1 MG/10ML-0.9% (100 MCG/ML),Phenylephrine HCl IV Soln Pref Syr 1 MG/10ML (100 MCG/ML),Phenylephrine HCl IV Soln 1 MG/10ML (100 MCG/ML),Phenylephrine HCl (PF) IV Soln 0.5 MG/5ML (100 MCG/ML),Phenylephrine HCl IV Soln 0.5 MG/5ML (100 MCG/ML)","drug_information":{"unit":10.0,"type":"ML"},"code_information":[{"code":"900104","type":"CDM"},{"code":"70092104646","type":"NDC"}],"standard_charges":[{"gross_charge":72.77,"discounted_cash":40.02,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Phenylephrine-NaCl PF Pref Syr 1 MG/10ML-0.9% (100 MCG/ML),Phenylephrine-NaCl Pref Syr 1 MG/10ML-0.9% (100 MCG/ML),Phenylephrine HCl IV Soln Pref Syr 1 MG/10ML (100 MCG/ML),Phenylephrine HCl IV Soln 1 MG/10ML (100 MCG/ML),Phenylephrine HCl (PF) IV Soln 0.5 MG/5ML (100 MCG/ML),Phenylephrine HCl IV Soln 0.5 MG/5ML (100 MCG/ML)","drug_information":{"unit":10.0,"type":"ML"},"code_information":[{"code":"900104","type":"CDM"},{"code":"69374095710","type":"NDC"}],"standard_charges":[{"gross_charge":57.7,"discounted_cash":31.74,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Phenol Liquid 1.4%,Phenol-Phenolate Sodium - Aero Soln,Phenol-Phenolate Sodium - Liquid,Phenol-Glycerin Spray 1.5-33%","drug_information":{"unit":177.0,"type":"ML"},"code_information":[{"code":"900109","type":"CDM"},{"code":"536122858","type":"NDC"}],"standard_charges":[{"gross_charge":31.97,"discounted_cash":17.58,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Alteplase For Inj 100 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"9002","type":"CDM"},{"code":"50242008527","type":"NDC"}],"standard_charges":[{"gross_charge":14800.1,"discounted_cash":8140.06,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Ophthalmic Irrigation Solution - Intraocular","drug_information":{"unit":500.0,"type":"ML"},"code_information":[{"code":"900283","type":"CDM"},{"code":"65179504","type":"NDC"}],"standard_charges":[{"gross_charge":77.1,"discounted_cash":42.40,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Sumatriptan Succinate Inj 6 MG/0.5ML,Sumatriptan Succinate Solution Jet-injector 6 MG/0.*,Sumatriptan Succinate Solution Prefilled Syringe 6 *,Sumatriptan Succinate Solution Cartridge 6 MG/0.5ML,Sumatriptan Succinate Solution Auto-injector 6 MG/0*,Sumatriptan Succinate Solution Cartridge 6 MG/0.5ML","drug_information":{"unit":0.5,"type":"ML"},"code_information":[{"code":"900288","type":"CDM"},{"code":"143963801","type":"NDC"}],"standard_charges":[{"gross_charge":62.68,"discounted_cash":34.47,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Sumatriptan Succinate Inj 6 MG/0.5ML,Sumatriptan Succinate Solution Jet-injector 6 MG/0.*,Sumatriptan Succinate Solution Prefilled Syringe 6 *,Sumatriptan Succinate Solution Cartridge 6 MG/0.5ML,Sumatriptan Succinate Solution Auto-injector 6 MG/0*,Sumatriptan Succinate Solution Cartridge 6 MG/0.5ML","drug_information":{"unit":0.5,"type":"ML"},"code_information":[{"code":"900288","type":"CDM"},{"code":"143963805","type":"NDC"}],"standard_charges":[{"gross_charge":62.68,"discounted_cash":34.47,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Neostigmine Methylsulfate IV Soln 10 MG/10 ML (1 MG/ML)","drug_information":{"unit":0.5,"type":"ML"},"code_information":[{"code":"900329","type":"CDM"},{"code":"641614910","type":"NDC"}],"standard_charges":[{"gross_charge":36.66,"discounted_cash":20.16,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Neostigmine Methylsulfate IV Soln 10 MG/10 ML (1 MG/ML)","drug_information":{"unit":0.5,"type":"ML"},"code_information":[{"code":"900329","type":"CDM"},{"code":"641614901","type":"NDC"}],"standard_charges":[{"gross_charge":36.66,"discounted_cash":20.16,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Neostigmine Methylsulfate Soln Pref Syr 5 MG/5ML (1 MG/ML)","drug_information":{"unit":0.5,"type":"ML"},"code_information":[{"code":"900329","type":"CDM"},{"code":"8888900329","type":"NDC"}],"standard_charges":[{"gross_charge":36.5,"discounted_cash":20.08,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Etoposide Inj 20 MG/ML,Etoposide Inj 100MG/5ML (20 MG/ML),Etoposide Inj 500MG/25ML (20 MG/ML),Etoposide Inj 1 GM/50ML (20 MG/ML)","drug_information":{"unit":25.0,"type":"ML"},"code_information":[{"code":"900356","type":"CDM"},{"code":"63323010425","type":"NDC"}],"standard_charges":[{"gross_charge":337.31,"discounted_cash":185.52,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Famotidine Inj 10 MG/ML,Famotidine Inj 20 MG/2ML,Famotidine Inj 40 MG/4ML,Famotidine Inj 200 MG/20ML,Famotidine Inj 500 MG/50ML,Famotidine Preservative Free Inj 20 MG/2ML","drug_information":{"unit":1.0,"type":"ML"},"code_information":[{"code":"900357","type":"CDM"},{"code":"63323073911","type":"NDC"}],"standard_charges":[{"gross_charge":33.4,"discounted_cash":18.37,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Famotidine Inj 10 MG/ML,Famotidine Inj 20 MG/2ML,Famotidine Inj 40 MG/4ML,Famotidine Inj 200 MG/20ML,Famotidine Inj 500 MG/50ML,Famotidine Preservative Free Inj 20 MG/2ML","drug_information":{"unit":1.0,"type":"ML"},"code_information":[{"code":"900357","type":"CDM"},{"code":"8890035702","type":"NDC"}],"standard_charges":[{"gross_charge":33.4,"discounted_cash":18.37,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Famotidine Inj 10 MG/ML,Famotidine Inj 20 MG/2ML,Famotidine Inj 40 MG/4ML,Famotidine Inj 200 MG/20ML,Famotidine Inj 500 MG/50ML,Famotidine Preservative Free Inj 20 MG/2ML","drug_information":{"unit":1.0,"type":"ML"},"code_information":[{"code":"900357","type":"CDM"},{"code":"63323073912","type":"NDC"}],"standard_charges":[{"gross_charge":33.4,"discounted_cash":18.37,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Dexamethasone Sodium Phosphate Inj 4 MG/ML,Dexamethasone Sodium Phosphate Inj 20 MG/5ML,Dexamethasone Sodium Phosphate Inj 120 MG/30ML,Dexamethasone Sodium Phosphate Inj Soln Pref Syr 4 MG/ML","drug_information":{"unit":1.0,"type":"ML"},"code_information":[{"code":"900358","type":"CDM"},{"code":"67457042200","type":"NDC"}],"standard_charges":[{"gross_charge":36.72,"discounted_cash":20.20,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Dexamethasone Sodium Phosphate Inj 4 MG/ML,Dexamethasone Sodium Phosphate Inj 20 MG/5ML,Dexamethasone Sodium Phosphate Inj 120 MG/30ML,Dexamethasone Sodium Phosphate Inj Soln Pref Syr 4 MG/ML","drug_information":{"unit":1.0,"type":"ML"},"code_information":[{"code":"900358","type":"CDM"},{"code":"67457042300","type":"NDC"}],"standard_charges":[{"gross_charge":39.2,"discounted_cash":21.56,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Dexamethasone Sodium Phosphate Inj 4 MG/ML,Dexamethasone Sodium Phosphate Inj 20 MG/5ML,Dexamethasone Sodium Phosphate Inj 120 MG/30ML,Dexamethasone Sodium Phosphate Inj Soln Pref Syr 4 MG/ML","drug_information":{"unit":1.0,"type":"ML"},"code_information":[{"code":"900358","type":"CDM"},{"code":"67457042254","type":"NDC"}],"standard_charges":[{"gross_charge":36.72,"discounted_cash":20.20,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Dexamethasone Sodium Phosphate Inj 10 MG/ML,Dexamethasone Sodium Phosphate Inj 100 MG/10ML,Dexamethasone Sodium Phophate PF Inj 10 MG/ML,Dexamethasone Sod Phos Inj Sol Pref Syr 10 MG/ML (PF)","drug_information":{"unit":0.5,"type":"ML"},"code_information":[{"code":"900359","type":"CDM"},{"code":"63323050600","type":"NDC"}],"standard_charges":[{"gross_charge":45.85,"discounted_cash":25.22,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Dexamethasone Sodium Phosphate Inj 10 MG/ML,Dexamethasone Sodium Phosphate Inj 100 MG/10ML,Dexamethasone Sodium Phophate PF Inj 10 MG/ML,Dexamethasone Sod Phos Inj Sol Pref Syr 10 MG/ML (PF)","drug_information":{"unit":0.5,"type":"ML"},"code_information":[{"code":"900359","type":"CDM"},{"code":"72485011801","type":"NDC"}],"standard_charges":[{"gross_charge":35.75,"discounted_cash":19.66,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Dexamethasone Sodium Phosphate Inj 10 MG/ML,Dexamethasone Sodium Phosphate Inj 100 MG/10ML,Dexamethasone Sodium Phophate PF Inj 10 MG/ML,Dexamethasone Sod Phos Inj Sol Pref Syr 10 MG/ML (PF)","drug_information":{"unit":0.5,"type":"ML"},"code_information":[{"code":"900359","type":"CDM"},{"code":"72485011825","type":"NDC"}],"standard_charges":[{"gross_charge":35.75,"discounted_cash":19.66,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Dexamethasone Sodium Phosphate Inj 10 MG/ML,Dexamethasone Sodium Phosphate Inj 100 MG/10ML,Dexamethasone Sodium Phophate PF Inj 10 MG/ML,Dexamethasone Sod Phos Inj Sol Pref Syr 10 MG/ML (PF)","drug_information":{"unit":0.5,"type":"ML"},"code_information":[{"code":"900359","type":"CDM"},{"code":"55150030401","type":"NDC"}],"standard_charges":[{"gross_charge":39.71,"discounted_cash":21.84,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Dexamethasone Sodium Phosphate Inj 10 MG/ML,Dexamethasone Sodium Phosphate Inj 100 MG/10ML,Dexamethasone Sodium Phophate PF Inj 10 MG/ML,Dexamethasone Sod Phos Inj Sol Pref Syr 10 MG/ML (PF)","drug_information":{"unit":0.5,"type":"ML"},"code_information":[{"code":"900359","type":"CDM"},{"code":"55150030425","type":"NDC"}],"standard_charges":[{"gross_charge":39.71,"discounted_cash":21.84,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Dexamethasone Sodium Phosphate Inj 10 MG/ML,Dexamethasone Sodium Phosphate Inj 100 MG/10ML,Dexamethasone Sodium Phophate PF Inj 10 MG/ML,Dexamethasone Sod Phos Inj Sol Pref Syr 10 MG/ML (PF)","drug_information":{"unit":0.5,"type":"ML"},"code_information":[{"code":"900359","type":"CDM"},{"code":"63323050601","type":"NDC"}],"standard_charges":[{"gross_charge":45.85,"discounted_cash":25.22,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Potassium Phosphates Inj 15 mM/5ML (Phos) 22 mEq/5ML,Potassium Phosphates Inj 45 mM/15ML (Phos) 66 mEq/15,Potassium Phosphate Dibasic Inj 3 MMole/ML,Potassium Phosphate Inj 150 mM/50ML (Phos) 220 mEq","drug_information":{"unit":15.0,"type":"ML"},"code_information":[{"code":"900378","type":"CDM"},{"code":"517210225","type":"NDC"}],"standard_charges":[{"gross_charge":252.53,"discounted_cash":138.89,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Potassium Phosphates Inj 15 mM/5ML (Phos) 22 mEq/5ML,Potassium Phosphates Inj 45 mM/15ML (Phos) 66 mEq/15,Potassium Phosphate Dibasic Inj 3 MMole/ML,Potassium Phosphate Inj 150 mM/50ML (Phos) 220 mEq","drug_information":{"unit":15.0,"type":"ML"},"code_information":[{"code":"900378","type":"CDM"},{"code":"517210201","type":"NDC"}],"standard_charges":[{"gross_charge":252.53,"discounted_cash":138.89,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Potassium Phosphates Inj 15 mM/5ML (Phos) 22 mEq/5ML,Potassium Phosphates Inj 45 mM/15ML (Phos) 66 mEq/15,Potassium Phosphate Dibasic Inj 3 MMole/ML,Potassium Phosphate Inj 150 mM/50ML (Phos) 220 mEq","drug_information":{"unit":5.0,"type":"ML"},"code_information":[{"code":"900378","type":"CDM"},{"code":"65219005229","type":"NDC"}],"standard_charges":[{"gross_charge":125.96,"discounted_cash":69.28,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Potassium Phosphates Inj 15 mM/5ML (Phos) 22 mEq/5ML,Potassium Phosphates Inj 45 mM/15ML (Phos) 66 mEq/15,Potassium Phosphate Dibasic Inj 3 MMole/ML,Potassium Phosphate Inj 150 mM/50ML (Phos) 220 mEq","drug_information":{"unit":5.0,"type":"ML"},"code_information":[{"code":"900378","type":"CDM"},{"code":"65219005209","type":"NDC"}],"standard_charges":[{"gross_charge":125.97,"discounted_cash":69.28,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Potassium Phosphates Inj 15 mM/5ML (Phos) 22 mEq/5ML,Potassium Phosphates Inj 45 mM/15ML (Phos) 66 mEq/15,Potassium Phosphate Dibasic Inj 3 MMole/ML,Potassium Phosphate Inj 150 mM/50ML (Phos) 220 mEq","drug_information":{"unit":50.0,"type":"ML"},"code_information":[{"code":"900378","type":"CDM"},{"code":"63323008650","type":"NDC"}],"standard_charges":[{"gross_charge":341.7,"discounted_cash":187.94,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Glucagon HCl (rDNA) For Inj 1 MG (Base Equiv),Glucagon HCl (rDNA) Diagnostic For Inj 1 MG (Base E*,Glucagon HCl Diagnostic For Inj 1 MG (Base Equiv),GLUCAGON EMERGENCY 1 MG IJ KIT,Glucagon Hcl For Inj 1mg,Glucagon For Inj 1 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"900396","type":"CDM"},{"code":"63323059613","type":"NDC"}],"standard_charges":[{"gross_charge":485.82,"discounted_cash":267.20,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Glucagon HCl (rDNA) For Inj 1 MG (Base Equiv),Glucagon HCl (rDNA) Diagnostic For Inj 1 MG (Base E*,Glucagon HCl Diagnostic For Inj 1 MG (Base Equiv),GLUCAGON EMERGENCY 1 MG IJ KIT,Glucagon Hcl For Inj 1mg,Glucagon For Inj 1 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"900396","type":"CDM"},{"code":"63323059608","type":"NDC"}],"standard_charges":[{"gross_charge":337.0,"discounted_cash":185.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Furosemide Inj 10 MG/ML","drug_information":{"unit":22.0,"type":"ML"},"code_information":[{"code":"900408","type":"CDM"},{"code":"63323028026","type":"NDC"}],"standard_charges":[{"gross_charge":60.37,"discounted_cash":33.20,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Furosemide Inj 10 MG/ML","drug_information":{"unit":22.0,"type":"ML"},"code_information":[{"code":"900408","type":"CDM"},{"code":"409610225","type":"NDC"}],"standard_charges":[{"gross_charge":204.8,"discounted_cash":112.64,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Furosemide Inj 10 MG/ML","drug_information":{"unit":22.0,"type":"ML"},"code_information":[{"code":"900408","type":"CDM"},{"code":"25021031102","type":"NDC"}],"standard_charges":[{"gross_charge":119.11,"discounted_cash":65.51,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Furosemide Inj 10 MG/ML","drug_information":{"unit":22.0,"type":"ML"},"code_information":[{"code":"900408","type":"CDM"},{"code":"25021031104","type":"NDC"}],"standard_charges":[{"gross_charge":89.74,"discounted_cash":49.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Furosemide Inj 10 MG/ML","drug_information":{"unit":22.0,"type":"ML"},"code_information":[{"code":"900408","type":"CDM"},{"code":"63323028036","type":"NDC"}],"standard_charges":[{"gross_charge":49.01,"discounted_cash":26.96,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Furosemide Inj 10 MG/ML","drug_information":{"unit":22.0,"type":"ML"},"code_information":[{"code":"900408","type":"CDM"},{"code":"63323028003","type":"NDC"}],"standard_charges":[{"gross_charge":113.24,"discounted_cash":62.28,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Furosemide Inj 10 MG/ML","drug_information":{"unit":22.0,"type":"ML"},"code_information":[{"code":"900408","type":"CDM"},{"code":"409610219","type":"NDC"}],"standard_charges":[{"gross_charge":243.6,"discounted_cash":133.98,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Furosemide Inj 10 MG/ML","drug_information":{"unit":22.0,"type":"ML"},"code_information":[{"code":"900408","type":"CDM"},{"code":"63323028005","type":"NDC"}],"standard_charges":[{"gross_charge":68.59,"discounted_cash":37.72,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Epinephrine Inj 1 MG/ML (1:1000),Epinephrine Inj 30 MG/30ML (1 MG/ML) (1:1000),Epinephrine PF Inj 1 MG/ML,Epinephrine Inj 30 MG/30ML,Epinephrine Inj 1 MG/ML","drug_information":{"unit":0.15,"type":"ML"},"code_information":[{"code":"900426","type":"CDM"},{"code":"42023015925","type":"NDC"}],"standard_charges":[{"gross_charge":38.41,"discounted_cash":21.13,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Epinephrine Inj 1 MG/ML (1:1000),Epinephrine Inj 30 MG/30ML (1 MG/ML) (1:1000),Epinephrine PF Inj 1 MG/ML,Epinephrine Inj 30 MG/30ML,Epinephrine Inj 1 MG/ML","drug_information":{"unit":0.15,"type":"ML"},"code_information":[{"code":"900426","type":"CDM"},{"code":"517303001","type":"NDC"}],"standard_charges":[{"gross_charge":34.96,"discounted_cash":19.23,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Epinephrine Inj 1 MG/ML (1:1000),Epinephrine Inj 30 MG/30ML (1 MG/ML) (1:1000),Epinephrine PF Inj 1 MG/ML,Epinephrine Inj 30 MG/30ML,Epinephrine Inj 1 MG/ML","drug_information":{"unit":0.15,"type":"ML"},"code_information":[{"code":"900426","type":"CDM"},{"code":"42023015901","type":"NDC"}],"standard_charges":[{"gross_charge":38.41,"discounted_cash":21.13,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Sorbitol Oral Solution 70%,Sorbitol Solution (Bulk)","drug_information":{"unit":15.0,"type":"ML"},"code_information":[{"code":"900463","type":"CDM"},{"code":"46287050030","type":"NDC"}],"standard_charges":[{"gross_charge":26.01,"discounted_cash":14.31,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Sodium Chloride IV Soln 0.9%","drug_information":{"unit":250.0,"type":"ML"},"code_information":[{"code":"900866","type":"CDM"},{"code":"264180031","type":"NDC"}],"standard_charges":[{"gross_charge":120.31,"discounted_cash":66.17,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Sodium Chloride IV Soln 0.9%","drug_information":{"unit":250.0,"type":"ML"},"code_information":[{"code":"900866","type":"CDM"},{"code":"264180032","type":"NDC"}],"standard_charges":[{"gross_charge":84.71,"discounted_cash":46.59,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Sodium Chloride IV Soln 0.9%","drug_information":{"unit":250.0,"type":"ML"},"code_information":[{"code":"900866","type":"CDM"},{"code":"264780010","type":"NDC"}],"standard_charges":[{"gross_charge":62.06,"discounted_cash":34.13,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Sodium Chloride IV Soln 0.9%","drug_information":{"unit":250.0,"type":"ML"},"code_information":[{"code":"900866","type":"CDM"},{"code":"264780020","type":"NDC"}],"standard_charges":[{"gross_charge":64.36,"discounted_cash":35.40,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Sodium Chloride IV Soln 0.9%","drug_information":{"unit":250.0,"type":"ML"},"code_information":[{"code":"900866","type":"CDM"},{"code":"264780009","type":"NDC"}],"standard_charges":[{"gross_charge":60.15,"discounted_cash":33.08,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Lactated Ringer's Solution","drug_information":{"unit":250.0,"type":"ML"},"code_information":[{"code":"900867","type":"CDM"},{"code":"338011704","type":"NDC"}],"standard_charges":[{"gross_charge":61.3,"discounted_cash":33.72,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Oxytocin-Sodium Chloride 0.9% IV Soln 30 Unit/500 mL","drug_information":{"unit":500.0,"type":"ML"},"code_information":[{"code":"900903","type":"CDM"},{"code":"70092155207","type":"NDC"}],"standard_charges":[{"gross_charge":166.73,"discounted_cash":91.70,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Ampicillin & Sulbactam Sodium For Inj 3 (2-1) GM","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"9009084","type":"CDM"},{"code":"55150011720","type":"NDC"}],"standard_charges":[{"gross_charge":35.94,"discounted_cash":19.77,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Dextrose Inj 10%","drug_information":{"unit":250.0,"type":"ML"},"code_information":[{"code":"901044","type":"CDM"},{"code":"338002302","type":"NDC"}],"standard_charges":[{"gross_charge":26.0,"discounted_cash":14.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Dextrose Inj 5%","drug_information":{"unit":100.0,"type":"ML"},"code_information":[{"code":"901045","type":"CDM"},{"code":"264751010","type":"NDC"}],"standard_charges":[{"gross_charge":60.53,"discounted_cash":33.29,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Heparin Sodium (Porcine) 10 Unit/ML in Sodium Chloride 0.9%,Heparin Sodium (Porcine) 10 Unit/ML in Sodium Chloride 0.9%,Heparin Sodium (Porcine) Lock Flush PF IV Soln 10 Unit/ML","drug_information":{"unit":1.0,"type":"ML"},"code_information":[{"code":"901046","type":"CDM"},{"code":"8290306414","type":"NDC"}],"standard_charges":[{"gross_charge":31.72,"discounted_cash":17.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Heparin Sodium (Porcine) 10 Unit/ML in Sodium Chloride 0.9%,Heparin Sodium (Porcine) 10 Unit/ML in Sodium Chloride 0.9%,Heparin Sodium (Porcine) Lock Flush PF IV Soln 10 Unit/ML","drug_information":{"unit":1.0,"type":"ML"},"code_information":[{"code":"901046","type":"CDM"},{"code":"64253022235","type":"NDC"}],"standard_charges":[{"gross_charge":34.21,"discounted_cash":18.82,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Polyvinyl Alcohol-Povidone Ophth Soln 2.7-2%,Polyvinyl Alcohol,Polyvinyl Alcohol Ophth Soln 1.4%,Polyvinyl Alcohol Ophth Soln 0.6%,Polyvinyl Alcohol-Povidone Ophth Soln 2.7-2%,Polyvinyl Alcohol-Povidone Ophth Soln 5-6 MG/ML (0.5-0.6%),Artificial Tear Ophth Solution,Methylcellulose Ophth Soln 1%,Hypromellose Ophth Soln 0.5%,Glycerin-Hypromellose-PEG 400 Ophth Soln 0.2-0.2-1%,Hypromellose Ophth Soln 0.4%,Carboxymethylcellulose Sodium Ophth Soln 0.5%,Carboxymethylcell-Glycerin-Polysorb 80 Ophth Soln 0.5-1-0.5%,Dextran 70-Hypromellose (PF) Ophth Soln 0.1-0.3%,Carboxymethylcell-Glyc-Polysorb 80 (PF) Ophth Sol 0.5-1-0.5%,Dextran 70-Hypromellose Ophth Soln 0.1-0.3%,Polyvinyl Alcohol-Povidone (PF) Ophth Soln 1.4-0.6%,Polyethylene Glycol-Propylene Glycol Ophth Soln 0.4-0.3%,Carboxymethylcellulose Sodium Ophth Soln 0.25%,Polyethylene Glycol 400 Ophth Soln 0.25%,Propylene Glycol-Glycerin Ophth Soln 1-0.3%,Polyethylene Glycol 400 Ophth Soln 1%,Propylene Glycol Ophth Soln 0.6%,Carboxymethylcellulose Sodium (PF) Ophth Soln 0.25%,Carboxymethylcellulose Sodium (PF) Ophth Gel 1%","drug_information":{"unit":15.0,"type":"ML"},"code_information":[{"code":"901057","type":"CDM"},{"code":"65042915","type":"NDC"}],"standard_charges":[{"gross_charge":68.53,"discounted_cash":37.69,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Ferrous Sulfate Tab 325 MG (65 MG Elemental Fe),Ferrous Sulfate Tab EC 325 MG (65 MG Fe Equivalent),Ferrous Sulfate Tab 300 MG (60 MG Elemental Fe)","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"901059","type":"CDM"},{"code":"904759182","type":"NDC"}],"standard_charges":[{"gross_charge":8.1,"discounted_cash":4.46,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Oyster Shell Calcium Tab 500 MG,,","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"901060","type":"CDM"},{"code":"904188361","type":"NDC"}],"standard_charges":[{"gross_charge":8.21,"discounted_cash":4.52,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Pediatric Multiple Vitamins w/ Iron Drops 10 MG/ML,Pediatric Multiple Vitamins w/ Iron Drops 11 MG/ML","drug_information":{"unit":0.5,"type":"ML"},"code_information":[{"code":"901070","type":"CDM"},{"code":"69618006359","type":"NDC"}],"standard_charges":[{"gross_charge":18.0,"discounted_cash":9.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Sodium Chloride IV Soln 0.9%","drug_information":{"unit":250.0,"type":"ML"},"code_information":[{"code":"901127","type":"CDM"},{"code":"264780009","type":"NDC"}],"standard_charges":[{"gross_charge":20.34,"discounted_cash":11.19,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Sodium Chloride IV Soln 0.9%","drug_information":{"unit":250.0,"type":"ML"},"code_information":[{"code":"901127","type":"CDM"},{"code":"264780020","type":"NDC"}],"standard_charges":[{"gross_charge":32.58,"discounted_cash":17.92,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Sodium Chloride IV Soln 0.9%","drug_information":{"unit":250.0,"type":"ML"},"code_information":[{"code":"901127","type":"CDM"},{"code":"264780010","type":"NDC"}],"standard_charges":[{"gross_charge":25.9,"discounted_cash":14.24,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Calcium Gluconate Inj 10%","drug_information":{"unit":10.0,"type":"ML"},"code_information":[{"code":"901135","type":"CDM"},{"code":"63323036019","type":"NDC"}],"standard_charges":[{"gross_charge":77.28,"discounted_cash":42.50,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Magnesium Sulfate Inj 50%","drug_information":{"unit":2.0,"type":"ML"},"code_information":[{"code":"901136","type":"CDM"},{"code":"63323006401","type":"NDC"}],"standard_charges":[{"gross_charge":41.47,"discounted_cash":22.81,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Magnesium Sulfate Inj 50%","drug_information":{"unit":2.0,"type":"ML"},"code_information":[{"code":"901136","type":"CDM"},{"code":"63323006403","type":"NDC"}],"standard_charges":[{"gross_charge":41.49,"discounted_cash":22.82,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Magnesium Sulfate Inj 50%","drug_information":{"unit":50.0,"type":"ML"},"code_information":[{"code":"901136","type":"CDM"},{"code":"63323064250","type":"NDC"}],"standard_charges":[{"gross_charge":155.38,"discounted_cash":85.46,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Lactated Ringer's Solution","drug_information":{"unit":250.0,"type":"ML"},"code_information":[{"code":"901197","type":"CDM"},{"code":"338011704","type":"NDC"}],"standard_charges":[{"gross_charge":61.3,"discounted_cash":33.72,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Insulin Aspart Inj 100 Unit/ML,Insulin Aspart Inj Soln 100 Unit/ML","drug_information":{"unit":10.0,"type":"ML"},"code_information":[{"code":"901198","type":"CDM"},{"code":"169750111","type":"NDC"}],"standard_charges":[{"gross_charge":137.03,"discounted_cash":75.37,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Sodium Chloride IV Soln 0.9%","drug_information":{"unit":500.0,"type":"ML"},"code_information":[{"code":"901213","type":"CDM"},{"code":"264780009","type":"NDC"}],"standard_charges":[{"gross_charge":61.3,"discounted_cash":33.72,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Sodium Chloride IV Soln 0.9%","drug_information":{"unit":500.0,"type":"ML"},"code_information":[{"code":"901213","type":"CDM"},{"code":"264780020","type":"NDC"}],"standard_charges":[{"gross_charge":69.71,"discounted_cash":38.34,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Sodium Chloride IV Soln 0.9%","drug_information":{"unit":500.0,"type":"ML"},"code_information":[{"code":"901213","type":"CDM"},{"code":"264780010","type":"NDC"}],"standard_charges":[{"gross_charge":65.12,"discounted_cash":35.82,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Sodium Chloride IV Soln 0.9%","drug_information":{"unit":500.0,"type":"ML"},"code_information":[{"code":"901213","type":"CDM"},{"code":"264180032","type":"NDC"}],"standard_charges":[{"gross_charge":121.43,"discounted_cash":66.79,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Sodium Chloride IV Soln 0.9%","drug_information":{"unit":500.0,"type":"ML"},"code_information":[{"code":"901213","type":"CDM"},{"code":"264180031","type":"NDC"}],"standard_charges":[{"gross_charge":192.63,"discounted_cash":105.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Dextrose Inj 5%","drug_information":{"unit":10.0,"type":"ML"},"code_information":[{"code":"901236","type":"CDM"},{"code":"264151031","type":"NDC"}],"standard_charges":[{"gross_charge":50.63,"discounted_cash":27.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Dextrose 5% w/ Sodium Chloride 0.9%","drug_information":{"unit":100.0,"type":"ML"},"code_information":[{"code":"901244","type":"CDM"},{"code":"264761000","type":"NDC"}],"standard_charges":[{"gross_charge":16.2,"discounted_cash":8.91,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Doxorubicin HCl For Inj 50 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"901275","type":"CDM"},{"code":"143927701","type":"NDC"}],"standard_charges":[{"gross_charge":523.46,"discounted_cash":287.90,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Dextrose 5% in Lactated Ringers","drug_information":{"unit":100.0,"type":"ML"},"code_information":[{"code":"901340","type":"CDM"},{"code":"338012504","type":"NDC"}],"standard_charges":[{"gross_charge":60.07,"discounted_cash":33.04,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Dextrose 5% in Lactated Ringers","drug_information":{"unit":100.0,"type":"ML"},"code_information":[{"code":"901340","type":"CDM"},{"code":"264775100","type":"NDC"}],"standard_charges":[{"gross_charge":59.61,"discounted_cash":32.79,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Sodium Chloride IV Soln 0.9%","drug_information":{"unit":500.0,"type":"ML"},"code_information":[{"code":"901536","type":"CDM"},{"code":"264780009","type":"NDC"}],"standard_charges":[{"gross_charge":61.3,"discounted_cash":33.72,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Sodium Chloride IV Soln 0.9%","drug_information":{"unit":500.0,"type":"ML"},"code_information":[{"code":"901536","type":"CDM"},{"code":"264780010","type":"NDC"}],"standard_charges":[{"gross_charge":65.12,"discounted_cash":35.82,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Sodium Chloride IV Soln 0.9%","drug_information":{"unit":500.0,"type":"ML"},"code_information":[{"code":"901536","type":"CDM"},{"code":"264780020","type":"NDC"}],"standard_charges":[{"gross_charge":69.71,"discounted_cash":38.34,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Lactated Ringer's Solution","drug_information":{"unit":500.0,"type":"ML"},"code_information":[{"code":"901537","type":"CDM"},{"code":"338011704","type":"NDC"}],"standard_charges":[{"gross_charge":63.59,"discounted_cash":34.97,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Cefazolin Sodium For Inj 1 GM","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"901543","type":"CDM"},{"code":"143926225","type":"NDC"}],"standard_charges":[{"gross_charge":35.86,"discounted_cash":19.72,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Cefepime HCl For IV Soln 2 GM","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"901545","type":"CDM"},{"code":"409022001","type":"NDC"}],"standard_charges":[{"gross_charge":61.13,"discounted_cash":33.62,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Prenatal Vit w/ Fe Fumarate-FA Tab 28-0.8 MG,Prenatal Multivitamins & Minerals w/Iron & FA Tab 0*,Prenatal Vit w/ Fe Fumarate-FA Tab 27-0.8 MG,Prenatal Vit w/ Fe Sulfate-FA Tab 27-0.8 MG,Prenatal Vit w/ Fe Fumarate-FA Tab 27-1 MG,Prenatal Vit w/ Iron Carbonyl-FA Tab 29-1 MG,Prenatal Vit w/ Fe Fumarate-FA Tab 60-1 MG,Prenatal-U 106.5-1 mg po caps,Prenatal Vit w/ Fe Fumarate-FA Tab 29-1 MG,Prenatal Vit w/ Fe Fum-Methylfolate-FA Tab 27-0.6-0.4 MG,Prenatal Vit w/ DSS-Iron Carbonyl-FA Tab 90-1 MG,Prenatal Vit w/ DSS-Fe Fumarate-FA Tab 29-1 MG,Multiple Vitamins w/ Minerals & FA Tab 1 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"901772","type":"CDM"},{"code":"48433011201","type":"NDC"}],"standard_charges":[{"gross_charge":9.17,"discounted_cash":5.04,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Adenosine IV Soln 3 MG/ML,Adenosine IV Soln 6 MG/2ML,Adenosine IV Soln 12 MG/4ML","drug_information":{"unit":2.0,"type":"ML"},"code_information":[{"code":"901774","type":"CDM"},{"code":"63323065189","type":"NDC"}],"standard_charges":[{"gross_charge":93.96,"discounted_cash":51.68,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Adenosine IV Soln 3 MG/ML,Adenosine IV Soln 6 MG/2ML,Adenosine IV Soln 12 MG/4ML","drug_information":{"unit":2.0,"type":"ML"},"code_information":[{"code":"901774","type":"CDM"},{"code":"63323065123","type":"NDC"}],"standard_charges":[{"gross_charge":82.28,"discounted_cash":45.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Adenosine IV Soln 3 MG/ML,Adenosine IV Soln 6 MG/2ML,Adenosine IV Soln 12 MG/4ML","drug_information":{"unit":2.0,"type":"ML"},"code_information":[{"code":"901774","type":"CDM"},{"code":"63323065121","type":"NDC"}],"standard_charges":[{"gross_charge":93.96,"discounted_cash":51.68,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Amikacin Sulfate Inj 250 MG/ML,Amikacin Sulfate Inj 500 MG/2ML,Amikacin Sulfate Inj 1 GM/4ML","drug_information":{"unit":2.0,"type":"ML"},"code_information":[{"code":"901775","type":"CDM"},{"code":"63323081502","type":"NDC"}],"standard_charges":[{"gross_charge":77.13,"discounted_cash":42.42,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Amiodarone HCl Inj 50 MG/ML,Amiodarone HCl Inj 150 MG/3ML (50 MG/ML),Amiodarone HCl Inj 450 MG/9ML (50 MG/ML),Amiodarone HCl Inj 900 MG/18ML (50 MG/ML)","drug_information":{"unit":3.0,"type":"ML"},"code_information":[{"code":"901776","type":"CDM"},{"code":"143987525","type":"NDC"}],"standard_charges":[{"gross_charge":18.86,"discounted_cash":10.37,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Amiodarone HCl Inj 50 MG/ML,Amiodarone HCl Inj 150 MG/3ML (50 MG/ML),Amiodarone HCl Inj 450 MG/9ML (50 MG/ML),Amiodarone HCl Inj 900 MG/18ML (50 MG/ML)","drug_information":{"unit":3.0,"type":"ML"},"code_information":[{"code":"901776","type":"CDM"},{"code":"143987501","type":"NDC"}],"standard_charges":[{"gross_charge":19.0,"discounted_cash":10.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Amiodarone HCl Inj 50 MG/ML,Amiodarone HCl Inj 150 MG/3ML (50 MG/ML),Amiodarone HCl Inj 450 MG/9ML (50 MG/ML),Amiodarone HCl Inj 900 MG/18ML (50 MG/ML)","drug_information":{"unit":3.0,"type":"ML"},"code_information":[{"code":"901776","type":"CDM"},{"code":"63323061609","type":"NDC"}],"standard_charges":[{"gross_charge":18.56,"discounted_cash":10.21,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Amiodarone HCl Inj 900 MG/18ML (50 MG/ML)","drug_information":{"unit":3.0,"type":"ML"},"code_information":[{"code":"901776","type":"CDM"},{"code":"70436023250","type":"NDC"}],"standard_charges":[{"gross_charge":19.42,"discounted_cash":10.68,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Clindamycin Phosphate Inj 150 MG/ML,Clindamycin Phosphate Inj 600 MG/4ML,Clindamycin Phosphate Inj 900 MG/6ML,Clindamycin Phosphate Inj 9 GM/60ML,Clindamycin Phosphate Inj 300 MG/2ML,Clindamycin Phosphate IV Soln 600 MG/4ML,Clindamycin Phosphate IV Soln 300 MG/2ML,Clindamycin Phosphate IV Soln 900 MG/6ML","drug_information":{"unit":6.0,"type":"ML"},"code_information":[{"code":"901779","type":"CDM"},{"code":"9509505","type":"NDC"}],"standard_charges":[{"gross_charge":47.77,"discounted_cash":26.27,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Diltiazem HCl IV Soln 5 MG/ML,Dilteiazm HCl IV Soln 125MG/5ML,Diltiazem HCl IV Soln 25 MG/5ML (5 MG/ML),Diltiazem HCl IV Soln 50 MG/10ML (5 MG/ML)","drug_information":{"unit":2.0,"type":"ML"},"code_information":[{"code":"901781","type":"CDM"},{"code":"641601501","type":"NDC"}],"standard_charges":[{"gross_charge":34.89,"discounted_cash":19.19,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Diltiazem HCl IV Soln 5 MG/ML,Dilteiazm HCl IV Soln 125MG/5ML,Diltiazem HCl IV Soln 25 MG/5ML (5 MG/ML),Diltiazem HCl IV Soln 50 MG/10ML (5 MG/ML)","drug_information":{"unit":2.0,"type":"ML"},"code_information":[{"code":"901781","type":"CDM"},{"code":"641601510","type":"NDC"}],"standard_charges":[{"gross_charge":34.89,"discounted_cash":19.19,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Diltiazem HCl IV Soln 5 MG/ML,Dilteiazm HCl IV Soln 125MG/5ML,Diltiazem HCl IV Soln 25 MG/5ML (5 MG/ML),Diltiazem HCl IV Soln 50 MG/10ML (5 MG/ML)","drug_information":{"unit":2.0,"type":"ML"},"code_information":[{"code":"901781","type":"CDM"},{"code":"641921701","type":"NDC"}],"standard_charges":[{"gross_charge":35.65,"discounted_cash":19.61,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Diltiazem HCl IV Soln 5 MG/ML,Dilteiazm HCl IV Soln 125MG/5ML,Diltiazem HCl IV Soln 25 MG/5ML (5 MG/ML),Diltiazem HCl IV Soln 50 MG/10ML (5 MG/ML)","drug_information":{"unit":2.0,"type":"ML"},"code_information":[{"code":"901781","type":"CDM"},{"code":"641921710","type":"NDC"}],"standard_charges":[{"gross_charge":35.65,"discounted_cash":19.61,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Flumazenil IV Soln 0.5 MG/5ML (0.1 MG/ML)","drug_information":{"unit":5.0,"type":"ML"},"code_information":[{"code":"901783","type":"CDM"},{"code":"143978401","type":"NDC"}],"standard_charges":[{"gross_charge":62.28,"discounted_cash":34.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Flumazenil IV Soln 0.5 MG/5ML (0.1 MG/ML)","drug_information":{"unit":5.0,"type":"ML"},"code_information":[{"code":"901783","type":"CDM"},{"code":"143978410","type":"NDC"}],"standard_charges":[{"gross_charge":62.28,"discounted_cash":34.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Fluorouracil IV Soln 5 GM/100ML (50 MG/ML)","drug_information":{"unit":100.0,"type":"ML"},"code_information":[{"code":"901784","type":"CDM"},{"code":"63323011761","type":"NDC"}],"standard_charges":[{"gross_charge":206.64,"discounted_cash":113.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Fosphenytoin Sodium Inj 75 MG/ML (Phenytoin Equiv 5*,Fosphenytoin Sodium Inj 100 MG/2ML (Phenytoin Equiv),Fosphenytoin Sodium Inj 500 MG/10ML (Phenytoin Equi*","drug_information":{"unit":2.0,"type":"ML"},"code_information":[{"code":"901785","type":"CDM"},{"code":"25021079810","type":"NDC"}],"standard_charges":[{"gross_charge":49.48,"discounted_cash":27.21,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Fosphenytoin Sodium Inj 75 MG/ML (Phenytoin Equiv 5*,Fosphenytoin Sodium Inj 100 MG/2ML (Phenytoin Equiv),Fosphenytoin Sodium Inj 500 MG/10ML (Phenytoin Equi*","drug_information":{"unit":2.0,"type":"ML"},"code_information":[{"code":"901785","type":"CDM"},{"code":"25021079802","type":"NDC"}],"standard_charges":[{"gross_charge":53.13,"discounted_cash":29.22,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Midazolam HCl Inj 1 MG/ML (Base Equivalent),Midazolam HCl Inj 2 MG/2ML (Base Equivalent),Midazolam HCl Inj 5 MG/5ML (Base Equivalent),Midazolam HCl Inj 10 MG/10ML (Base Equivalent),Midazolam HCl Inj PF 2 MG/2ML (Base Equivalent),Midazolam HCl Inj PF 5 MG/5ML (Base Equivalent)","drug_information":{"unit":5.0,"type":"ML"},"code_information":[{"code":"901793","type":"CDM"},{"code":"409230504","type":"NDC"}],"standard_charges":[{"gross_charge":37.1,"discounted_cash":20.40,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Midazolam HCl Inj 2 MG/2ML (Base Equivalent)","drug_information":{"unit":2.0,"type":"ML"},"code_information":[{"code":"901793","type":"CDM"},{"code":"23155060041","type":"NDC"}],"standard_charges":[{"gross_charge":35.69,"discounted_cash":19.63,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Midazolam HCl Inj 1 MG/ML (Base Equivalent),Midazolam HCl Inj 2 MG/2ML (Base Equivalent),Midazolam HCl Inj 5 MG/5ML (Base Equivalent),Midazolam HCl Inj 10 MG/10ML (Base Equivalent),Midazolam HCl Inj PF 2 MG/2ML (Base Equivalent),Midazolam HCl Inj PF 5 MG/5ML (Base Equivalent)","drug_information":{"unit":2.0,"type":"ML"},"code_information":[{"code":"901793","type":"CDM"},{"code":"641605725","type":"NDC"}],"standard_charges":[{"gross_charge":34.47,"discounted_cash":18.96,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Midazolam HCl Inj 2 MG/2ML (Base Equivalent)","drug_information":{"unit":2.0,"type":"ML"},"code_information":[{"code":"901793","type":"CDM"},{"code":"23155060031","type":"NDC"}],"standard_charges":[{"gross_charge":35.69,"discounted_cash":19.63,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Midazolam HCl Inj 1 MG/ML (Base Equivalent),Midazolam HCl Inj 2 MG/2ML (Base Equivalent),Midazolam HCl Inj 5 MG/5ML (Base Equivalent),Midazolam HCl Inj 10 MG/10ML (Base Equivalent),Midazolam HCl Inj PF 2 MG/2ML (Base Equivalent),Midazolam HCl Inj PF 5 MG/5ML (Base Equivalent)","drug_information":{"unit":5.0,"type":"ML"},"code_information":[{"code":"901793","type":"CDM"},{"code":"409230505","type":"NDC"}],"standard_charges":[{"gross_charge":37.07,"discounted_cash":20.39,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Midazolam HCl Inj 1 MG/ML (Base Equivalent),Midazolam HCl Inj 2 MG/2ML (Base Equivalent),Midazolam HCl Inj 5 MG/5ML (Base Equivalent),Midazolam HCl Inj 10 MG/10ML (Base Equivalent),Midazolam HCl Inj PF 2 MG/2ML (Base Equivalent),Midazolam HCl Inj PF 5 MG/5ML (Base Equivalent)","drug_information":{"unit":2.0,"type":"ML"},"code_information":[{"code":"901793","type":"CDM"},{"code":"641605701","type":"NDC"}],"standard_charges":[{"gross_charge":34.47,"discounted_cash":18.96,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Midazolam HCl Inj 5 MG/ML (Base Equivalent),Midazolam HCl Inj 10 MG/2ML (Base Equivalent),Midazolam HCl Inj 25 MG/5ML (Base Equivalent),Midazolam HCl Inj 50 MG/10ML (Base Equivalent),Midazolam HCl Inj PF 10 MG/2ML (Base Equivalent),Midazolam HCl Inj PF 5 MG/ML (Base Equivalent)","drug_information":{"unit":0.2,"type":"ML"},"code_information":[{"code":"901794","type":"CDM"},{"code":"641606010","type":"NDC"}],"standard_charges":[{"gross_charge":35.29,"discounted_cash":19.41,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Midazolam HCl Inj 5 MG/ML (Base Equivalent),Midazolam HCl Inj 10 MG/2ML (Base Equivalent),Midazolam HCl Inj 25 MG/5ML (Base Equivalent),Midazolam HCl Inj 50 MG/10ML (Base Equivalent),Midazolam HCl Inj PF 10 MG/2ML (Base Equivalent),Midazolam HCl Inj PF 5 MG/ML (Base Equivalent)","drug_information":{"unit":0.2,"type":"ML"},"code_information":[{"code":"901794","type":"CDM"},{"code":"409230801","type":"NDC"}],"standard_charges":[{"gross_charge":35.61,"discounted_cash":19.59,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Midazolam HCl Inj 5 MG/ML (Base Equivalent),Midazolam HCl Inj 10 MG/2ML (Base Equivalent),Midazolam HCl Inj 25 MG/5ML (Base Equivalent),Midazolam HCl Inj 50 MG/10ML (Base Equivalent),Midazolam HCl Inj PF 10 MG/2ML (Base Equivalent),Midazolam HCl Inj PF 5 MG/ML (Base Equivalent)","drug_information":{"unit":0.2,"type":"ML"},"code_information":[{"code":"901794","type":"CDM"},{"code":"409230802","type":"NDC"}],"standard_charges":[{"gross_charge":35.27,"discounted_cash":19.40,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Midazolam HCl Inj 5 MG/ML (Base Equivalent),Midazolam HCl Inj 10 MG/2ML (Base Equivalent),Midazolam HCl Inj 25 MG/5ML (Base Equivalent),Midazolam HCl Inj 50 MG/10ML (Base Equivalent),Midazolam HCl Inj PF 10 MG/2ML (Base Equivalent),Midazolam HCl Inj PF 5 MG/ML (Base Equivalent)","drug_information":{"unit":0.2,"type":"ML"},"code_information":[{"code":"901794","type":"CDM"},{"code":"641606001","type":"NDC"}],"standard_charges":[{"gross_charge":35.29,"discounted_cash":19.41,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Midazolam HCl Inj 5 MG/ML (Base Equivalent),Midazolam HCl Inj 10 MG/2ML (Base Equivalent),Midazolam HCl Inj 25 MG/5ML (Base Equivalent),Midazolam HCl Inj 50 MG/10ML (Base Equivalent),Midazolam HCl Inj PF 10 MG/2ML (Base Equivalent),Midazolam HCl Inj PF 5 MG/ML (Base Equivalent)","drug_information":{"unit":0.2,"type":"ML"},"code_information":[{"code":"901794","type":"CDM"},{"code":"409230822","type":"NDC"}],"standard_charges":[{"gross_charge":35.27,"discounted_cash":19.40,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Ondansetron HCl Inj 2 MG/ML,Ondansetron HCl Inj 4 MG/2ML (2 MG/ML),Ondansetron HCl Inj 40 MG/20ML (2 MG/ML),Ondansetron HCl Inj Soln Pref Syr 4 MG/2ML","drug_information":{"unit":2.0,"type":"ML"},"code_information":[{"code":"901796","type":"CDM"},{"code":"60505613000","type":"NDC"}],"standard_charges":[{"gross_charge":37.92,"discounted_cash":20.86,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Ondansetron HCl Inj 2 MG/ML,Ondansetron HCl Inj 4 MG/2ML (2 MG/ML),Ondansetron HCl Inj 40 MG/20ML (2 MG/ML),Ondansetron HCl Inj Soln Pref Syr 4 MG/2ML","drug_information":{"unit":2.0,"type":"ML"},"code_information":[{"code":"901796","type":"CDM"},{"code":"23155054831","type":"NDC"}],"standard_charges":[{"gross_charge":37.14,"discounted_cash":20.43,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Ondansetron HCl Inj 2 MG/ML,Ondansetron HCl Inj 4 MG/2ML (2 MG/ML),Ondansetron HCl Inj 40 MG/20ML (2 MG/ML),Ondansetron HCl Inj Soln Pref Syr 4 MG/2ML","drug_information":{"unit":2.0,"type":"ML"},"code_information":[{"code":"901796","type":"CDM"},{"code":"23155054842","type":"NDC"}],"standard_charges":[{"gross_charge":37.14,"discounted_cash":20.43,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Infliximab For IV Inj 100 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"901804","type":"CDM"},{"code":"57894016001","type":"NDC"}],"standard_charges":[{"gross_charge":857.5,"discounted_cash":471.62,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Alteplase For Inj 100 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"901923","type":"CDM"},{"code":"50242008527","type":"NDC"}],"standard_charges":[{"gross_charge":15343.62,"discounted_cash":8438.99,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Alteplase For Inj 100 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"901924","type":"CDM"},{"code":"50242008527","type":"NDC"}],"standard_charges":[{"gross_charge":15343.62,"discounted_cash":8438.99,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Ketorolac Tromethamine IM Inj 30 MG/ML,,,","drug_information":{"unit":0.5,"type":"ML"},"code_information":[{"code":"902047","type":"CDM"},{"code":"63323016200","type":"NDC"}],"standard_charges":[{"gross_charge":46.47,"discounted_cash":25.56,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Ketorolac Tromethamine IM Inj 30 MG/ML,,,","drug_information":{"unit":0.5,"type":"ML"},"code_information":[{"code":"902047","type":"CDM"},{"code":"63323016201","type":"NDC"}],"standard_charges":[{"gross_charge":46.47,"discounted_cash":25.56,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Artificial Tear Ophth Ointment,White Petrolatum-Mineral Oil Ophth Ointment","drug_information":{"unit":3.5,"type":"GM"},"code_information":[{"code":"902062","type":"CDM"},{"code":"65051801","type":"NDC"}],"standard_charges":[{"gross_charge":50.03,"discounted_cash":27.52,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Rocuronium Bromide IV Soln 10 MG/ML,Rocuronium Bromide IV Soln 50 MG/5ML (10 MG/ML),Rocuronium Bromide IV Soln 100 MG/10ML (10 MG/ML),Rocuronium Bromide IV Soln Pref Syr 100 MG/10ML (10 MG/ML),Rocuronium Bromide IV Soln Pref Syringe 50 MG/5ML (10 MG/ML)","drug_information":{"unit":5.0,"type":"ML"},"code_information":[{"code":"902077","type":"CDM"},{"code":"25021068705","type":"NDC"}],"standard_charges":[{"gross_charge":56.1,"discounted_cash":30.86,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Sufentanil Citrate Inj 50 MCG/ML,Sufentanil Citrate Inj 100 MCG/2ML (50 MCG/ML),Sufentanil Citrate Inj 250 MCG/5ML (50 MCG/ML)","drug_information":{"unit":0.2,"type":"ML"},"code_information":[{"code":"902079","type":"CDM"},{"code":"17478005005","type":"NDC"}],"standard_charges":[{"gross_charge":33.96,"discounted_cash":18.68,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Tobramycin Sulfate Inj 40 MG/ML,Tobramycin Sulfate Inj 80 MG/2ML (40 MG/ML),Tobramycin Sulfate Inj 1.2 GM/30ML (40 MG/ML),Tobramycin Sulfate Inj 2 GM/50ML (40 MG/ML)","drug_information":{"unit":2.0,"type":"ML"},"code_information":[{"code":"902080","type":"CDM"},{"code":"63323030602","type":"NDC"}],"standard_charges":[{"gross_charge":46.66,"discounted_cash":25.66,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Tobramycin Sulfate Inj 40 MG/ML,Tobramycin Sulfate Inj 80 MG/2ML (40 MG/ML),Tobramycin Sulfate Inj 1.2 GM/30ML (40 MG/ML),Tobramycin Sulfate Inj 2 GM/50ML (40 MG/ML)","drug_information":{"unit":2.0,"type":"ML"},"code_information":[{"code":"902080","type":"CDM"},{"code":"63323030630","type":"NDC"}],"standard_charges":[{"gross_charge":38.83,"discounted_cash":21.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Tobramycin Sulfate Inj 40 MG/ML,Tobramycin Sulfate Inj 80 MG/2ML (40 MG/ML),Tobramycin Sulfate Inj 1.2 GM/30ML (40 MG/ML),Tobramycin Sulfate Inj 2 GM/50ML (40 MG/ML)","drug_information":{"unit":2.0,"type":"ML"},"code_information":[{"code":"902080","type":"CDM"},{"code":"63323030601","type":"NDC"}],"standard_charges":[{"gross_charge":46.66,"discounted_cash":25.66,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Tocilizumab IV Inj 80 MG/4ML,Tocilizumab IV Inj 200 MG/10ML,Tocilizumab IV Inj 400 MG/20ML","drug_information":{"unit":4.0,"type":"ML"},"code_information":[{"code":"902081","type":"CDM"},{"code":"50242013501","type":"NDC"}],"standard_charges":[{"gross_charge":1114.57,"discounted_cash":613.01,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Tocilizumab IV Inj 80 MG/4ML,Tocilizumab IV Inj 200 MG/10ML,Tocilizumab IV Inj 400 MG/20ML","drug_information":{"unit":10.0,"type":"ML"},"code_information":[{"code":"902081","type":"CDM"},{"code":"50242013601","type":"NDC"}],"standard_charges":[{"gross_charge":2739.93,"discounted_cash":1506.96,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Tocilizumab IV Inj 80 MG/4ML,Tocilizumab IV Inj 200 MG/10ML,Tocilizumab IV Inj 400 MG/20ML","drug_information":{"unit":20.0,"type":"ML"},"code_information":[{"code":"902081","type":"CDM"},{"code":"50242013701","type":"NDC"}],"standard_charges":[{"gross_charge":5448.87,"discounted_cash":2996.88,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Chlorpromazine HCl Inj 50 MG/2ML","drug_information":{"unit":1.0,"type":"ML"},"code_information":[{"code":"902345","type":"CDM"},{"code":"641139835","type":"NDC"}],"standard_charges":[{"gross_charge":85.62,"discounted_cash":47.09,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Tobramycin Sulfate Inj 40 MG/ML,Tobramycin Sulfate Inj 80 MG/2ML (40 MG/ML),Tobramycin Sulfate Inj 1.2 GM/30ML (40 MG/ML),Tobramycin Sulfate Inj 2 GM/50ML (40 MG/ML)","drug_information":{"unit":2.0,"type":"ML"},"code_information":[{"code":"902364","type":"CDM"},{"code":"36000024401","type":"NDC"}],"standard_charges":[{"gross_charge":41.9,"discounted_cash":23.04,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Fentanyl Citrate Inj 0.05 MG/ML,Fentanyl Citrate Preservative Free (PF) Inj 100 MCG/2ML,Fentanyl Citrate Preservative Free (PF) Inj 1000 MCG/20ML,Fentanyl Citrate Preservative Free (PF) Inj 250 MCG/5ML,Fentanyl Citrate Preservative Free (PF) Inj 2500 MCG/50ML,Fentanyl Citrate Preservative Free (PF) Inj 500 MCG/10ML,Fentanyl Citrate PF Soln Cartridge 100 MCG/2ML,Fentanyl Citrate (PF) IV Soln Prefilled Syringe 100 MCG/2ML,Fentanyl Citrate Soln Prefilled Syringe 50 MCG/ML,Fentanyl Citrate Soln Prefilled Syringe 100 MCG/2ML,Fentanyl Citrate Preservative Free (PF) Inj 50 MCG/ML,Fentanyl Citrate IV Soln 2500 MCG/50ML,Fentanyl Citrate PF Soln Prefilled Syringe 50 MCG/ML","drug_information":{"unit":0.5,"type":"ML"},"code_information":[{"code":"902482","type":"CDM"},{"code":"409909422","type":"NDC"}],"standard_charges":[{"gross_charge":37.87,"discounted_cash":20.83,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Fentanyl Citrate Preservative Free (PF) Inj 2500 MCG/50ML","drug_information":{"unit":0.5,"type":"ML"},"code_information":[{"code":"902482","type":"CDM"},{"code":"409909461","type":"NDC"}],"standard_charges":[{"gross_charge":36.29,"discounted_cash":19.96,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Fentanyl Citrate Preservative Free (PF) Inj 2500 MCG/50ML","drug_information":{"unit":0.5,"type":"ML"},"code_information":[{"code":"902482","type":"CDM"},{"code":"641603001","type":"NDC"}],"standard_charges":[{"gross_charge":35.93,"discounted_cash":19.76,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Fentanyl Citrate Preservative Free (PF) Inj 2500 MCG/50ML","drug_information":{"unit":0.5,"type":"ML"},"code_information":[{"code":"902482","type":"CDM"},{"code":"409909441","type":"NDC"}],"standard_charges":[{"gross_charge":36.29,"discounted_cash":19.96,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Fentanyl Citrate Inj 0.05 MG/ML,Fentanyl Citrate Preservative Free (PF) Inj 100 MCG/2ML,Fentanyl Citrate Preservative Free (PF) Inj 1000 MCG/20ML,Fentanyl Citrate Preservative Free (PF) Inj 250 MCG/5ML,Fentanyl Citrate Preservative Free (PF) Inj 2500 MCG/50ML,Fentanyl Citrate Preservative Free (PF) Inj 500 MCG/10ML,Fentanyl Citrate PF Soln Cartridge 100 MCG/2ML,Fentanyl Citrate (PF) IV Soln Prefilled Syringe 100 MCG/2ML,Fentanyl Citrate Soln Prefilled Syringe 50 MCG/ML,Fentanyl Citrate Soln Prefilled Syringe 100 MCG/2ML,Fentanyl Citrate Preservative Free (PF) Inj 50 MCG/ML,Fentanyl Citrate IV Soln 2500 MCG/50ML,Fentanyl Citrate PF Soln Prefilled Syringe 50 MCG/ML","drug_information":{"unit":0.5,"type":"ML"},"code_information":[{"code":"902482","type":"CDM"},{"code":"409909418","type":"NDC"}],"standard_charges":[{"gross_charge":36.45,"discounted_cash":20.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Fentanyl Citrate Inj 0.05 MG/ML,Fentanyl Citrate Preservative Free (PF) Inj 100 MCG/2ML,Fentanyl Citrate Preservative Free (PF) Inj 1000 MCG/20ML,Fentanyl Citrate Preservative Free (PF) Inj 250 MCG/5ML,Fentanyl Citrate Preservative Free (PF) Inj 2500 MCG/50ML,Fentanyl Citrate Preservative Free (PF) Inj 500 MCG/10ML,Fentanyl Citrate PF Soln Cartridge 100 MCG/2ML,Fentanyl Citrate (PF) IV Soln Prefilled Syringe 100 MCG/2ML,Fentanyl Citrate Soln Prefilled Syringe 50 MCG/ML,Fentanyl Citrate Soln Prefilled Syringe 100 MCG/2ML,Fentanyl Citrate Preservative Free (PF) Inj 50 MCG/ML,Fentanyl Citrate IV Soln 2500 MCG/50ML,Fentanyl Citrate PF Soln Prefilled Syringe 50 MCG/ML","drug_information":{"unit":0.5,"type":"ML"},"code_information":[{"code":"902482","type":"CDM"},{"code":"63323080614","type":"NDC"}],"standard_charges":[{"gross_charge":35.71,"discounted_cash":19.64,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Methotrexate Sodium Inj PF 25 MG/ML,Methotrexate Sodium Inj PF 100 MG/4ML (25 MG/ML),Methotrexate Sodium Inj PF 50 MG/2ML (25 MG/ML),Methotrexate Sodium Inj PF 250 MG/10ML (25 MG/ML),Methotrexate Sodium Inj PF 1000 MG/40ML (25 MG/ML),Methotrexate Sodium Inj PF 200 MG/8ML (25 MG/ML),Methotrexate Sodium 50 MG/2ML IJ SOLN,Methotrexate Sodium 250 MG/10ML IJ SOLN","drug_information":{"unit":0.4,"type":"ML"},"code_information":[{"code":"902483","type":"CDM"},{"code":"143951910","type":"NDC"}],"standard_charges":[{"gross_charge":53.1,"discounted_cash":29.20,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Propofol IV Emul 10 MG/ML,Propofol IV Emul 100 MG/10ML (10 MG/ML),Propofol IV Emul 200 MG/20ML (10 MG/ML),Propofol IV Emul 500 MG/50ML (10 MG/ML)","drug_information":{"unit":20.0,"type":"ML"},"code_information":[{"code":"902485","type":"CDM"},{"code":"63323026929","type":"NDC"}],"standard_charges":[{"gross_charge":63.04,"discounted_cash":34.67,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Propofol IV Emul 100 MG/10ML (10 MG/ML)","drug_information":{"unit":10.0,"type":"ML"},"code_information":[{"code":"902485","type":"CDM"},{"code":"63323026906","type":"NDC"}],"standard_charges":[{"gross_charge":37.41,"discounted_cash":20.58,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Propofol IV Emul 10 MG/ML,Propofol IV Emul 100 MG/10ML (10 MG/ML),Propofol IV Emul 200 MG/20ML (10 MG/ML),Propofol IV Emul 500 MG/50ML (10 MG/ML)","drug_information":{"unit":20.0,"type":"ML"},"code_information":[{"code":"902485","type":"CDM"},{"code":"69020901","type":"NDC"}],"standard_charges":[{"gross_charge":54.05,"discounted_cash":29.73,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Sodium Chloride IV Soln 0.9%","drug_information":{"unit":1000.0,"type":"ML"},"code_information":[{"code":"902522","type":"CDM"},{"code":"264780009","type":"NDC"}],"standard_charges":[{"gross_charge":63.59,"discounted_cash":34.97,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Glucose Gel 40%","drug_information":{"unit":37.5,"type":"GM"},"code_information":[{"code":"902536","type":"CDM"},{"code":"574006915","type":"NDC"}],"standard_charges":[{"gross_charge":25.52,"discounted_cash":14.04,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Multiple Vitamins w/ Minerals Tab,Multiple Vitamins w/Minerals Tab,Multiple Vitamins w/ Minerals EC Tab,Multiple Vitamins w/ Iron Tab","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"902580","type":"CDM"},{"code":"904053061","type":"NDC"}],"standard_charges":[{"gross_charge":8.2,"discounted_cash":4.51,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Multiple Vitamins w/ Minerals Tab,Multiple Vitamins w/Minerals Tab,Multiple Vitamins w/ Minerals EC Tab,Multiple Vitamins w/ Iron Tab","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"902580","type":"CDM"},{"code":"904053961","type":"NDC"}],"standard_charges":[{"gross_charge":8.25,"discounted_cash":4.54,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Sodium Chloride IV Soln 0.9%","drug_information":{"unit":20.0,"type":"ML"},"code_information":[{"code":"902588","type":"CDM"},{"code":"264780009","type":"NDC"}],"standard_charges":[{"gross_charge":59.09,"discounted_cash":32.50,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"GI COCKTAIL","drug_information":{"unit":40.0,"type":"ML"},"code_information":[{"code":"902595","type":"CDM"},{"code":"8890259540","type":"NDC"}],"standard_charges":[{"gross_charge":201.8,"discounted_cash":110.99,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Menthol Lozenge","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"902616","type":"CDM"},{"code":"36602019210","type":"NDC"}],"standard_charges":[{"gross_charge":18.0,"discounted_cash":9.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Benzocaine-Menthol Lozenge 6-10 MG,Benzocaine-Menthol Lozenge 15-3.6 MG,Throat Lozenges - Lozenges,Benzocaine-Menthol Lozenge 15-4 MG,Benzocaine-Menthol Lozenge 15-2.6 MG,Benzocaine-Menthol Lozenge 15-3.6 MG,Benzocaine-Menthol Lozenge 6-10 MG,Menthol 3 mg mt lozg,Menthol 5 mg mt lozg,Menthol Lozenge 7 MG,Menthol Lozenge 9.1 MG,Menthol Lozenge,Benzocaine-Menthol Lozenge 15-4 MG,Menthol Lozenge 4.8 mg,DM-Benzocaine-Menthol 5-6-10 MG MT LOZG,Menthol Lozenge 7.6 MG,Menthol Lozenge 5.8 MG,Menthol Lozenge 7.5 MG,Sucrets Sore Throat 2 mg,Benzocaine-Menthol Lozenge 15-10 MG,Pectin Lozenge 2.8 MG,Menthol Lozenge 1.5 mg,Hexylresorcinol Lozg 2 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"902616","type":"CDM"},{"code":"9990261601","type":"NDC"}],"standard_charges":[{"gross_charge":18.0,"discounted_cash":9.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Propofol IV Emul 10 MG/ML,Propofol IV Emul 100 MG/10ML (10 MG/ML),Propofol IV Emul 1000 MG/100ML (10 MG/ML),Propofol IV Emul 200 MG/20ML (10 MG/ML),Propofol IV Emul 500 MG/50ML (10 MG/ML)","drug_information":{"unit":50.0,"type":"ML"},"code_information":[{"code":"902644","type":"CDM"},{"code":"591213655","type":"NDC"}],"standard_charges":[{"gross_charge":107.1,"discounted_cash":58.90,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Propofol IV Emul 1000 MG/100ML (10 MG/ML)","drug_information":{"unit":100.0,"type":"ML"},"code_information":[{"code":"902644","type":"CDM"},{"code":"409469954","type":"NDC"}],"standard_charges":[{"gross_charge":146.26,"discounted_cash":80.44,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Propofol IV Emul 10 MG/ML,Propofol IV Emul 100 MG/10ML (10 MG/ML),Propofol IV Emul 200 MG/20ML (10 MG/ML),Propofol IV Emul 500 MG/50ML (10 MG/ML)","drug_information":{"unit":20.0,"type":"ML"},"code_information":[{"code":"902644","type":"CDM"},{"code":"69020901","type":"NDC"}],"standard_charges":[{"gross_charge":54.05,"discounted_cash":29.73,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Propofol IV Emul 1000 MG/100ML (10 MG/ML)","drug_information":{"unit":100.0,"type":"ML"},"code_information":[{"code":"902644","type":"CDM"},{"code":"69024801","type":"NDC"}],"standard_charges":[{"gross_charge":146.26,"discounted_cash":80.44,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Propofol IV Emul 1000 MG/100ML (10 MG/ML)","drug_information":{"unit":100.0,"type":"ML"},"code_information":[{"code":"902644","type":"CDM"},{"code":"409469924","type":"NDC"}],"standard_charges":[{"gross_charge":146.26,"discounted_cash":80.44,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Propofol IV Emul 1000 MG/100ML (10 MG/ML)","drug_information":{"unit":100.0,"type":"ML"},"code_information":[{"code":"902644","type":"CDM"},{"code":"69024810","type":"NDC"}],"standard_charges":[{"gross_charge":146.26,"discounted_cash":80.44,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Morphine Sulfate IV Soln 1 MG/ML,Morphine Sulfate-Sodium Chloride 0.9% IV Soln 100 MG/100ML,Morphine Sulfate-NaCl Sol Pref Syr 50 MG/50ML-0.9% (1 MG/ML),Morphine Sulfate-Sodium Chloride 0.9% IV Soln 50 MG/50ML,Morphine Sulfate-NaCl Sol Pref Syr 30 MG/30ML-0.9% (1 MG/ML),Morphine Sulfate-NaCl Sol Pref Syr 55 MG/55ML-0.9% (1 MG/ML),Morphine Sulfate IV Soln PF 1 MG/ML","drug_information":{"unit":50.0,"type":"ML"},"code_information":[{"code":"902685","type":"CDM"},{"code":"70092112850","type":"NDC"}],"standard_charges":[{"gross_charge":122.09,"discounted_cash":67.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Rectal Protectant-Emollient Ointments,Phenylephrine-Shark Liver Oil-MO-Pet Oint 0.25-3-14*,Phenylephrine-Mineral Oil-PET 0.25-14-74.9 % RE OINT,Phenylephrine-Mineral Oil-Petrolatum Oint 0.25-14-71.9%","drug_information":{"unit":57.0,"type":"GM"},"code_information":[{"code":"902753","type":"CDM"},{"code":"45802018816","type":"NDC"}],"standard_charges":[{"gross_charge":39.32,"discounted_cash":21.63,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Sodium Chloride Inj 3%","drug_information":{"unit":100.0,"type":"ML"},"code_information":[{"code":"902787","type":"CDM"},{"code":"338005403","type":"NDC"}],"standard_charges":[{"gross_charge":61.3,"discounted_cash":33.72,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Gemcitabine HCl Inj 1 GM/26.3ml (38 MG/ML) (Base Eq,Gemcitabine HCl Inj 2 GM/52.6ML (38 MG/ML) (Base Eq,Gemcitabine HCl Inj 200 MG/5.26ML (38 MG/ML) (Base","drug_information":{"unit":52.6,"type":"ML"},"code_information":[{"code":"902790","type":"CDM"},{"code":"71288011754","type":"NDC"}],"standard_charges":[{"gross_charge":255.55,"discounted_cash":140.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Ophthalmic Irrigation Solution,Ophthalmic Irrigation Solution - Extraocular","drug_information":{"unit":118.0,"type":"ML"},"code_information":[{"code":"902957","type":"CDM"},{"code":"10119000252","type":"NDC"}],"standard_charges":[{"gross_charge":34.85,"discounted_cash":19.17,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Ophthalmic Irrigation Solution,Ophthalmic Irrigation Solution - Extraocular","drug_information":{"unit":30.0,"type":"ML"},"code_information":[{"code":"902957","type":"CDM"},{"code":"65053001","type":"NDC"}],"standard_charges":[{"gross_charge":123.53,"discounted_cash":67.94,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Ophthalmic Irrigation Solution,Ophthalmic Irrigation Solution - Extraocular","drug_information":{"unit":118.0,"type":"ML"},"code_information":[{"code":"902957","type":"CDM"},{"code":"65053004","type":"NDC"}],"standard_charges":[{"gross_charge":180.83,"discounted_cash":99.46,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Furosemide Inj 10 MG/ML","drug_information":{"unit":22.0,"type":"ML"},"code_information":[{"code":"902962","type":"CDM"},{"code":"25021031102","type":"NDC"}],"standard_charges":[{"gross_charge":119.11,"discounted_cash":65.51,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Furosemide Inj 10 MG/ML","drug_information":{"unit":22.0,"type":"ML"},"code_information":[{"code":"902962","type":"CDM"},{"code":"63323028005","type":"NDC"}],"standard_charges":[{"gross_charge":68.59,"discounted_cash":37.72,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Furosemide Inj 10 MG/ML","drug_information":{"unit":22.0,"type":"ML"},"code_information":[{"code":"902962","type":"CDM"},{"code":"409610219","type":"NDC"}],"standard_charges":[{"gross_charge":243.6,"discounted_cash":133.98,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Furosemide Inj 10 MG/ML","drug_information":{"unit":22.0,"type":"ML"},"code_information":[{"code":"902962","type":"CDM"},{"code":"409610225","type":"NDC"}],"standard_charges":[{"gross_charge":204.8,"discounted_cash":112.64,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Furosemide Inj 10 MG/ML","drug_information":{"unit":22.0,"type":"ML"},"code_information":[{"code":"902962","type":"CDM"},{"code":"71288020305","type":"NDC"}],"standard_charges":[{"gross_charge":70.65,"discounted_cash":38.86,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Furosemide Inj 10 MG/ML","drug_information":{"unit":22.0,"type":"ML"},"code_information":[{"code":"902962","type":"CDM"},{"code":"71288020304","type":"NDC"}],"standard_charges":[{"gross_charge":70.65,"discounted_cash":38.86,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Furosemide Inj 10 MG/ML","drug_information":{"unit":22.0,"type":"ML"},"code_information":[{"code":"902963","type":"CDM"},{"code":"71288020305","type":"NDC"}],"standard_charges":[{"gross_charge":70.65,"discounted_cash":38.86,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Furosemide Inj 10 MG/ML","drug_information":{"unit":22.0,"type":"ML"},"code_information":[{"code":"902963","type":"CDM"},{"code":"71288020304","type":"NDC"}],"standard_charges":[{"gross_charge":70.65,"discounted_cash":38.86,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Furosemide Inj 10 MG/ML","drug_information":{"unit":22.0,"type":"ML"},"code_information":[{"code":"902963","type":"CDM"},{"code":"25021031102","type":"NDC"}],"standard_charges":[{"gross_charge":119.11,"discounted_cash":65.51,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Furosemide Inj 10 MG/ML","drug_information":{"unit":22.0,"type":"ML"},"code_information":[{"code":"902963","type":"CDM"},{"code":"25021031104","type":"NDC"}],"standard_charges":[{"gross_charge":89.74,"discounted_cash":49.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Furosemide Inj 10 MG/ML","drug_information":{"unit":22.0,"type":"ML"},"code_information":[{"code":"902963","type":"CDM"},{"code":"63323028003","type":"NDC"}],"standard_charges":[{"gross_charge":113.24,"discounted_cash":62.28,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Furosemide Inj 10 MG/ML","drug_information":{"unit":22.0,"type":"ML"},"code_information":[{"code":"902963","type":"CDM"},{"code":"409610219","type":"NDC"}],"standard_charges":[{"gross_charge":243.6,"discounted_cash":133.98,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Furosemide Inj 10 MG/ML","drug_information":{"unit":22.0,"type":"ML"},"code_information":[{"code":"902963","type":"CDM"},{"code":"409610225","type":"NDC"}],"standard_charges":[{"gross_charge":204.8,"discounted_cash":112.64,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Furosemide Inj 10 MG/ML","drug_information":{"unit":22.0,"type":"ML"},"code_information":[{"code":"902963","type":"CDM"},{"code":"63323028005","type":"NDC"}],"standard_charges":[{"gross_charge":68.59,"discounted_cash":37.72,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Furosemide Inj 10 MG/ML","drug_information":{"unit":22.0,"type":"ML"},"code_information":[{"code":"902964","type":"CDM"},{"code":"409610225","type":"NDC"}],"standard_charges":[{"gross_charge":204.8,"discounted_cash":112.64,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Furosemide Inj 10 MG/ML","drug_information":{"unit":22.0,"type":"ML"},"code_information":[{"code":"902964","type":"CDM"},{"code":"63323028026","type":"NDC"}],"standard_charges":[{"gross_charge":60.37,"discounted_cash":33.20,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Furosemide Inj 10 MG/ML","drug_information":{"unit":22.0,"type":"ML"},"code_information":[{"code":"902964","type":"CDM"},{"code":"71288020305","type":"NDC"}],"standard_charges":[{"gross_charge":70.65,"discounted_cash":38.86,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Furosemide Inj 10 MG/ML","drug_information":{"unit":22.0,"type":"ML"},"code_information":[{"code":"902964","type":"CDM"},{"code":"409610219","type":"NDC"}],"standard_charges":[{"gross_charge":243.6,"discounted_cash":133.98,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Furosemide Inj 10 MG/ML","drug_information":{"unit":22.0,"type":"ML"},"code_information":[{"code":"902964","type":"CDM"},{"code":"63323028003","type":"NDC"}],"standard_charges":[{"gross_charge":113.24,"discounted_cash":62.28,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Furosemide Inj 10 MG/ML","drug_information":{"unit":22.0,"type":"ML"},"code_information":[{"code":"902964","type":"CDM"},{"code":"63323028005","type":"NDC"}],"standard_charges":[{"gross_charge":68.59,"discounted_cash":37.72,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Furosemide Inj 10 MG/ML","drug_information":{"unit":22.0,"type":"ML"},"code_information":[{"code":"902964","type":"CDM"},{"code":"25021031104","type":"NDC"}],"standard_charges":[{"gross_charge":89.74,"discounted_cash":49.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Furosemide Inj 10 MG/ML","drug_information":{"unit":22.0,"type":"ML"},"code_information":[{"code":"902964","type":"CDM"},{"code":"63323028036","type":"NDC"}],"standard_charges":[{"gross_charge":49.01,"discounted_cash":26.96,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Furosemide Inj 10 MG/ML","drug_information":{"unit":22.0,"type":"ML"},"code_information":[{"code":"902964","type":"CDM"},{"code":"71288020304","type":"NDC"}],"standard_charges":[{"gross_charge":70.65,"discounted_cash":38.86,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Furosemide Inj 10 MG/ML","drug_information":{"unit":22.0,"type":"ML"},"code_information":[{"code":"902964","type":"CDM"},{"code":"25021031102","type":"NDC"}],"standard_charges":[{"gross_charge":119.11,"discounted_cash":65.51,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Hydromorphone HCl-Sodium Chloride 0.9% Inj 0.2 MG/ML,,,,,Hydromorphone HCl-NaCl Inj Soln Pref Syr 10 MG/50ML-0.9%,,,,Hydromorphone HCl IV Soln 0.2 MG/ML","drug_information":{"unit":50.0,"type":"ML"},"code_information":[{"code":"902986","type":"CDM"},{"code":"70092911450","type":"NDC"}],"standard_charges":[{"gross_charge":124.9,"discounted_cash":68.70,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Propofol IV Emul 500 MG/50ML (10 MG/ML)","drug_information":{"unit":50.0,"type":"ML"},"code_information":[{"code":"903009","type":"CDM"},{"code":"25021060850","type":"NDC"}],"standard_charges":[{"gross_charge":126.1,"discounted_cash":69.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Sodium Phosphates Inj 15 mM/5ML (Phos) 20 mEq/5ML (Na),Sodium Phosphates Inj 45 mM/15ML (Phos) 60 mEq/15ML (Na),Sodium Phosphates Inj 150 mM/50ML (Phos) 200 mEq/50ML (Na),","drug_information":{"unit":5.0,"type":"ML"},"code_information":[{"code":"903040","type":"CDM"},{"code":"63323088406","type":"NDC"}],"standard_charges":[{"gross_charge":120.67,"discounted_cash":66.37,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Sodium Phosphates Inj 15 mM/5ML (Phos) 20 mEq/5ML (Na),Sodium Phosphates Inj 45 mM/15ML (Phos) 60 mEq/15ML (Na),Sodium Phosphates Inj 150 mM/50ML (Phos) 200 mEq/50ML (Na),","drug_information":{"unit":15.0,"type":"ML"},"code_information":[{"code":"903040","type":"CDM"},{"code":"409739182","type":"NDC"}],"standard_charges":[{"gross_charge":216.78,"discounted_cash":119.23,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Atropine Sulfate Soln Prefill Syr 0.5 MG/5ML (0.1 MG/ML), Atropine Sulfate Soln Prefill Syr 1 MG/10ML (0.1 MG/ML),","drug_information":{"unit":5.0,"type":"ML"},"code_information":[{"code":"903041","type":"CDM"},{"code":"409491011","type":"NDC"}],"standard_charges":[{"gross_charge":121.09,"discounted_cash":66.60,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Atropine Sulfate Soln Prefill Syr 0.5 MG/5ML (0.1 MG/ML), Atropine Sulfate Soln Prefill Syr 1 MG/10ML (0.1 MG/ML),","drug_information":{"unit":5.0,"type":"ML"},"code_information":[{"code":"903041","type":"CDM"},{"code":"76329334001","type":"NDC"}],"standard_charges":[{"gross_charge":57.45,"discounted_cash":31.60,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Poractant Alfa Intratracheal Susp 240 MG/3ML","drug_information":{"unit":3.0,"type":"ML"},"code_information":[{"code":"903042","type":"CDM"},{"code":"10122051003","type":"NDC"}],"standard_charges":[{"gross_charge":2133.95,"discounted_cash":1173.67,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Benzocaine Dental Soln 20%,Benzocaine Mouth/Throat Aerosol 20%","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"903045","type":"CDM"},{"code":"283061043","type":"NDC"}],"standard_charges":[{"gross_charge":46.25,"discounted_cash":25.44,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Benzocaine Dental Soln 20%,Benzocaine Mouth/Throat Aerosol 20%","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"903045","type":"CDM"},{"code":"283061026","type":"NDC"}],"standard_charges":[{"gross_charge":46.25,"discounted_cash":25.44,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Infliximab-dyyb For IV Inj 100 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"903049","type":"CDM"},{"code":"69080901","type":"NDC"}],"standard_charges":[{"gross_charge":1677.53,"discounted_cash":922.64,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Infliximab-abda For IV Inj 100 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"903121","type":"CDM"},{"code":"78206016201","type":"NDC"}],"standard_charges":[{"gross_charge":1341.9,"discounted_cash":738.04,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Sodium Chloride IV Soln 0.9%","drug_information":{"unit":250.0,"type":"ML"},"code_information":[{"code":"903144","type":"CDM"},{"code":"264780009","type":"NDC"}],"standard_charges":[{"gross_charge":60.15,"discounted_cash":33.08,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Sodium Chloride IV Soln 0.9%","drug_information":{"unit":250.0,"type":"ML"},"code_information":[{"code":"903144","type":"CDM"},{"code":"264180031","type":"NDC"}],"standard_charges":[{"gross_charge":120.31,"discounted_cash":66.17,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Sodium Chloride IV Soln 0.9%","drug_information":{"unit":250.0,"type":"ML"},"code_information":[{"code":"903144","type":"CDM"},{"code":"264180032","type":"NDC"}],"standard_charges":[{"gross_charge":84.71,"discounted_cash":46.59,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Hydromorphone HCl-Sodium Chloride 0.9% Inj 1 MG/ML","drug_information":{"unit":50.0,"type":"ML"},"code_information":[{"code":"903226","type":"CDM"},{"code":"8888802316","type":"NDC"}],"standard_charges":[{"gross_charge":176.96,"discounted_cash":97.33,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Fentanyl Citrate (PF) IV Soln 2500 MCG/50ML,Fentanyl Citrate Preservative Free (PF) Inj 2500 MCG/50ML","drug_information":{"unit":50.0,"type":"ML"},"code_information":[{"code":"903228","type":"CDM"},{"code":"70092122335","type":"NDC"}],"standard_charges":[{"gross_charge":454.75,"discounted_cash":250.11,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Epinephrine PF Soln Prefilled Syringe 1 MG/10ML (0.1 MG/ML),Epinephrine HCl-NaCl IV Sol Pref Syr 1000 MCG/10ML-0.9%,Epinephrine Soln Prefilled Syringe 1 MG/10ML (0.1 MG/ML),Epinephrine IV Soln Prefilled Syringe 1MG/10ML (0.1 MG/ML),Epinephrine IV Soln 1MG/10ML (0.1 MG/ML)","drug_information":{"unit":10.0,"type":"ML"},"code_information":[{"code":"903238","type":"CDM"},{"code":"76329331801","type":"NDC"}],"standard_charges":[{"gross_charge":94.49,"discounted_cash":51.97,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Ephedrine Sulfate Inj 50 MG/ML,Ephedrine Sulfate IV Soln 50 MG/ML","drug_information":{"unit":0.1,"type":"ML"},"code_information":[{"code":"903259","type":"CDM"},{"code":"72572015010","type":"NDC"}],"standard_charges":[{"gross_charge":34.58,"discounted_cash":19.02,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Ephedrine Sulfate Inj 50 MG/ML,Ephedrine Sulfate IV Soln 50 MG/ML","drug_information":{"unit":0.1,"type":"ML"},"code_information":[{"code":"903259","type":"CDM"},{"code":"72572015001","type":"NDC"}],"standard_charges":[{"gross_charge":34.58,"discounted_cash":19.02,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Rabies Immune Globulin (Human) Inj 300 Unit/ML,,","drug_information":{"unit":1.0,"type":"ML"},"code_information":[{"code":"903290","type":"CDM"},{"code":"13533031810","type":"NDC"}],"standard_charges":[{"gross_charge":1259.4,"discounted_cash":692.67,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Rabies Immune Globulin (Human) Inj 300 Unit/ML,,","drug_information":{"unit":1.0,"type":"ML"},"code_information":[{"code":"903290","type":"CDM"},{"code":"13533031801","type":"NDC"}],"standard_charges":[{"gross_charge":1259.4,"discounted_cash":692.67,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Succinylcholine Chloride Inj 20 MG/ML,Succinylcholine Chloride Sol Pref Syr 100 MG/5ML (20 MG/ML),Succinylcholine Chloride Sol Pref Syr 140 MG/7ML (20 MG/ML),Succinylcholine Chloride Sol Pref Syr 200 MG/10ML (20 MG/ML),Succinylcholine Cl Inj Sol Pref Syr 100 MG/5ML (20 MG/ML)","drug_information":{"unit":10.0,"type":"ML"},"code_information":[{"code":"903299","type":"CDM"},{"code":"72572075010","type":"NDC"}],"standard_charges":[{"gross_charge":90.44,"discounted_cash":49.74,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Succinylcholine Chloride Inj 20 MG/ML,Succinylcholine Chloride Sol Pref Syr 100 MG/5ML (20 MG/ML),Succinylcholine Chloride Sol Pref Syr 140 MG/7ML (20 MG/ML),Succinylcholine Chloride Sol Pref Syr 200 MG/10ML (20 MG/ML),Succinylcholine Cl Inj Sol Pref Syr 100 MG/5ML (20 MG/ML)","drug_information":{"unit":5.0,"type":"ML"},"code_information":[{"code":"903299","type":"CDM"},{"code":"8888903299","type":"NDC"}],"standard_charges":[{"gross_charge":75.76,"discounted_cash":41.67,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Succinylcholine Chloride Inj 20 MG/ML,Succinylcholine Chloride Sol Pref Syr 100 MG/5ML (20 MG/ML),Succinylcholine Chloride Sol Pref Syr 140 MG/7ML (20 MG/ML),Succinylcholine Chloride Sol Pref Syr 200 MG/10ML (20 MG/ML),Succinylcholine Cl Inj Sol Pref Syr 100 MG/5ML (20 MG/ML)","drug_information":{"unit":10.0,"type":"ML"},"code_information":[{"code":"903299","type":"CDM"},{"code":"72572075001","type":"NDC"}],"standard_charges":[{"gross_charge":90.44,"discounted_cash":49.74,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Succinylcholine Chloride Inj 20 MG/ML","drug_information":{"unit":10.0,"type":"ML"},"code_information":[{"code":"903299","type":"CDM"},{"code":"71288071911","type":"NDC"}],"standard_charges":[{"gross_charge":57.7,"discounted_cash":31.74,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Succinylcholine Chloride Inj 20 MG/ML","drug_information":{"unit":10.0,"type":"ML"},"code_information":[{"code":"903299","type":"CDM"},{"code":"71288071910","type":"NDC"}],"standard_charges":[{"gross_charge":57.7,"discounted_cash":31.74,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Saline Injection Bacteriostatic,Saline injection w/benzyl alcohol","drug_information":{"unit":10.0,"type":"ML"},"code_information":[{"code":"903313","type":"CDM"},{"code":"63323092401","type":"NDC"}],"standard_charges":[{"gross_charge":40.52,"discounted_cash":22.29,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Ketamine HCl Inj 10 MG/ML,Ketamine HCl Soln Pref Syr 100 MG/10ML (10 MG/ML),Ketamine HCl Soln Pref Syr 30 MG/3ML (10 MG/ML),Ketamine HCl Soln Pref Syr 50 MG/5ML (10 MG/ML),Ketamine HCl-NaCl Inj Soln Pref Sy 50 MG/5ML-0.9% (10MG/ML),Ketamine HCl Soln Pref Syr 20 MG/2ML (10 MG/ML),Ketamine HCl IV Soln Pref Syr 50 MG/5ML (10 MG/ML),Ketamine HCl-NaCl Soln Pref Sy 10 MG/ML-0.9% (10MG/ML),Ketamine HCl-NaCl Soln Pref Sy 100 MG/10ML-0.9% (10MG/ML),Ketamine HCl-NaCl Soln Pref Sy 20 MG/2ML-0.9% (10MG/ML),Ketamine HCl-NaCl Soln Pref Sy 50 MG/5ML-0.9% (10MG/ML),Ketamine HCl-NaCl Inj Pref Syr 100 MG/10ML-0.9% (10MG/ML)","drug_information":{"unit":20.0,"type":"ML"},"code_information":[{"code":"903361","type":"CDM"},{"code":"25021068220","type":"NDC"}],"standard_charges":[{"gross_charge":143.04,"discounted_cash":78.67,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Ketamine HCl Inj 10 MG/ML,Ketamine HCl Soln Pref Syr 100 MG/10ML (10 MG/ML),Ketamine HCl Soln Pref Syr 30 MG/3ML (10 MG/ML),Ketamine HCl Soln Pref Syr 50 MG/5ML (10 MG/ML),Ketamine HCl-NaCl Inj Soln Pref Sy 50 MG/5ML-0.9% (10MG/ML),Ketamine HCl Soln Pref Syr 20 MG/2ML (10 MG/ML),Ketamine HCl IV Soln Pref Syr 50 MG/5ML (10 MG/ML),Ketamine HCl-NaCl Soln Pref Sy 10 MG/ML-0.9% (10MG/ML),Ketamine HCl-NaCl Soln Pref Sy 100 MG/10ML-0.9% (10MG/ML),Ketamine HCl-NaCl Soln Pref Sy 20 MG/2ML-0.9% (10MG/ML),Ketamine HCl-NaCl Soln Pref Sy 50 MG/5ML-0.9% (10MG/ML),Ketamine HCl-NaCl Inj Pref Syr 100 MG/10ML-0.9% (10MG/ML)","drug_information":{"unit":5.0,"type":"ML"},"code_information":[{"code":"903361","type":"CDM"},{"code":"880423505","type":"NDC"}],"standard_charges":[{"gross_charge":53.85,"discounted_cash":29.62,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Ketamine HCl Inj 10 MG/ML,Ketamine HCl Soln Pref Syr 100 MG/10ML (10 MG/ML),Ketamine HCl Soln Pref Syr 30 MG/3ML (10 MG/ML),Ketamine HCl Soln Pref Syr 50 MG/5ML (10 MG/ML),Ketamine HCl-NaCl Inj Soln Pref Sy 50 MG/5ML-0.9% (10MG/ML),Ketamine HCl Soln Pref Syr 20 MG/2ML (10 MG/ML),Ketamine HCl IV Soln Pref Syr 50 MG/5ML (10 MG/ML),Ketamine HCl-NaCl Soln Pref Sy 10 MG/ML-0.9% (10MG/ML),Ketamine HCl-NaCl Soln Pref Sy 100 MG/10ML-0.9% (10MG/ML),Ketamine HCl-NaCl Soln Pref Sy 20 MG/2ML-0.9% (10MG/ML),Ketamine HCl-NaCl Soln Pref Sy 50 MG/5ML-0.9% (10MG/ML),Ketamine HCl-NaCl Inj Pref Syr 100 MG/10ML-0.9% (10MG/ML)","drug_information":{"unit":5.0,"type":"ML"},"code_information":[{"code":"903361","type":"CDM"},{"code":"71266908002","type":"NDC"}],"standard_charges":[{"gross_charge":61.65,"discounted_cash":33.91,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Labetalol HCl IV Soln 5 MG/ML,Labetalol HCl IV Soln Prefilled Syringe 20 MG/4ML (5 MG/ML),Labetalol HCl IV Soln Prefilled Syringe 25 MG/5ML (5 MG/ML),Labetalol HCl IV Soln Prefilled Syringe 50 MG/10ML (5 MG/ML),Labetalol HCl IV Soln Prefilled Syringe 10 MG/2ML (5 MG/ML)","drug_information":{"unit":4.0,"type":"ML"},"code_information":[{"code":"903362","type":"CDM"},{"code":"409233924","type":"NDC"}],"standard_charges":[{"gross_charge":72.97,"discounted_cash":40.13,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Labetalol HCl IV Soln 5 MG/ML,Labetalol HCl IV Soln Prefilled Syringe 20 MG/4ML (5 MG/ML),Labetalol HCl IV Soln Prefilled Syringe 25 MG/5ML (5 MG/ML),Labetalol HCl IV Soln Prefilled Syringe 50 MG/10ML (5 MG/ML),Labetalol HCl IV Soln Prefilled Syringe 10 MG/2ML (5 MG/ML)","drug_information":{"unit":4.0,"type":"ML"},"code_information":[{"code":"903362","type":"CDM"},{"code":"8890336205","type":"NDC"}],"standard_charges":[{"gross_charge":35.24,"discounted_cash":19.38,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Labetalol HCl IV Soln 5 MG/ML,Labetalol HCl IV Soln Prefilled Syringe 20 MG/4ML (5 MG/ML),Labetalol HCl IV Soln Prefilled Syringe 25 MG/5ML (5 MG/ML),Labetalol HCl IV Soln Prefilled Syringe 50 MG/10ML (5 MG/ML),Labetalol HCl IV Soln Prefilled Syringe 10 MG/2ML (5 MG/ML)","drug_information":{"unit":4.0,"type":"ML"},"code_information":[{"code":"903362","type":"CDM"},{"code":"409233934","type":"NDC"}],"standard_charges":[{"gross_charge":72.97,"discounted_cash":40.13,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Labetalol HCl IV Soln 5 MG/ML,Labetalol HCl IV Soln Prefilled Syringe 20 MG/4ML (5 MG/ML),Labetalol HCl IV Soln Prefilled Syringe 25 MG/5ML (5 MG/ML),Labetalol HCl IV Soln Prefilled Syringe 50 MG/10ML (5 MG/ML),Labetalol HCl IV Soln Prefilled Syringe 10 MG/2ML (5 MG/ML)","drug_information":{"unit":20.0,"type":"ML"},"code_information":[{"code":"903362","type":"CDM"},{"code":"36000032202","type":"NDC"}],"standard_charges":[{"gross_charge":42.3,"discounted_cash":23.26,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Labetalol HCl IV Soln 5 MG/ML,Labetalol HCl IV Soln Prefilled Syringe 20 MG/4ML (5 MG/ML),Labetalol HCl IV Soln Prefilled Syringe 25 MG/5ML (5 MG/ML),Labetalol HCl IV Soln Prefilled Syringe 50 MG/10ML (5 MG/ML),Labetalol HCl IV Soln Prefilled Syringe 10 MG/2ML (5 MG/ML)","drug_information":{"unit":4.0,"type":"ML"},"code_information":[{"code":"903362","type":"CDM"},{"code":"36000032001","type":"NDC"}],"standard_charges":[{"gross_charge":50.5,"discounted_cash":27.78,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Zinc Sulfate Cap 220 MG (50 MG Elemental Zn),Zinc Sulfate Cap 50 MG (Elemental Zn)","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"903363","type":"CDM"},{"code":"20555004000","type":"NDC"}],"standard_charges":[{"gross_charge":3.22,"discounted_cash":1.77,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Atropine Sulfate Inj 0.4 MG/ML,Atropine Sulfate Inj 8 MG/20ML (0.4 MG/ML),Atropine Sulfate IV Soln 0.4 MG/ML","drug_information":{"unit":0.5,"type":"ML"},"code_information":[{"code":"903389","type":"CDM"},{"code":"517100425","type":"NDC"}],"standard_charges":[{"gross_charge":49.53,"discounted_cash":27.24,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Atropine Sulfate Inj 0.4 MG/ML,Atropine Sulfate Inj 8 MG/20ML (0.4 MG/ML),Atropine Sulfate IV Soln 0.4 MG/ML","drug_information":{"unit":0.5,"type":"ML"},"code_information":[{"code":"903389","type":"CDM"},{"code":"517100401","type":"NDC"}],"standard_charges":[{"gross_charge":49.54,"discounted_cash":27.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Heparin Sod (Porcine)-NaCl IV Soln 1000 Unit/500ML-0.9%,Heparin Sod (Porcine)-NaCl IV Soln 2000 Unit/L-0.9%,","drug_information":{"unit":500.0,"type":"ML"},"code_information":[{"code":"903400","type":"CDM"},{"code":"409100520","type":"NDC"}],"standard_charges":[{"gross_charge":64.38,"discounted_cash":35.41,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Heparin Sod (Porcine)-NaCl IV Soln 1000 Unit/500ML-0.9%,Heparin Sod (Porcine)-NaCl IV Soln 2000 Unit/L-0.9%,","drug_information":{"unit":500.0,"type":"ML"},"code_information":[{"code":"903400","type":"CDM"},{"code":"338043103","type":"NDC"}],"standard_charges":[{"gross_charge":57.7,"discounted_cash":31.74,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Heparin Sod (Porcine)-NaCl IV Soln 1000 Unit/500ML-0.9%,Heparin Sod (Porcine)-NaCl IV Soln 2000 Unit/L-0.9%,","drug_information":{"unit":500.0,"type":"ML"},"code_information":[{"code":"903400","type":"CDM"},{"code":"264987210","type":"NDC"}],"standard_charges":[{"gross_charge":55.48,"discounted_cash":30.51,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Lidocaine HCl (Cardiac) IV Soln Pref Syr 50 MG/5ML (1%),Lidocaine HCl (Cardiac) IV PF Soln Pref Syr 50 MG/5ML(1%),Lidocaine HCl IV Inj 10 MG/ML","drug_information":{"unit":5.0,"type":"ML"},"code_information":[{"code":"903401","type":"CDM"},{"code":"409490411","type":"NDC"}],"standard_charges":[{"gross_charge":117.2,"discounted_cash":64.46,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Lidocaine HCl (Cardiac) IV Soln 100 MG/5ML (2%),Lidocaine HCl (Cardiac) IV Soln Pref Syr 100 MG/5ML (2%),Lidocaine HCl (Cardiac) IV PF Soln 100 MG/5ML (2%),Lidocaine HCl(Cardiac) IV PF Soln Pref Syr 100 MG/5ML (2%),Lidocaine HCl IV Inj 20 MG/ML","drug_information":{"unit":5.0,"type":"ML"},"code_information":[{"code":"903402","type":"CDM"},{"code":"76329339001","type":"NDC"}],"standard_charges":[{"gross_charge":77.5,"discounted_cash":42.62,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Prochlorperazine Edisylate Inj 10 MG/2ML,Prochlorperazine Edisylate Inj 50 MG/10ML,Prochlorperazine Edisylate Inj 5 MG/ML","drug_information":{"unit":1.0,"type":"ML"},"code_information":[{"code":"903403","type":"CDM"},{"code":"25021079002","type":"NDC"}],"standard_charges":[{"gross_charge":43.24,"discounted_cash":23.78,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Prochlorperazine Edisylate Inj 10 MG/2ML,Prochlorperazine Edisylate Inj 50 MG/10ML,Prochlorperazine Edisylate Inj 5 MG/ML","drug_information":{"unit":1.0,"type":"ML"},"code_information":[{"code":"903403","type":"CDM"},{"code":"23155029442","type":"NDC"}],"standard_charges":[{"gross_charge":43.94,"discounted_cash":24.17,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Prochlorperazine Edisylate Inj 10 MG/2ML,Prochlorperazine Edisylate Inj 50 MG/10ML,Prochlorperazine Edisylate Inj 5 MG/ML","drug_information":{"unit":1.0,"type":"ML"},"code_information":[{"code":"903403","type":"CDM"},{"code":"23155029431","type":"NDC"}],"standard_charges":[{"gross_charge":43.94,"discounted_cash":24.17,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Sodium Chloride IV Soln 0.9%","drug_information":{"unit":250.0,"type":"ML"},"code_information":[{"code":"903406","type":"CDM"},{"code":"264780009","type":"NDC"}],"standard_charges":[{"gross_charge":60.15,"discounted_cash":33.08,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Lactated Ringer's Solution","drug_information":{"unit":250.0,"type":"ML"},"code_information":[{"code":"903408","type":"CDM"},{"code":"338011704","type":"NDC"}],"standard_charges":[{"gross_charge":61.3,"discounted_cash":33.72,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Oxytocin-Sodium Chloride 0.9% IV Soln 30 Unit/500 mL","drug_information":{"unit":500.0,"type":"ML"},"code_information":[{"code":"903466","type":"CDM"},{"code":"70092155207","type":"NDC"}],"standard_charges":[{"gross_charge":166.73,"discounted_cash":91.70,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Morphine Sulfate IV Soln 1 MG/ML,Morphine Sulfate-Sodium Chloride 0.9% IV Soln 100 MG/100ML,Morphine Sulfate-NaCl Sol Pref Syr 50 MG/50ML-0.9% (1 MG/ML),Morphine Sulfate-Sodium Chloride 0.9% IV Soln 50 MG/50ML,Morphine Sulfate-NaCl Sol Pref Syr 30 MG/30ML-0.9% (1 MG/ML),Morphine Sulfate-NaCl Sol Pref Syr 55 MG/55ML-0.9% (1 MG/ML),Morphine Sulfate IV Soln PF 1 MG/ML","drug_information":{"unit":50.0,"type":"ML"},"code_information":[{"code":"903472","type":"CDM"},{"code":"70092112850","type":"NDC"}],"standard_charges":[{"gross_charge":122.09,"discounted_cash":67.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Hydromorphone HCl-Sodium Chloride 0.9% Inj 0.2 MG/ML,,,,,Hydromorphone HCl-NaCl Inj Soln Pref Syr 10 MG/50ML-0.9%,,,,Hydromorphone HCl IV Soln 0.2 MG/ML","drug_information":{"unit":50.0,"type":"ML"},"code_information":[{"code":"903474","type":"CDM"},{"code":"70092911450","type":"NDC"}],"standard_charges":[{"gross_charge":124.9,"discounted_cash":68.70,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Calcium Carbonate (Antacid) Chew Tab 500 MG,Calcium Carbonate Chew Tab 500 MG,Calcium Carbonate Chew Tab 1250 MG (500 MG Elemental Ca)","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"903495","type":"CDM"},{"code":"68084098832","type":"NDC"}],"standard_charges":[{"gross_charge":11.93,"discounted_cash":6.56,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Calcium Carbonate (Antacid) Chew Tab 500 MG,Calcium Carbonate Chew Tab 500 MG,Calcium Carbonate Chew Tab 1250 MG (500 MG Elemental Ca)","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"903495","type":"CDM"},{"code":"536100715","type":"NDC"}],"standard_charges":[{"gross_charge":8.1,"discounted_cash":4.46,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Calcium Carbonate (Antacid) Chew Tab 500 MG,Calcium Carbonate Chew Tab 500 MG,Calcium Carbonate Chew Tab 1250 MG (500 MG Elemental Ca)","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"903495","type":"CDM"},{"code":"68084098833","type":"NDC"}],"standard_charges":[{"gross_charge":11.93,"discounted_cash":6.56,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Argatroban IV Soln 50 MG/50ML (1 MG/ML),","drug_information":{"unit":50.0,"type":"ML"},"code_information":[{"code":"903499","type":"CDM"},{"code":"55150024101","type":"NDC"}],"standard_charges":[{"gross_charge":931.9,"discounted_cash":512.54,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Argatroban IV Soln 50 MG/50ML (1 MG/ML),","drug_information":{"unit":50.0,"type":"ML"},"code_information":[{"code":"903499","type":"CDM"},{"code":"143955901","type":"NDC"}],"standard_charges":[{"gross_charge":945.76,"discounted_cash":520.17,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Argatroban IV Soln 50 MG/50ML (1 MG/ML),","drug_information":{"unit":50.0,"type":"ML"},"code_information":[{"code":"903499","type":"CDM"},{"code":"55150024110","type":"NDC"}],"standard_charges":[{"gross_charge":996.25,"discounted_cash":547.94,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Lanolin,Lanolin Cream,Lanolin Ointment,Lanolin Oint 30%","drug_information":{"unit":1.0,"type":"GM"},"code_information":[{"code":"903506","type":"CDM"},{"code":"60592041211","type":"NDC"}],"standard_charges":[{"gross_charge":18.02,"discounted_cash":9.91,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Lanolin,Lanolin Cream,Lanolin Ointment,Lanolin Oint 30%","drug_information":{"unit":7.0,"type":"GM"},"code_information":[{"code":"903506","type":"CDM"},{"code":"2045187712","type":"NDC"}],"standard_charges":[{"gross_charge":28.21,"discounted_cash":15.52,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Skin Protectants Misc - Ointment,Diaper Rash Products - Ointment,Vitamins A & D Oint,Lanolin-Petrolatum Oint 15.5-53.4%","drug_information":{"unit":60.0,"type":"GM"},"code_information":[{"code":"903522","type":"CDM"},{"code":"168003501","type":"NDC"}],"standard_charges":[{"gross_charge":32.22,"discounted_cash":17.72,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Skin Protectants Misc - Ointment,Diaper Rash Products - Ointment,Vitamins A & D Oint,Lanolin-Petrolatum Oint 15.5-53.4%","drug_information":{"unit":42.5,"type":"GM"},"code_information":[{"code":"903522","type":"CDM"},{"code":"65197040010","type":"NDC"}],"standard_charges":[{"gross_charge":31.18,"discounted_cash":17.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Cisatracurium Besylate (PF) IV Soln 200 MG/20ML (10 MG/ML),Cisatracurium Besylate IV Soln 10 MG/ML","drug_information":{"unit":20.0,"type":"ML"},"code_information":[{"code":"903555","type":"CDM"},{"code":"63323041820","type":"NDC"}],"standard_charges":[{"gross_charge":690.74,"discounted_cash":379.91,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Vitamin E Cap 400 Unit,Vitamin E Cap 180 MG,Vitamin E Cap 268 MG (400 Unit)","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"903557","type":"CDM"},{"code":"77333095125","type":"NDC"}],"standard_charges":[{"gross_charge":9.14,"discounted_cash":5.03,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Fentanyl Cit 0.4 MG/200ML-Ropiv 0.1%-NaCl 0.9% Epidural Inj","drug_information":{"unit":250.0,"type":"ML"},"code_information":[{"code":"903558","type":"CDM"},{"code":"8888801585","type":"NDC"}],"standard_charges":[{"gross_charge":281.41,"discounted_cash":154.78,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Rituximab-pvvr IV Soln 100 MG/10ML (10 MG/ML),Rituximab-pvvr IV Soln 500 MG/50ML (10 MG/ML)","drug_information":{"unit":10.0,"type":"ML"},"code_information":[{"code":"903578","type":"CDM"},{"code":"69023801","type":"NDC"}],"standard_charges":[{"gross_charge":1708.31,"discounted_cash":939.57,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Rituximab-pvvr IV Soln 100 MG/10ML (10 MG/ML),Rituximab-pvvr IV Soln 500 MG/50ML (10 MG/ML)","drug_information":{"unit":50.0,"type":"ML"},"code_information":[{"code":"903578","type":"CDM"},{"code":"69024901","type":"NDC"}],"standard_charges":[{"gross_charge":8417.56,"discounted_cash":4629.66,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"ETELCALCETIDE HCL 2.5 MG/0.5ML IV SOLN,ETELCALCETIDE HCL 5 MG/ML IV SOLN,ETELCALCETIDE HCL 10 MG/2ML IV SOLN","drug_information":{"unit":0.5,"type":"ML"},"code_information":[{"code":"903599","type":"CDM"},{"code":"55513074001","type":"NDC"}],"standard_charges":[{"gross_charge":241.6,"discounted_cash":132.88,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"ETELCALCETIDE HCL 2.5 MG/0.5ML IV SOLN,ETELCALCETIDE HCL 5 MG/ML IV SOLN,ETELCALCETIDE HCL 10 MG/2ML IV SOLN","drug_information":{"unit":0.5,"type":"ML"},"code_information":[{"code":"903599","type":"CDM"},{"code":"55513074101","type":"NDC"}],"standard_charges":[{"gross_charge":241.58,"discounted_cash":132.87,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Calcium Carbonate-Vitamin D Tab 600 MG-400 Unit,Calcium Carbonate-Cholecalciferol Tab 600 MG-400 Unit","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"903602","type":"CDM"},{"code":"20555001700","type":"NDC"}],"standard_charges":[{"gross_charge":8.8,"discounted_cash":4.84,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Sodium Chloride IV Soln 4 mEq/ML (23.4%)","drug_information":{"unit":30.0,"type":"ML"},"code_information":[{"code":"903691","type":"CDM"},{"code":"63323009330","type":"NDC"}],"standard_charges":[{"gross_charge":71.85,"discounted_cash":39.52,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Rituximab-arrx IV Soln 100 MG/10ML (10 MG/ML),Rituximab-arrx IV Soln 500 MG/50ML (10 MG/ML)","drug_information":{"unit":50.0,"type":"ML"},"code_information":[{"code":"903695","type":"CDM"},{"code":"55513032601","type":"NDC"}],"standard_charges":[{"gross_charge":8417.56,"discounted_cash":4629.66,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Infliximab-axxq For IV Inj 100 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"903714","type":"CDM"},{"code":"55513067001","type":"NDC"}],"standard_charges":[{"gross_charge":901.0,"discounted_cash":495.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Simethicone Susp 40 MG/0.6ML,Simethicone Liquid 40 MG/0.6ML","drug_information":{"unit":30.0,"type":"ML"},"code_information":[{"code":"903717","type":"CDM"},{"code":"46122054703","type":"NDC"}],"standard_charges":[{"gross_charge":60.07,"discounted_cash":33.04,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Simethicone Susp 40 MG/0.6ML,Simethicone Liquid 40 MG/0.6ML","drug_information":{"unit":0.6,"type":"ML"},"code_information":[{"code":"903717","type":"CDM"},{"code":"8890903917","type":"NDC"}],"standard_charges":[{"gross_charge":8.23,"discounted_cash":4.53,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Bacitracin Oint 500 Unit/GM,Bacitracin Zinc Oint 500 Unit/GM","drug_information":{"unit":30.0,"type":"GM"},"code_information":[{"code":"903727","type":"CDM"},{"code":"536125628","type":"NDC"}],"standard_charges":[{"gross_charge":5.43,"discounted_cash":2.99,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Bacitracin Oint 500 Unit/GM,Bacitracin Zinc Oint 500 Unit/GM","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"903727","type":"CDM"},{"code":"904740267","type":"NDC"}],"standard_charges":[{"gross_charge":3.14,"discounted_cash":1.73,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Bacitracin Oint 500 Unit/GM,Bacitracin Zinc Oint 500 Unit/GM","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"903727","type":"CDM"},{"code":"904702367","type":"NDC"}],"standard_charges":[{"gross_charge":3.13,"discounted_cash":1.72,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Bacitracin Oint 500 Unit/GM,Bacitracin Zinc Oint 500 Unit/GM","drug_information":{"unit":30.0,"type":"GM"},"code_information":[{"code":"903727","type":"CDM"},{"code":"713028031","type":"NDC"}],"standard_charges":[{"gross_charge":6.66,"discounted_cash":3.66,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Bacitracin Oint 500 Unit/GM,Bacitracin Zinc Oint 500 Unit/GM","drug_information":{"unit":28.0,"type":"GM"},"code_information":[{"code":"903727","type":"CDM"},{"code":"472110556","type":"NDC"}],"standard_charges":[{"gross_charge":11.48,"discounted_cash":6.31,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Casirivimab IV Soln 1332 MG/11.1ML,Casirivimab IV Soln 300 MG/2.5ML","drug_information":{"unit":11.1,"type":"ML"},"code_information":[{"code":"903780","type":"CDM"},{"code":"61755002401","type":"NDC"}],"standard_charges":[{"gross_charge":0.1,"discounted_cash":0.06,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Imdevimab IV Soln 1332 MG/11.1ML,Imdevimab IV Soln 300 MG/2.5ML","drug_information":{"unit":11.1,"type":"ML"},"code_information":[{"code":"903781","type":"CDM"},{"code":"61755002501","type":"NDC"}],"standard_charges":[{"gross_charge":0.1,"discounted_cash":0.06,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Thiamine HCl Tab 100 MG,Thiamine Mononitrate Tab 100 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"903785","type":"CDM"},{"code":"68094011661","type":"NDC"}],"standard_charges":[{"gross_charge":9.01,"discounted_cash":4.96,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Desmopressin Acetate Inj 4 MCG/ML,Desmopressin Acetate Preservative Free (PF) Inj 4 MCG/ML","drug_information":{"unit":0.5,"type":"ML"},"code_information":[{"code":"903817","type":"CDM"},{"code":"69918089910","type":"NDC"}],"standard_charges":[{"gross_charge":81.16,"discounted_cash":44.64,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Desmopressin Acetate Inj 4 MCG/ML,Desmopressin Acetate Preservative Free (PF) Inj 4 MCG/ML","drug_information":{"unit":0.5,"type":"ML"},"code_information":[{"code":"903817","type":"CDM"},{"code":"69918089901","type":"NDC"}],"standard_charges":[{"gross_charge":81.16,"discounted_cash":44.64,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Tenecteplase For IV Soln Kit 50 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"903822","type":"CDM"},{"code":"50242017601","type":"NDC"}],"standard_charges":[{"gross_charge":14468.23,"discounted_cash":7957.53,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Tenecteplase For IV Soln Kit 50 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"903822","type":"CDM"},{"code":"50242012047","type":"NDC"}],"standard_charges":[{"gross_charge":14468.23,"discounted_cash":7957.53,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Dexamethasone Sodium Phosphate Inj 4 MG/ML,Dexamethasone Sodium Phosphate Inj 20 MG/5ML,Dexamethasone Sodium Phosphate Inj 120 MG/30ML","drug_information":{"unit":1.0,"type":"ML"},"code_information":[{"code":"903833","type":"CDM"},{"code":"67457042312","type":"NDC"}],"standard_charges":[{"gross_charge":39.2,"discounted_cash":21.56,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Dexamethasone Sodium Phosphate Inj 4 MG/ML,Dexamethasone Sodium Phosphate Inj 20 MG/5ML,Dexamethasone Sodium Phosphate Inj 120 MG/30ML,Dexamethasone Sodium Phosphate Inj Soln Pref Syr 4 MG/ML","drug_information":{"unit":1.0,"type":"ML"},"code_information":[{"code":"903833","type":"CDM"},{"code":"67457042300","type":"NDC"}],"standard_charges":[{"gross_charge":39.2,"discounted_cash":21.56,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Baricitinib Tab 2 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"903840","type":"CDM"},{"code":"90384001","type":"NDC"}],"standard_charges":[{"gross_charge":115.93,"discounted_cash":63.76,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy | NDC EA = 1 HALF TABLET"}]},{"description":"Fat Emulsion Plant Based IV Emulsion 20%,Fat Emulsion Plant Based (Soy) IV Emulsion 20%,Fat Emulsion Plant Based (Soy/Olive) IV Emulsion 20%","drug_information":{"unit":250.0,"type":"ML"},"code_information":[{"code":"903846","type":"CDM"},{"code":"338051909","type":"NDC"}],"standard_charges":[{"gross_charge":282.43,"discounted_cash":155.34,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Fat Emulsion Plant Based IV Emulsion 20%,Fat Emulsion Plant Based (Soy) IV Emulsion 20%,Fat Emulsion Plant Based (Soy/Olive) IV Emulsion 20%","drug_information":{"unit":250.0,"type":"ML"},"code_information":[{"code":"903846","type":"CDM"},{"code":"338051913","type":"NDC"}],"standard_charges":[{"gross_charge":142.25,"discounted_cash":78.24,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Hepatitis B Immune Globulin (Human) IM Inj Soln,Hepatitis B Immun Glob (Human) IM Soln Pref Syr 110 Ut/0.5ML,Hepatitis B Immune Globulin (Human) IM Soln 220 Unit/ML,Hepatitis B Immun Glob (Human) IM Soln Pref Syr 220 Unit/ML","drug_information":{"unit":0.5,"type":"ML"},"code_information":[{"code":"903847","type":"CDM"},{"code":"13533063601","type":"NDC"}],"standard_charges":[{"gross_charge":201.13,"discounted_cash":110.62,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Na Chondroitin Sulfate-Na Hyaluronate Ophth Soln 40-30 MG/ML,Na Chondroit Sulf-Na Hyaluron Pref Syr 20-15 MG/0.5ML,Na Chondroit Sulf-Na Hyaluron Pref Syr 30-22.5 MG/0.75ML","drug_information":{"unit":0.2,"type":"ML"},"code_information":[{"code":"903848","type":"CDM"},{"code":"8065183905","type":"NDC"}],"standard_charges":[{"gross_charge":148.74,"discounted_cash":81.81,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Octreotide Acetate Inj 100 MCG/ML (0.1 MG/ML),Octreotide Acetate Subcutaneous Soln Pref Syr 100 MCG/ML","drug_information":{"unit":0.5,"type":"ML"},"code_information":[{"code":"903849","type":"CDM"},{"code":"641617501","type":"NDC"}],"standard_charges":[{"gross_charge":20.96,"discounted_cash":11.53,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Octreotide Acetate Inj 100 MCG/ML (0.1 MG/ML),Octreotide Acetate Subcutaneous Soln Pref Syr 100 MCG/ML","drug_information":{"unit":0.5,"type":"ML"},"code_information":[{"code":"903849","type":"CDM"},{"code":"641617510","type":"NDC"}],"standard_charges":[{"gross_charge":20.96,"discounted_cash":11.53,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Octreotide Acetate Inj 50 MCG/ML (0.05 MG/ML),Octreotide Acetate Subcutaneous Soln Pref Syr 50 MCG/ML","drug_information":{"unit":0.5,"type":"ML"},"code_information":[{"code":"903850","type":"CDM"},{"code":"641617401","type":"NDC"}],"standard_charges":[{"gross_charge":19.28,"discounted_cash":10.60,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Octreotide Acetate Inj 50 MCG/ML (0.05 MG/ML),Octreotide Acetate Subcutaneous Soln Pref Syr 50 MCG/ML","drug_information":{"unit":0.5,"type":"ML"},"code_information":[{"code":"903850","type":"CDM"},{"code":"25021045101","type":"NDC"}],"standard_charges":[{"gross_charge":19.28,"discounted_cash":10.60,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Octreotide Acetate Inj 500 MCG/ML (0.5 MG/ML),Octreotide Acetate Subcutaneous Soln Pref Syr 500 MCG/ML","drug_information":{"unit":0.4,"type":"ML"},"code_information":[{"code":"903851","type":"CDM"},{"code":"641617601","type":"NDC"}],"standard_charges":[{"gross_charge":67.96,"discounted_cash":37.38,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Octreotide Acetate Inj 500 MCG/ML (0.5 MG/ML),Octreotide Acetate Subcutaneous Soln Pref Syr 500 MCG/ML","drug_information":{"unit":0.4,"type":"ML"},"code_information":[{"code":"903851","type":"CDM"},{"code":"641617610","type":"NDC"}],"standard_charges":[{"gross_charge":67.96,"discounted_cash":37.38,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Tet Tox-Diph-Acell Pertuss Ad Inj 5-2.5-18.5 LF-LF-MCG/0.5ML,Tet-Diph-Acell Pertuss Ad Pref Syr 5-2.5-18.5 LF-MCG/0.5ML","drug_information":{"unit":0.5,"type":"ML"},"code_information":[{"code":"903852","type":"CDM"},{"code":"58160084252","type":"NDC"}],"standard_charges":[{"gross_charge":150.59,"discounted_cash":82.82,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Tet Tox-Diph-Acell Pertuss Ad Inj 5-2.5-18.5 LF-LF-MCG/0.5ML,Tet-Diph-Acell Pertuss Ad Pref Syr 5-2.5-18.5 LF-MCG/0.5ML","drug_information":{"unit":0.5,"type":"ML"},"code_information":[{"code":"903852","type":"CDM"},{"code":"58160084243","type":"NDC"}],"standard_charges":[{"gross_charge":150.59,"discounted_cash":82.82,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Methacholine Chloride Inhal For Soln 100 MG,Methacholine Chloride IN Kit","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"903858","type":"CDM"},{"code":"64281010006","type":"NDC"}],"standard_charges":[{"gross_charge":243.94,"discounted_cash":134.17,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Albumin, Human Inj 25%","drug_information":{"unit":50.0,"type":"ML"},"code_information":[{"code":"903879","type":"CDM"},{"code":"68516521601","type":"NDC"}],"standard_charges":[{"gross_charge":93.69,"discounted_cash":51.53,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Albumin, Human Inj 5%","drug_information":{"unit":250.0,"type":"ML"},"code_information":[{"code":"903880","type":"CDM"},{"code":"68516521407","type":"NDC"}],"standard_charges":[{"gross_charge":93.55,"discounted_cash":51.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Sodium Hyaluronate Intraocular Inj 10 MG/ML,Sodium Hyaluronate Intraocular Soln Pref Syr 4 MG/0.4ML,Sodium Hyaluronate Intraocular Soln Pref Syr 5.5 MG/0.55ML,Sodium Hyaluronate Intraocular Soln Pref Syr 8.5 MG/0.85ML","drug_information":{"unit":0.2,"type":"ML"},"code_information":[{"code":"903899","type":"CDM"},{"code":"50474063697","type":"NDC"}],"standard_charges":[{"gross_charge":107.48,"discounted_cash":59.11,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Sodium Hyaluronate Intraocular Inj 10 MG/ML,Sodium Hyaluronate Intraocular Soln Pref Syr 4 MG/0.4ML,Sodium Hyaluronate Intraocular Soln Pref Syr 5.5 MG/0.55ML,Sodium Hyaluronate Intraocular Soln Pref Syr 8.5 MG/0.85ML","drug_information":{"unit":0.2,"type":"ML"},"code_information":[{"code":"903899","type":"CDM"},{"code":"50475047063","type":"NDC"}],"standard_charges":[{"gross_charge":103.33,"discounted_cash":56.83,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Sodium Hyaluronate Intraocular Inj 10 MG/ML,Sodium Hyaluronate Intraocular Soln Pref Syr 4 MG/0.4ML,Sodium Hyaluronate Intraocular Soln Pref Syr 5.5 MG/0.55ML,Sodium Hyaluronate Intraocular Soln Pref Syr 8.5 MG/0.85ML","drug_information":{"unit":0.2,"type":"ML"},"code_information":[{"code":"903899","type":"CDM"},{"code":"8065183085","type":"NDC"}],"standard_charges":[{"gross_charge":134.92,"discounted_cash":74.21,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Furosemide Inj 10 MG/ML","drug_information":{"unit":25.0,"type":"ML"},"code_information":[{"code":"903918","type":"CDM"},{"code":"9990391825","type":"NDC"}],"standard_charges":[{"gross_charge":51.92,"discounted_cash":28.56,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Furosemide Inj 10 MG/ML","drug_information":{"unit":50.0,"type":"ML"},"code_information":[{"code":"903918","type":"CDM"},{"code":"9990391850","type":"NDC"}],"standard_charges":[{"gross_charge":72.83,"discounted_cash":40.06,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Furosemide Inj 10 MG/ML","drug_information":{"unit":100.0,"type":"ML"},"code_information":[{"code":"903918","type":"CDM"},{"code":"9990391899","type":"NDC"}],"standard_charges":[{"gross_charge":114.66,"discounted_cash":63.06,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Heparin Sodium (Porcine) Lock Flush IV Soln 100 Unit/ML,Heparin Sodium (Porcine) Lock Flush PF IV Soln 100 Unit/ML","drug_information":{"unit":1.0,"type":"ML"},"code_information":[{"code":"903923","type":"CDM"},{"code":"64253033335","type":"NDC"}],"standard_charges":[{"gross_charge":34.3,"discounted_cash":18.86,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Heparin Sodium (Porcine) Lock Flush IV Soln 100 Unit/ML,Heparin Sodium (Porcine) Lock Flush PF IV Soln 100 Unit/ML","drug_information":{"unit":1.0,"type":"ML"},"code_information":[{"code":"903923","type":"CDM"},{"code":"8290306424","type":"NDC"}],"standard_charges":[{"gross_charge":31.74,"discounted_cash":17.46,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Hepatitis B Vaccine (Recombinant) Susp 20 MCG/ML,Hepatitis B Vaccine (Recombinant) Susp Pref Syr 20 MCG/ML","drug_information":{"unit":1.0,"type":"ML"},"code_information":[{"code":"903935","type":"CDM"},{"code":"58160082111","type":"NDC"}],"standard_charges":[{"gross_charge":159.44,"discounted_cash":87.69,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Hepatitis B Vaccine (Recombinant) Susp 20 MCG/ML,Hepatitis B Vaccine (Recombinant) Susp Pref Syr 20 MCG/ML","drug_information":{"unit":1.0,"type":"ML"},"code_information":[{"code":"903935","type":"CDM"},{"code":"58160082101","type":"NDC"}],"standard_charges":[{"gross_charge":159.44,"discounted_cash":87.69,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Hepatitis B Vaccine (Recombinant) Susp 20 MCG/ML,Hepatitis B Vaccine (Recombinant) Susp Pref Syr 20 MCG/ML","drug_information":{"unit":1.0,"type":"ML"},"code_information":[{"code":"903935","type":"CDM"},{"code":"58160082152","type":"NDC"}],"standard_charges":[{"gross_charge":159.44,"discounted_cash":87.69,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Esmolol HCl-Sodium Chloride IV Soln 2500 MG/250ML,Esmolol HCl Inj 2500 MG/250ML (10 MG/ML)","drug_information":{"unit":250.0,"type":"ML"},"code_information":[{"code":"903983","type":"CDM"},{"code":"25021030884","type":"NDC"}],"standard_charges":[{"gross_charge":912.1,"discounted_cash":501.66,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Insulin Regular (Human) in NaCl 0.9% IV Soln 100 Unit/100ML","drug_information":{"unit":5.0,"type":"ML"},"code_information":[{"code":"903988","type":"CDM"},{"code":"8888801778","type":"NDC"}],"standard_charges":[{"gross_charge":40.35,"discounted_cash":22.19,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Nicardipine HCl IV Soln 20 MG/200ML in Sodium Chloride 0.9%,Nicardipine HCl IV Soln 20 MG/200ML in Sodium Chloride 0.86%","drug_information":{"unit":200.0,"type":"ML"},"code_information":[{"code":"903991","type":"CDM"},{"code":"43066000910","type":"NDC"}],"standard_charges":[{"gross_charge":298.0,"discounted_cash":163.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Nicardipine HCl IV Soln 20 MG/200ML in Sodium Chloride 0.9%,Nicardipine HCl IV Soln 20 MG/200ML in Sodium Chloride 0.86%","drug_information":{"unit":200.0,"type":"ML"},"code_information":[{"code":"903991","type":"CDM"},{"code":"43066002110","type":"NDC"}],"standard_charges":[{"gross_charge":338.94,"discounted_cash":186.42,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Nicardipine HCl IV Soln 20 MG/200ML in Sodium Chloride 0.9%","drug_information":{"unit":200.0,"type":"ML"},"code_information":[{"code":"903991","type":"CDM"},{"code":"69097000722","type":"NDC"}],"standard_charges":[{"gross_charge":298.0,"discounted_cash":163.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Nicardipine HCl IV Soln 20 MG/200ML in Sodium Chloride 0.9%","drug_information":{"unit":200.0,"type":"ML"},"code_information":[{"code":"903991","type":"CDM"},{"code":"69097000745","type":"NDC"}],"standard_charges":[{"gross_charge":298.0,"discounted_cash":163.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Ampicillin & Sulbactam Sodium For Inj 1.5 (1-0.5) GM","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"904015","type":"CDM"},{"code":"55150011620","type":"NDC"}],"standard_charges":[{"gross_charge":26.33,"discounted_cash":14.48,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Ampicillin & Sulbactam Sodium For Inj 1.5 (1-0.5) GM","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"904015","type":"CDM"},{"code":"49001383","type":"NDC"}],"standard_charges":[{"gross_charge":28.46,"discounted_cash":15.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Ampicillin & Sulbactam Sodium For Inj 1.5 (1-0.5) GM","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"904015","type":"CDM"},{"code":"49001381","type":"NDC"}],"standard_charges":[{"gross_charge":28.45,"discounted_cash":15.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Witch Hazel-Glycerin Cleansing Pads,Witch Hazel (Hamamelis Virginiana) Cleansing Pads","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"904021","type":"CDM"},{"code":"50289325001","type":"NDC"}],"standard_charges":[{"gross_charge":8.34,"discounted_cash":4.59,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Psyllium Powder Packet 58.12%,Psyllium Powder Packet 28%,Psyllium Powder Packet 51.7%","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"904037","type":"CDM"},{"code":"37000002310","type":"NDC"}],"standard_charges":[{"gross_charge":10.43,"discounted_cash":5.74,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Psyllium Powder Packet 58.12%,Psyllium Powder Packet 28%,Psyllium Powder Packet 51.7%","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"904037","type":"CDM"},{"code":"37000002404","type":"NDC"}],"standard_charges":[{"gross_charge":10.43,"discounted_cash":5.74,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Alteplase For Inj 100 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"904117","type":"CDM"},{"code":"50242008527","type":"NDC"}],"standard_charges":[{"gross_charge":15343.62,"discounted_cash":8438.99,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Nitroprusside Sodium IV Soln 25 MG/ML","drug_information":{"unit":2.0,"type":"ML"},"code_information":[{"code":"904176","type":"CDM"},{"code":"72485010501","type":"NDC"}],"standard_charges":[{"gross_charge":97.0,"discounted_cash":53.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Olanzapine For IM Inj 10 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"904205","type":"CDM"},{"code":"31722030801","type":"NDC"}],"standard_charges":[{"gross_charge":124.57,"discounted_cash":68.51,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Indocyanine Green For IV Soln 25 MG,Indocyanine Green For Inj Soln 25 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"904224","type":"CDM"},{"code":"17478070110","type":"NDC"}],"standard_charges":[{"gross_charge":237.68,"discounted_cash":130.72,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Tranexamic Acid-Sodium Chloride IV Soln 1000 MG/100ML-0.7%","drug_information":{"unit":100.0,"type":"ML"},"code_information":[{"code":"904264","type":"CDM"},{"code":"25021041882","type":"NDC"}],"standard_charges":[{"gross_charge":157.47,"discounted_cash":86.61,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Aminocaproic Acid Tab 500 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"9063","type":"CDM"},{"code":"69680011530","type":"NDC"}],"standard_charges":[{"gross_charge":31.63,"discounted_cash":17.40,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Sodium Iodide I-123 Cap 7.4 MBq (200 Microcurie)","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"906380","type":"CDM"},{"code":"48815100401","type":"NDC"}],"standard_charges":[{"gross_charge":124.96,"discounted_cash":68.73,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy | NDC EA = 1 CAPSULE"}]},{"description":"Sodium Iodide I-123 Cap 3.7 MBq (100 Microcurie)","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"906381","type":"CDM"},{"code":"48815100101","type":"NDC"}],"standard_charges":[{"gross_charge":266.2,"discounted_cash":146.41,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Amiodarone HCl Tab 200 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"9066","type":"CDM"},{"code":"60687043701","type":"NDC"}],"standard_charges":[{"gross_charge":10.7,"discounted_cash":5.88,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Amiodarone HCl Tab 200 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"9066","type":"CDM"},{"code":"60687043711","type":"NDC"}],"standard_charges":[{"gross_charge":10.7,"discounted_cash":5.88,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Amlodipine Besylate Tab 2.5 MG (Base Equivalent)","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"9070","type":"CDM"},{"code":"67877019790","type":"NDC"}],"standard_charges":[{"gross_charge":14.71,"discounted_cash":8.09,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Amlodipine Besylate Tab 5 MG (Base Equivalent)","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"9071","type":"CDM"},{"code":"69097012705","type":"NDC"}],"standard_charges":[{"gross_charge":14.66,"discounted_cash":8.06,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Amlodipine Besylate Tab 5 MG (Base Equivalent)","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"9071","type":"CDM"},{"code":"904637061","type":"NDC"}],"standard_charges":[{"gross_charge":14.33,"discounted_cash":7.88,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Amphetamine-Dextroamphetamine Tab 10 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"9081","type":"CDM"},{"code":"555097202","type":"NDC"}],"standard_charges":[{"gross_charge":14.6,"discounted_cash":8.03,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Liniments & Rubs - Ointment,Menthol-Methyl Salicyclate oint,Camphor-Menthol,Menthol-Methyl Salicylate Cream,Menthol-Camphor - Ointment,Camphor-Menthol-Methyl Salicylate Cream 4-10-30%","drug_information":{"unit":85.0,"type":"GM"},"code_information":[{"code":"908145","type":"CDM"},{"code":"536134957","type":"NDC"}],"standard_charges":[{"gross_charge":34.02,"discounted_cash":18.71,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Glycopyrrolate Inj 0.4 MG/2ML (0.2 MG/ML)","drug_information":{"unit":0.5,"type":"ML"},"code_information":[{"code":"908147","type":"CDM"},{"code":"43547054401","type":"NDC"}],"standard_charges":[{"gross_charge":41.84,"discounted_cash":23.01,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Atracurium Besylate IV Soln 10 MG/ML,Atracuriun Besylate IV Siln 50mg/5ml,Atracurium Besylate IV Soln 100mg/10","drug_information":{"unit":10.0,"type":"ML"},"code_information":[{"code":"908148","type":"CDM"},{"code":"71288070211","type":"NDC"}],"standard_charges":[{"gross_charge":74.66,"discounted_cash":41.06,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Cisatracurium Besylate IV Soln 2 MG/ML,Cisatracurium Besylate IV Soln 10mg/5ml (PF),Cisatracurium Besylate IV Soln 20mg/10ml","drug_information":{"unit":10.0,"type":"ML"},"code_information":[{"code":"908149","type":"CDM"},{"code":"63323041710","type":"NDC"}],"standard_charges":[{"gross_charge":116.01,"discounted_cash":63.81,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Cisatracurium Besylate IV Soln 2 MG/ML,Cisatracurium Besylate IV Soln 10mg/5ml (PF),Cisatracurium Besylate IV Soln 20mg/10ml","drug_information":{"unit":5.0,"type":"ML"},"code_information":[{"code":"908149","type":"CDM"},{"code":"409109812","type":"NDC"}],"standard_charges":[{"gross_charge":96.33,"discounted_cash":52.98,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Cisatracurium Besylate IV Soln 2 MG/ML,Cisatracurium Besylate IV Soln 10mg/5ml (PF),Cisatracurium Besylate IV Soln 20mg/10ml","drug_information":{"unit":10.0,"type":"ML"},"code_information":[{"code":"908149","type":"CDM"},{"code":"63323041701","type":"NDC"}],"standard_charges":[{"gross_charge":137.26,"discounted_cash":75.49,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Magnesium Oxide Tab 400 MG,Magnesium Oxide Tab 400 MG (240 MG Elemental Mg),Magnesium Oxide Tab 400 MG (241.3 MG Elemental Mg),Magnesium Oxide Tab 400 MG (241.3 MG Elemental Mg)","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"908150","type":"CDM"},{"code":"64980033990","type":"NDC"}],"standard_charges":[{"gross_charge":8.66,"discounted_cash":4.76,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Magnesium Oxide Tab 400 MG,Magnesium Oxide Tab 400 MG (240 MG Elemental Mg),Magnesium Oxide Tab 400 MG (241.3 MG Elemental Mg),Magnesium Oxide Tab 400 MG (241.3 MG Elemental Mg)","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"908150","type":"CDM"},{"code":"64980033901","type":"NDC"}],"standard_charges":[{"gross_charge":8.66,"discounted_cash":4.76,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Sodium Chloride IV Soln 0.9%","drug_information":{"unit":100.0,"type":"ML"},"code_information":[{"code":"908157","type":"CDM"},{"code":"264180032","type":"NDC"}],"standard_charges":[{"gross_charge":62.69,"discounted_cash":34.48,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Ampicillin & Sulbactam Sodium For Inj 1.5 (1-0.5) GM","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"9083","type":"CDM"},{"code":"49001381","type":"NDC"}],"standard_charges":[{"gross_charge":28.45,"discounted_cash":15.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Ampicillin & Sulbactam Sodium For Inj 1.5 (1-0.5) GM","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"9083","type":"CDM"},{"code":"55150011620","type":"NDC"}],"standard_charges":[{"gross_charge":26.33,"discounted_cash":14.48,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Ampicillin & Sulbactam Sodium For Inj 1.5 (1-0.5) GM","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"9083","type":"CDM"},{"code":"49001383","type":"NDC"}],"standard_charges":[{"gross_charge":28.46,"discounted_cash":15.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Noncdm Charge Record","code_information":[{"code":"90834","type":"CDM"},{"code":"914","type":"RC"},{"code":"90834","type":"HCPCS"}],"standard_charges":[{"gross_charge":176.0,"discounted_cash":96.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Ampicillin & Sulbactam Sodium For Inj 3 (2-1) GM","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"9084","type":"CDM"},{"code":"72485041710","type":"NDC"}],"standard_charges":[{"gross_charge":24.4,"discounted_cash":13.42,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Antithrombin III (Human) For Inj 500 Unit","drug_information":{"unit":500.0,"type":"UN"},"code_information":[{"code":"9116","type":"CDM"},{"code":"13533060250","type":"NDC"}],"standard_charges":[{"gross_charge":8858.5,"discounted_cash":4872.18,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Apraclonidine HCl Ophth Soln 1% (Base Equivalent)","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"9120","type":"CDM"},{"code":"65066010","type":"NDC"}],"standard_charges":[{"gross_charge":90.2,"discounted_cash":49.61,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Acetic Acid Soln 5%","drug_information":{"unit":500.0,"type":"ML"},"code_information":[{"code":"914702","type":"CDM"},{"code":"51552000556","type":"NDC"}],"standard_charges":[{"gross_charge":328.5,"discounted_cash":180.68,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Aspirin-Acetaminophen-Caffeine Tab 250-250-65 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"9158","type":"CDM"},{"code":"536132601","type":"NDC"}],"standard_charges":[{"gross_charge":8.15,"discounted_cash":4.48,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Betamethasone Dipropionate Augmented Oint 0.05%","drug_information":{"unit":15.0,"type":"GM"},"code_information":[{"code":"9178","type":"CDM"},{"code":"168026815","type":"NDC"}],"standard_charges":[{"gross_charge":291.53,"discounted_cash":160.34,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Azathioprine Tab 50 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"9183","type":"CDM"},{"code":"68084022911","type":"NDC"}],"standard_charges":[{"gross_charge":11.76,"discounted_cash":6.47,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Azathioprine Tab 50 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"9183","type":"CDM"},{"code":"68084022901","type":"NDC"}],"standard_charges":[{"gross_charge":11.76,"discounted_cash":6.47,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Aztreonam For Inj 1 GM","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"9185","type":"CDM"},{"code":"63323040120","type":"NDC"}],"standard_charges":[{"gross_charge":126.25,"discounted_cash":69.44,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Benztropine Mesylate Inj 1 MG/ML","drug_information":{"unit":0.5,"type":"ML"},"code_information":[{"code":"9259","type":"CDM"},{"code":"68382086010","type":"NDC"}],"standard_charges":[{"gross_charge":63.31,"discounted_cash":34.82,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Betamethasone Sod Phosphate & Acetate Inj Susp 6 (3-3) MG/ML","drug_information":{"unit":1.0,"type":"ML"},"code_information":[{"code":"9266","type":"CDM"},{"code":"78206011801","type":"NDC"}],"standard_charges":[{"gross_charge":59.81,"discounted_cash":32.90,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Betamethasone Sod Phosphate & Acetate Inj Susp 6 (3-3) MG/ML","drug_information":{"unit":1.0,"type":"ML"},"code_information":[{"code":"9266","type":"CDM"},{"code":"517072001","type":"NDC"}],"standard_charges":[{"gross_charge":67.32,"discounted_cash":37.03,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Bumetanide Inj 0.25 MG/ML","drug_information":{"unit":2.0,"type":"ML"},"code_information":[{"code":"9308","type":"CDM"},{"code":"25021032104","type":"NDC"}],"standard_charges":[{"gross_charge":5.78,"discounted_cash":3.18,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Bumetanide Inj 0.25 MG/ML","drug_information":{"unit":2.0,"type":"ML"},"code_information":[{"code":"9308","type":"CDM"},{"code":"68462046954","type":"NDC"}],"standard_charges":[{"gross_charge":5.78,"discounted_cash":3.18,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Bumetanide Inj 0.25 MG/ML","drug_information":{"unit":2.0,"type":"ML"},"code_information":[{"code":"9308","type":"CDM"},{"code":"68462046940","type":"NDC"}],"standard_charges":[{"gross_charge":5.78,"discounted_cash":3.18,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Bumetanide Inj 0.25 MG/ML","drug_information":{"unit":2.0,"type":"ML"},"code_information":[{"code":"9308","type":"CDM"},{"code":"25021032110","type":"NDC"}],"standard_charges":[{"gross_charge":4.86,"discounted_cash":2.67,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Bumetanide Tab 0.5 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"9309","type":"CDM"},{"code":"50268013015","type":"NDC"}],"standard_charges":[{"gross_charge":13.83,"discounted_cash":7.61,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Bumetanide Tab 0.5 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"9309","type":"CDM"},{"code":"50268013011","type":"NDC"}],"standard_charges":[{"gross_charge":13.83,"discounted_cash":7.61,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Bumetanide Tab 2 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"9311","type":"CDM"},{"code":"69238149101","type":"NDC"}],"standard_charges":[{"gross_charge":19.42,"discounted_cash":10.68,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Bupivacaine 0.75% in Dextrose Inj 8.25%","drug_information":{"unit":0.8,"type":"ML"},"code_information":[{"code":"9316","type":"CDM"},{"code":"409176110","type":"NDC"}],"standard_charges":[{"gross_charge":43.14,"discounted_cash":23.73,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Bupivacaine 0.75% in Dextrose Inj 8.25%","drug_information":{"unit":0.8,"type":"ML"},"code_information":[{"code":"9316","type":"CDM"},{"code":"409176118","type":"NDC"}],"standard_charges":[{"gross_charge":33.56,"discounted_cash":18.46,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Bupivacaine Inj 0.25% w/ Epinephrine 1:200000","drug_information":{"unit":50.0,"type":"ML"},"code_information":[{"code":"9317","type":"CDM"},{"code":"63323046157","type":"NDC"}],"standard_charges":[{"gross_charge":145.18,"discounted_cash":79.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Bupivacaine Inj 0.5% w/ Epinephrine 1:200000","drug_information":{"unit":1.8,"type":"ML"},"code_information":[{"code":"9318","type":"CDM"},{"code":"362055705","type":"NDC"}],"standard_charges":[{"gross_charge":43.92,"discounted_cash":24.16,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Bupropion HCl Tab 100 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"9321","type":"CDM"},{"code":"60687035101","type":"NDC"}],"standard_charges":[{"gross_charge":14.87,"discounted_cash":8.18,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Bupropion HCl Tab 100 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"9321","type":"CDM"},{"code":"60687035111","type":"NDC"}],"standard_charges":[{"gross_charge":14.87,"discounted_cash":8.18,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Bupropion HCl Tab 75 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"9322","type":"CDM"},{"code":"60505015801","type":"NDC"}],"standard_charges":[{"gross_charge":11.53,"discounted_cash":6.34,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Buspirone HCl Tab 5 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"9324","type":"CDM"},{"code":"904712261","type":"NDC"}],"standard_charges":[{"gross_charge":8.69,"discounted_cash":4.78,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Calcitonin (Salmon) Inj 200 Unit/ML","drug_information":{"unit":0.25,"type":"ML"},"code_information":[{"code":"9347","type":"CDM"},{"code":"69097077032","type":"NDC"}],"standard_charges":[{"gross_charge":357.25,"discounted_cash":196.49,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Calcitriol Cap 0.25 MCG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"9350","type":"CDM"},{"code":"64380072306","type":"NDC"}],"standard_charges":[{"gross_charge":12.66,"discounted_cash":6.96,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Captopril Tab 12.5 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"9401","type":"CDM"},{"code":"60687030421","type":"NDC"}],"standard_charges":[{"gross_charge":14.54,"discounted_cash":8.00,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Captopril Tab 12.5 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"9401","type":"CDM"},{"code":"60687030411","type":"NDC"}],"standard_charges":[{"gross_charge":14.54,"discounted_cash":8.00,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Captopril Tab 50 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"9403","type":"CDM"},{"code":"27241016201","type":"NDC"}],"standard_charges":[{"gross_charge":19.16,"discounted_cash":10.54,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Carbidopa & Levodopa Tab 10-100 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"9406","type":"CDM"},{"code":"50228045701","type":"NDC"}],"standard_charges":[{"gross_charge":11.44,"discounted_cash":6.29,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Carbidopa & Levodopa Tab 25-100 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"9407","type":"CDM"},{"code":"60687066111","type":"NDC"}],"standard_charges":[{"gross_charge":11.65,"discounted_cash":6.41,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Carbidopa & Levodopa Tab 25-100 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"9407","type":"CDM"},{"code":"60687066101","type":"NDC"}],"standard_charges":[{"gross_charge":11.65,"discounted_cash":6.41,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Carbidopa & Levodopa Tab 25-250 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"9408","type":"CDM"},{"code":"93970301","type":"NDC"}],"standard_charges":[{"gross_charge":12.28,"discounted_cash":6.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Carboprost Tromethamine IM Soln 250 MCG/ML","drug_information":{"unit":1.0,"type":"ML"},"code_information":[{"code":"9413","type":"CDM"},{"code":"43598069858","type":"NDC"}],"standard_charges":[{"gross_charge":605.18,"discounted_cash":332.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Cefoxitin Sodium For IV Soln 1 GM","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"9461","type":"CDM"},{"code":"63323034129","type":"NDC"}],"standard_charges":[{"gross_charge":45.83,"discounted_cash":25.21,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Cefoxitin Sodium For IV Soln 10 GM","drug_information":{"unit":0.02,"type":"EA"},"code_information":[{"code":"9462","type":"CDM"},{"code":"44567024710","type":"NDC"}],"standard_charges":[{"gross_charge":35.21,"discounted_cash":19.37,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Cefoxitin Sodium For IV Soln 2 GM","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"9463","type":"CDM"},{"code":"25021011020","type":"NDC"}],"standard_charges":[{"gross_charge":64.0,"discounted_cash":35.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Cefprozil Tab 250 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"9472","type":"CDM"},{"code":"68180040301","type":"NDC"}],"standard_charges":[{"gross_charge":24.86,"discounted_cash":13.67,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Ceftazidime For Inj 1 GM","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"9474","type":"CDM"},{"code":"44567023525","type":"NDC"}],"standard_charges":[{"gross_charge":48.82,"discounted_cash":26.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Ceftriaxone Sodium For Inj 1 GM","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"9487","type":"CDM"},{"code":"409733211","type":"NDC"}],"standard_charges":[{"gross_charge":18.05,"discounted_cash":9.93,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Ceftriaxone Sodium For Inj 1 GM","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"9487","type":"CDM"},{"code":"409733201","type":"NDC"}],"standard_charges":[{"gross_charge":18.06,"discounted_cash":9.93,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Ceftriaxone Sodium For Inj 2 GM","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"9488","type":"CDM"},{"code":"25021010768","type":"NDC"}],"standard_charges":[{"gross_charge":41.19,"discounted_cash":22.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Ceftriaxone Sodium For Inj 2 GM","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"9488","type":"CDM"},{"code":"409733513","type":"NDC"}],"standard_charges":[{"gross_charge":44.36,"discounted_cash":24.40,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Ceftriaxone Sodium For Inj 500 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"9490","type":"CDM"},{"code":"409733801","type":"NDC"}],"standard_charges":[{"gross_charge":17.12,"discounted_cash":9.42,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Ceftriaxone Sodium For Inj 500 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"9490","type":"CDM"},{"code":"409733811","type":"NDC"}],"standard_charges":[{"gross_charge":17.12,"discounted_cash":9.42,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Ceftriaxone Sodium For Inj 10 GM","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"9491","type":"CDM"},{"code":"409733410","type":"NDC"}],"standard_charges":[{"gross_charge":88.15,"discounted_cash":48.48,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Cephalexin Cap 250 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"9499","type":"CDM"},{"code":"60687015201","type":"NDC"}],"standard_charges":[{"gross_charge":11.17,"discounted_cash":6.14,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Cephalexin Cap 250 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"9499","type":"CDM"},{"code":"60687015211","type":"NDC"}],"standard_charges":[{"gross_charge":11.17,"discounted_cash":6.14,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Cephalexin Cap 500 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"9500","type":"CDM"},{"code":"67877021901","type":"NDC"}],"standard_charges":[{"gross_charge":15.59,"discounted_cash":8.57,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Cephalexin For Susp 250 MG/5ML","drug_information":{"unit":100.0,"type":"ML"},"code_information":[{"code":"9502","type":"CDM"},{"code":"67877054588","type":"NDC"}],"standard_charges":[{"gross_charge":118.91,"discounted_cash":65.40,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Chlorhexidine Gluconate Soln 0.12%","drug_information":{"unit":15.0,"type":"ML"},"code_information":[{"code":"9516","type":"CDM"},{"code":"121089315","type":"NDC"}],"standard_charges":[{"gross_charge":27.15,"discounted_cash":14.93,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Chlorhexidine Gluconate Soln 0.12%","drug_information":{"unit":118.0,"type":"ML"},"code_information":[{"code":"9516","type":"CDM"},{"code":"116200104","type":"NDC"}],"standard_charges":[{"gross_charge":50.61,"discounted_cash":27.84,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Chlorhexidine Gluconate Soln 0.12%","drug_information":{"unit":15.0,"type":"ML"},"code_information":[{"code":"9516","type":"CDM"},{"code":"121089340","type":"NDC"}],"standard_charges":[{"gross_charge":27.15,"discounted_cash":14.93,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Chlorothiazide Sodium For Inj 500 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"9526","type":"CDM"},{"code":"25021030566","type":"NDC"}],"standard_charges":[{"gross_charge":114.64,"discounted_cash":63.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Chlorothiazide Sodium For Inj 500 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"9526","type":"CDM"},{"code":"25021030520","type":"NDC"}],"standard_charges":[{"gross_charge":171.4,"discounted_cash":94.27,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Imipenem-Cilastatin Intravenous For Soln 500 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"9603","type":"CDM"},{"code":"63323032201","type":"NDC"}],"standard_charges":[{"gross_charge":110.16,"discounted_cash":60.59,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Ciprofloxacin HCl Ophth Soln 0.3% (Base Equivalent)","drug_information":{"unit":2.5,"type":"ML"},"code_information":[{"code":"9610","type":"CDM"},{"code":"50090175400","type":"NDC"}],"standard_charges":[{"gross_charge":85.83,"discounted_cash":47.21,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Ciprofloxacin HCl Ophth Soln 0.3% (Base Equivalent)","drug_information":{"unit":5.0,"type":"ML"},"code_information":[{"code":"9610","type":"CDM"},{"code":"61314065605","type":"NDC"}],"standard_charges":[{"gross_charge":173.12,"discounted_cash":95.22,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Clarithromycin Tab 250 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"9616","type":"CDM"},{"code":"50268017811","type":"NDC"}],"standard_charges":[{"gross_charge":27.26,"discounted_cash":14.99,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Clarithromycin Tab 250 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"9616","type":"CDM"},{"code":"50268017815","type":"NDC"}],"standard_charges":[{"gross_charge":27.26,"discounted_cash":14.99,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Clindamycin Phosphate in D5W IV Soln 600 MG/50ML","drug_information":{"unit":50.0,"type":"ML"},"code_information":[{"code":"9626","type":"CDM"},{"code":"43066099324","type":"NDC"}],"standard_charges":[{"gross_charge":87.96,"discounted_cash":48.38,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Clindamycin Phosphate in D5W IV Soln 900 MG/50ML","drug_information":{"unit":50.0,"type":"ML"},"code_information":[{"code":"9627","type":"CDM"},{"code":"338381450","type":"NDC"}],"standard_charges":[{"gross_charge":100.64,"discounted_cash":55.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Clonazepam Tab 0.5 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"9637","type":"CDM"},{"code":"904722761","type":"NDC"}],"standard_charges":[{"gross_charge":10.79,"discounted_cash":5.93,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Clonazepam Tab 1 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"9638","type":"CDM"},{"code":"43547040710","type":"NDC"}],"standard_charges":[{"gross_charge":11.8,"discounted_cash":6.49,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Clotrimazole Troche 10 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"9644","type":"CDM"},{"code":"574010770","type":"NDC"}],"standard_charges":[{"gross_charge":14.19,"discounted_cash":7.80,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Clozapine Tab 100 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"9647","type":"CDM"},{"code":"51079092220","type":"NDC"}],"standard_charges":[{"gross_charge":21.2,"discounted_cash":11.66,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Clozapine Tab 100 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"9647","type":"CDM"},{"code":"51079092201","type":"NDC"}],"standard_charges":[{"gross_charge":21.21,"discounted_cash":11.67,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Clozapine Tab 25 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"9648","type":"CDM"},{"code":"378082501","type":"NDC"}],"standard_charges":[{"gross_charge":13.08,"discounted_cash":7.19,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Collagenase Oint 250 Unit/GM","drug_information":{"unit":30.0,"type":"GM"},"code_information":[{"code":"9682","type":"CDM"},{"code":"50484001030","type":"NDC"}],"standard_charges":[{"gross_charge":1064.67,"discounted_cash":585.57,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Cosyntropin For Inj 0.25 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"9686","type":"CDM"},{"code":"548590000","type":"NDC"}],"standard_charges":[{"gross_charge":280.4,"discounted_cash":154.22,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Cyclopentolate HCl Ophth Soln 2%","drug_information":{"unit":2.0,"type":"ML"},"code_information":[{"code":"9700","type":"CDM"},{"code":"65039702","type":"NDC"}],"standard_charges":[{"gross_charge":139.41,"discounted_cash":76.68,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Dantrolene Sodium For IV Soln 20 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"9716","type":"CDM"},{"code":"78670000367","type":"NDC"}],"standard_charges":[{"gross_charge":194.8,"discounted_cash":107.14,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Dantrolene Sodium Cap 25 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"9718","type":"CDM"},{"code":"50268021711","type":"NDC"}],"standard_charges":[{"gross_charge":17.15,"discounted_cash":9.43,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Dantrolene Sodium Cap 25 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"9718","type":"CDM"},{"code":"50268021715","type":"NDC"}],"standard_charges":[{"gross_charge":17.15,"discounted_cash":9.43,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Deferoxamine Mesylate For Inj 500 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"9723","type":"CDM"},{"code":"63323059710","type":"NDC"}],"standard_charges":[{"gross_charge":79.7,"discounted_cash":43.84,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Desflurane Inhal Soln","drug_information":{"unit":240.0,"type":"ML"},"code_information":[{"code":"9747","type":"CDM"},{"code":"10019064164","type":"NDC"}],"standard_charges":[{"gross_charge":872.47,"discounted_cash":479.86,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Dextrose 5% in Lactated Ringers","drug_information":{"unit":1000.0,"type":"ML"},"code_information":[{"code":"9788","type":"CDM"},{"code":"264775100","type":"NDC"}],"standard_charges":[{"gross_charge":65.12,"discounted_cash":35.82,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Dextrose 5% in Lactated Ringers","drug_information":{"unit":1000.0,"type":"ML"},"code_information":[{"code":"9788","type":"CDM"},{"code":"338012504","type":"NDC"}],"standard_charges":[{"gross_charge":69.71,"discounted_cash":38.34,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Diatrizoate Meglumine & Sodium Oral Soln 66-10%","drug_information":{"unit":30.0,"type":"ML"},"code_information":[{"code":"9828","type":"CDM"},{"code":"270044535","type":"NDC"}],"standard_charges":[{"gross_charge":172.3,"discounted_cash":94.76,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Diatrizoate Meglumine & Sodium Oral Soln 66-10%","drug_information":{"unit":120.0,"type":"ML"},"code_information":[{"code":"9828","type":"CDM"},{"code":"270044540","type":"NDC"}],"standard_charges":[{"gross_charge":431.79,"discounted_cash":237.48,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Dimethyl Sulfoxide Soln 50%","drug_information":{"unit":50.0,"type":"ML"},"code_information":[{"code":"9873","type":"CDM"},{"code":"67457017750","type":"NDC"}],"standard_charges":[{"gross_charge":2425.18,"discounted_cash":1333.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Benzonatate Cap 100 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"988","type":"CDM"},{"code":"42806071401","type":"NDC"}],"standard_charges":[{"gross_charge":17.64,"discounted_cash":9.70,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Dipyridamole IV Soln 5 MG/ML","drug_information":{"unit":10.0,"type":"ML"},"code_information":[{"code":"9891","type":"CDM"},{"code":"641256944","type":"NDC"}],"standard_charges":[{"gross_charge":122.48,"discounted_cash":67.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Dobutamine HCl Inj 12.5 MG/ML","drug_information":{"unit":20.0,"type":"ML"},"code_information":[{"code":"9892","type":"CDM"},{"code":"143914101","type":"NDC"}],"standard_charges":[{"gross_charge":71.67,"discounted_cash":39.42,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Doxazosin Mesylate Tab 1 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"9894","type":"CDM"},{"code":"60505009300","type":"NDC"}],"standard_charges":[{"gross_charge":13.19,"discounted_cash":7.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Doxazosin Mesylate Tab 2 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"9895","type":"CDM"},{"code":"904552361","type":"NDC"}],"standard_charges":[{"gross_charge":11.2,"discounted_cash":6.16,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Doxycycline Monohydrate Cap 100 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"9900","type":"CDM"},{"code":"50268028115","type":"NDC"}],"standard_charges":[{"gross_charge":12.78,"discounted_cash":7.03,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Dronabinol Cap 2.5 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"9904","type":"CDM"},{"code":"60687037511","type":"NDC"}],"standard_charges":[{"gross_charge":36.02,"discounted_cash":19.81,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Dronabinol Cap 2.5 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"9904","type":"CDM"},{"code":"60687037521","type":"NDC"}],"standard_charges":[{"gross_charge":36.02,"discounted_cash":19.81,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Noncdm Charge Record","code_information":[{"code":"99214","type":"CDM"},{"code":"914","type":"RC"},{"code":"99214","type":"HCPCS"}],"standard_charges":[{"gross_charge":113.0,"discounted_cash":62.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Enalapril Maleate Tab 10 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"9924","type":"CDM"},{"code":"23155077201","type":"NDC"}],"standard_charges":[{"gross_charge":15.48,"discounted_cash":8.51,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Enalapril Maleate Tab 2.5 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"9925","type":"CDM"},{"code":"23155070401","type":"NDC"}],"standard_charges":[{"gross_charge":13.61,"discounted_cash":7.49,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Enalapril Maleate Tab 5 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"9927","type":"CDM"},{"code":"43547054610","type":"NDC"}],"standard_charges":[{"gross_charge":15.13,"discounted_cash":8.32,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Enalaprilat IV Soln 1.25 MG/ML","drug_information":{"unit":0.5,"type":"ML"},"code_information":[{"code":"9929","type":"CDM"},{"code":"143978610","type":"NDC"}],"standard_charges":[{"gross_charge":40.39,"discounted_cash":22.21,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Enalaprilat IV Soln 1.25 MG/ML","drug_information":{"unit":0.5,"type":"ML"},"code_information":[{"code":"9929","type":"CDM"},{"code":"43598007811","type":"NDC"}],"standard_charges":[{"gross_charge":41.51,"discounted_cash":22.83,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Enalaprilat IV Soln 1.25 MG/ML","drug_information":{"unit":0.5,"type":"ML"},"code_information":[{"code":"9929","type":"CDM"},{"code":"43598007858","type":"NDC"}],"standard_charges":[{"gross_charge":41.51,"discounted_cash":22.83,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Epoetin Alfa Inj 10000 Unit/ML","drug_information":{"unit":1.0,"type":"ML"},"code_information":[{"code":"9938","type":"CDM"},{"code":"59676031000","type":"NDC"}],"standard_charges":[{"gross_charge":420.91,"discounted_cash":231.50,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Estradiol Vaginal Cream 0.01%","drug_information":{"unit":42.5,"type":"GM"},"code_information":[{"code":"9969","type":"CDM"},{"code":"66993000210","type":"NDC"}],"standard_charges":[{"gross_charge":1040.68,"discounted_cash":572.37,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Estrogens, Conjugated For Inj 25 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"9972","type":"CDM"},{"code":"46074905","type":"NDC"}],"standard_charges":[{"gross_charge":709.39,"discounted_cash":390.16,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Estrogens, Conjugated Tab 0.625 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"9974","type":"CDM"},{"code":"46110281","type":"NDC"}],"standard_charges":[{"gross_charge":36.0,"discounted_cash":19.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Estrogens, Conjugated Vaginal Cream 0.625 MG/GM","drug_information":{"unit":30.0,"type":"GM"},"code_information":[{"code":"9977","type":"CDM"},{"code":"46087221","type":"NDC"}],"standard_charges":[{"gross_charge":1537.81,"discounted_cash":845.80,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Ethambutol HCl Tab 100 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"9982","type":"CDM"},{"code":"68180028001","type":"NDC"}],"standard_charges":[{"gross_charge":10.63,"discounted_cash":5.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Benztropine Mesylate Tab 1 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"999","type":"CDM"},{"code":"68084038801","type":"NDC"}],"standard_charges":[{"gross_charge":10.62,"discounted_cash":5.84,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Benztropine Mesylate Tab 1 MG","drug_information":{"unit":1.0,"type":"EA"},"code_information":[{"code":"999","type":"CDM"},{"code":"68084038811","type":"NDC"}],"standard_charges":[{"gross_charge":10.63,"discounted_cash":5.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Pharmacy"}]},{"description":"Noncdm Charge Record","code_information":[{"code":"Q3014","type":"CDM"},{"code":"780","type":"RC"},{"code":"Q3014","type":"HCPCS"}],"standard_charges":[{"gross_charge":60.0,"discounted_cash":33.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Tray Safe-T-Centesis","code_information":[{"code":"SUP100010","type":"CDM"},{"code":"278","type":"RC"},{"code":"C1729","type":"HCPCS"}],"standard_charges":[{"gross_charge":216.08,"discounted_cash":118.84,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Central Line Catheter Single Lumen","code_information":[{"code":"SUP100028","type":"CDM"},{"code":"272","type":"RC"},{"code":"C1751","type":"HCPCS"}],"standard_charges":[{"gross_charge":248.65,"discounted_cash":136.76,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"},{"gross_charge":243.06,"discounted_cash":133.68,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Midline Insertion Kit","code_information":[{"code":"SUP100029","type":"CDM"},{"code":"278","type":"RC"},{"code":"C1751","type":"HCPCS"}],"standard_charges":[{"gross_charge":323.58,"discounted_cash":177.97,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"},{"gross_charge":316.3,"discounted_cash":173.96,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Trach Tube Shiley #4 Cuffless","code_information":[{"code":"SUP100048","type":"CDM"},{"code":"272","type":"RC"}],"standard_charges":[{"gross_charge":139.75,"discounted_cash":76.86,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Alarm Sensor Toilet","code_information":[{"code":"SUP100299","type":"CDM"},{"code":"271","type":"RC"}],"standard_charges":[{"gross_charge":141.9,"discounted_cash":78.04,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Kt Cath Pneumothorax 8Fr X 16Cm","code_information":[{"code":"SUP100404","type":"CDM"},{"code":"272","type":"RC"}],"standard_charges":[{"gross_charge":339.47,"discounted_cash":186.71,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Nasopore Std 8.0Mm","code_information":[{"code":"SUP100422","type":"CDM"},{"code":"272","type":"RC"}],"standard_charges":[{"gross_charge":527.94,"discounted_cash":290.37,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"},{"gross_charge":527.94,"discounted_cash":290.37,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Cath Balloon Esophageal","code_information":[{"code":"SUP100455","type":"CDM"},{"code":"272","type":"RC"},{"code":"C1726","type":"HCPCS"}],"standard_charges":[{"gross_charge":625.75,"discounted_cash":344.16,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Drsg Gauze Surgicel 2 X 3","code_information":[{"code":"SUP100468","type":"CDM"},{"code":"270","type":"RC"}],"standard_charges":[{"gross_charge":207.78,"discounted_cash":114.28,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"},{"gross_charge":203.49,"discounted_cash":111.92,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."},{"gross_charge":203.32,"discounted_cash":111.83,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Cricothyrotomy Catheter Set","code_information":[{"code":"SUP100620","type":"CDM"},{"code":"270","type":"RC"}],"standard_charges":[{"gross_charge":565.42,"discounted_cash":310.98,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Knee Support Neoprene Large","code_information":[{"code":"SUP100677","type":"CDM"},{"code":"270","type":"RC"}],"standard_charges":[{"gross_charge":284.97,"discounted_cash":156.73,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"},{"gross_charge":280.7,"discounted_cash":154.38,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Knee Support Neoprene Medium","code_information":[{"code":"SUP100678","type":"CDM"},{"code":"270","type":"RC"}],"standard_charges":[{"gross_charge":280.44,"discounted_cash":154.24,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"},{"gross_charge":280.44,"discounted_cash":154.24,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."},{"gross_charge":274.12,"discounted_cash":150.77,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Knee Support Neoprene Small","code_information":[{"code":"SUP100679","type":"CDM"},{"code":"270","type":"RC"}],"standard_charges":[{"gross_charge":275.89,"discounted_cash":151.74,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"},{"gross_charge":269.69,"discounted_cash":148.33,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Cath Epidural Radio Opaque Brevi","code_information":[{"code":"SUP100832","type":"CDM"},{"code":"272","type":"RC"}],"standard_charges":[{"gross_charge":292.93,"discounted_cash":161.11,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Sling Lift 72X48In C1000Lb Gld Sht Ltx","code_information":[{"code":"SUP100923","type":"CDM"},{"code":"270","type":"RC"}],"standard_charges":[{"gross_charge":277.35,"discounted_cash":152.54,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Tube Trach Distal Cuff Xln 7.0Mm","code_information":[{"code":"SUP101053","type":"CDM"},{"code":"272","type":"RC"}],"standard_charges":[{"gross_charge":214.58,"discounted_cash":118.02,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Tube Trach Distal Cuff Xln 8.0Mm","code_information":[{"code":"SUP101054","type":"CDM"},{"code":"272","type":"RC"}],"standard_charges":[{"gross_charge":214.58,"discounted_cash":118.02,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Sys Turn And Pos Prevalon Std","code_information":[{"code":"SUP101122","type":"CDM"},{"code":"270","type":"RC"}],"standard_charges":[{"gross_charge":163.23,"discounted_cash":89.78,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."},{"gross_charge":163.25,"discounted_cash":89.79,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."},{"gross_charge":163.33,"discounted_cash":89.83,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Balln Cath Cerv Ripe 18Fr 40X80","code_information":[{"code":"SUP101430","type":"CDM"},{"code":"272","type":"RC"},{"code":"C1726","type":"HCPCS"}],"standard_charges":[{"gross_charge":1405.57,"discounted_cash":773.06,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"},{"gross_charge":1373.97,"discounted_cash":755.68,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Trach Tube Adult Shiley Uncuffed 6","code_information":[{"code":"SUP101577","type":"CDM"},{"code":"272","type":"RC"}],"standard_charges":[{"gross_charge":139.75,"discounted_cash":76.86,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Drsg Mepilex Silicon Foam 4X12","code_information":[{"code":"SUP101849","type":"CDM"},{"code":"272","type":"RC"}],"standard_charges":[{"gross_charge":133.37,"discounted_cash":73.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."},{"gross_charge":133.18,"discounted_cash":73.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Drsg Melgisorb Cl Alg 8X12 W/Silver","code_information":[{"code":"SUP101852","type":"CDM"},{"code":"272","type":"RC"}],"standard_charges":[{"gross_charge":133.97,"discounted_cash":73.68,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"},{"gross_charge":132.46,"discounted_cash":72.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Kit Flexi Seal Fms","code_information":[{"code":"SUP101910","type":"CDM"},{"code":"272","type":"RC"}],"standard_charges":[{"gross_charge":884.45,"discounted_cash":486.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"},{"gross_charge":864.56,"discounted_cash":475.51,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."},{"gross_charge":865.84,"discounted_cash":476.21,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Tube Trach Adult Shiley Proximal Xlt Cuffed 6","code_information":[{"code":"SUP102051","type":"CDM"},{"code":"271","type":"RC"}],"standard_charges":[{"gross_charge":214.58,"discounted_cash":118.02,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Tube Trach Quicktrach 4.0Mm","code_information":[{"code":"SUP102058","type":"CDM"},{"code":"272","type":"RC"}],"standard_charges":[{"gross_charge":653.23,"discounted_cash":359.28,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hc Tube Trach Quicktrach 2.0Mm","code_information":[{"code":"SUP102059","type":"CDM"},{"code":"272","type":"RC"}],"standard_charges":[{"gross_charge":653.23,"discounted_cash":359.28,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Tube Trach Cuffed 6.0","code_information":[{"code":"SUP102177","type":"CDM"},{"code":"272","type":"RC"}],"standard_charges":[{"gross_charge":202.1,"discounted_cash":111.16,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Tube Trach Cuffed 8.0","code_information":[{"code":"SUP102181","type":"CDM"},{"code":"272","type":"RC"}],"standard_charges":[{"gross_charge":214.58,"discounted_cash":118.02,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Drsg Nsl Ant Rapid Rhino 5.5Cm Rr550","code_information":[{"code":"SUP102401","type":"CDM"},{"code":"272","type":"RC"}],"standard_charges":[{"gross_charge":153.27,"discounted_cash":84.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"},{"gross_charge":149.82,"discounted_cash":82.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Kit Cvc Line","code_information":[{"code":"SUP102603","type":"CDM"},{"code":"278","type":"RC"},{"code":"C1751","type":"HCPCS"}],"standard_charges":[{"gross_charge":148.73,"discounted_cash":81.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Needle Ez Io 25Mm","code_information":[{"code":"SUP102748","type":"CDM"},{"code":"272","type":"RC"}],"standard_charges":[{"gross_charge":441.65,"discounted_cash":242.91,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"},{"gross_charge":441.65,"discounted_cash":242.91,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Balln Bakri Tamp 24Fr 54 X 500Ml","code_information":[{"code":"SUP102812","type":"CDM"},{"code":"272","type":"RC"}],"standard_charges":[{"gross_charge":609.69,"discounted_cash":335.33,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Aspen Collar","code_information":[{"code":"SUP103092","type":"CDM"},{"code":"274","type":"RC"},{"code":"L0172","type":"HCPCS"}],"standard_charges":[{"gross_charge":156.68,"discounted_cash":86.17,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"},{"gross_charge":153.16,"discounted_cash":84.24,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Needle Ez Io 45Mm 15 Ga","code_information":[{"code":"SUP103483","type":"CDM"},{"code":"272","type":"RC"}],"standard_charges":[{"gross_charge":441.65,"discounted_cash":242.91,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Tube Gastro Mic Adult 18Fr","code_information":[{"code":"SUP103497","type":"CDM"},{"code":"272","type":"RC"}],"standard_charges":[{"gross_charge":211.18,"discounted_cash":116.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"},{"gross_charge":206.43,"discounted_cash":113.54,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Tube Gastro Mic Low Volume 16Fr","code_information":[{"code":"SUP103498","type":"CDM"},{"code":"272","type":"RC"}],"standard_charges":[{"gross_charge":156.68,"discounted_cash":86.17,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"},{"gross_charge":153.16,"discounted_cash":84.24,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Balln Bakri Postpartum","code_information":[{"code":"SUP103506","type":"CDM"},{"code":"272","type":"RC"}],"standard_charges":[{"gross_charge":823.14,"discounted_cash":452.73,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Kit Prevena Peel And Place","code_information":[{"code":"SUP103643","type":"CDM"},{"code":"272","type":"RC"}],"standard_charges":[{"gross_charge":1369.24,"discounted_cash":753.08,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"},{"gross_charge":1338.45,"discounted_cash":736.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Kit Prevena Customizable","code_information":[{"code":"SUP103645","type":"CDM"},{"code":"272","type":"RC"}],"standard_charges":[{"gross_charge":2166.26,"discounted_cash":1191.44,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Flexima Apd Firm Cath Sys 10Fx25Cm","code_information":[{"code":"SUP103652","type":"CDM"},{"code":"272","type":"RC"},{"code":"C1729","type":"HCPCS"}],"standard_charges":[{"gross_charge":251.55,"discounted_cash":138.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Dressing Silverlon 4X12","code_information":[{"code":"SUP103673","type":"CDM"},{"code":"272","type":"RC"}],"standard_charges":[{"gross_charge":155.54,"discounted_cash":85.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"},{"gross_charge":152.05,"discounted_cash":83.63,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Dressing Silverlon 4X10","code_information":[{"code":"SUP103674","type":"CDM"},{"code":"272","type":"RC"}],"standard_charges":[{"gross_charge":129.43,"discounted_cash":71.19,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Blade Lopro S3 Single Use Glidescope","code_information":[{"code":"SUP103678","type":"CDM"},{"code":"272","type":"RC"}],"standard_charges":[{"gross_charge":168.03,"discounted_cash":92.42,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"},{"gross_charge":164.51,"discounted_cash":90.48,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Blade Lopro S4 Single Use Glidescope","code_information":[{"code":"SUP103679","type":"CDM"},{"code":"272","type":"RC"}],"standard_charges":[{"gross_charge":168.03,"discounted_cash":92.42,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"},{"gross_charge":164.7,"discounted_cash":90.58,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Introducer Endotracheal Flex Guide","code_information":[{"code":"SUP103685","type":"CDM"},{"code":"272","type":"RC"}],"standard_charges":[{"gross_charge":367.85,"discounted_cash":202.32,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"},{"gross_charge":359.59,"discounted_cash":197.77,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Needle Biopsy Aspiration","code_information":[{"code":"SUP103692","type":"CDM"},{"code":"272","type":"RC"}],"standard_charges":[{"gross_charge":718.12,"discounted_cash":394.97,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Knee Support Neoprene Xlarge","code_information":[{"code":"SUP103695","type":"CDM"},{"code":"270","type":"RC"}],"standard_charges":[{"gross_charge":283.84,"discounted_cash":156.11,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"},{"gross_charge":277.46,"discounted_cash":152.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Tube Trach Jackson Sz8","code_information":[{"code":"SUP103758","type":"CDM"},{"code":"272","type":"RC"},{"code":"A7522","type":"HCPCS"}],"standard_charges":[{"gross_charge":1448.34,"discounted_cash":796.59,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Kt Cath Balln Pace 5Fr","code_information":[{"code":"SUP103769","type":"CDM"},{"code":"272","type":"RC"},{"code":"C1730","type":"HCPCS"}],"standard_charges":[{"gross_charge":766.37,"discounted_cash":421.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Tray Cath Emerg Cricothyrectomy","code_information":[{"code":"SUP103870","type":"CDM"},{"code":"272","type":"RC"},{"code":"C1769","type":"HCPCS"}],"standard_charges":[{"gross_charge":1401.03,"discounted_cash":770.57,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Tracker Patient","code_information":[{"code":"SUP103876","type":"CDM"},{"code":"272","type":"RC"}],"standard_charges":[{"gross_charge":1145.92,"discounted_cash":630.26,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Patch Novii","code_information":[{"code":"SUP103923","type":"CDM"},{"code":"271","type":"RC"}],"standard_charges":[{"gross_charge":152.65,"discounted_cash":83.96,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Kit Cath Umbilical Vessel","code_information":[{"code":"SUP103930","type":"CDM"},{"code":"272","type":"RC"}],"standard_charges":[{"gross_charge":294.06,"discounted_cash":161.73,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Extractor Katz Oto Rhino","code_information":[{"code":"SUP104344","type":"CDM"},{"code":"272","type":"RC"}],"standard_charges":[{"gross_charge":44.28,"discounted_cash":24.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"},{"gross_charge":43.28,"discounted_cash":23.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Blade Lopro S1 Single Use Glidescope","code_information":[{"code":"SUP104413","type":"CDM"},{"code":"272","type":"RC"}],"standard_charges":[{"gross_charge":179.39,"discounted_cash":98.66,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Blade Lopro S2 Single Use Glidescope","code_information":[{"code":"SUP104414","type":"CDM"},{"code":"272","type":"RC"}],"standard_charges":[{"gross_charge":179.39,"discounted_cash":98.66,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Blade Spectrum Su Mac Sz 4","code_information":[{"code":"SUP104457","type":"CDM"},{"code":"272","type":"RC"}],"standard_charges":[{"gross_charge":141.92,"discounted_cash":78.06,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"},{"gross_charge":139.18,"discounted_cash":76.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Cath Coude 16Fr","code_information":[{"code":"SUP104587","type":"CDM"},{"code":"272","type":"RC"}],"standard_charges":[{"gross_charge":115.8,"discounted_cash":63.69,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"},{"gross_charge":113.05,"discounted_cash":62.18,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Alarm Sensor Chair","code_information":[{"code":"SUP104622","type":"CDM"},{"code":"271","type":"RC"}],"standard_charges":[{"gross_charge":113.95,"discounted_cash":62.67,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Kt Oral Care Vent","code_information":[{"code":"SUP104765","type":"CDM"},{"code":"272","type":"RC"}],"standard_charges":[{"gross_charge":356.31,"discounted_cash":195.97,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Set Pressure Montr Stryker","code_information":[{"code":"SUP104820","type":"CDM"},{"code":"270","type":"RC"}],"standard_charges":[{"gross_charge":367.85,"discounted_cash":202.32,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Kt Cath Pleurx 1000Ml Plr Strt","code_information":[{"code":"SUP105073","type":"CDM"},{"code":"278","type":"RC"},{"code":"C1729","type":"HCPCS"}],"standard_charges":[{"gross_charge":966.66,"discounted_cash":531.66,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Kt Cath Pleurx Pleural","code_information":[{"code":"SUP105074","type":"CDM"},{"code":"272","type":"RC"},{"code":"C1729","type":"HCPCS"}],"standard_charges":[{"gross_charge":1657.28,"discounted_cash":911.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Blade Spectrum Su Mac Sz 3","code_information":[{"code":"SUP105101","type":"CDM"},{"code":"272","type":"RC"}],"standard_charges":[{"gross_charge":141.92,"discounted_cash":78.06,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"},{"gross_charge":138.73,"discounted_cash":76.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Wound Vac Veraflo Medium","code_information":[{"code":"SUP106072","type":"CDM"},{"code":"272","type":"RC"}],"standard_charges":[{"gross_charge":199.82,"discounted_cash":109.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Veraflo Cassette","code_information":[{"code":"SUP106073","type":"CDM"},{"code":"272","type":"RC"}],"standard_charges":[{"gross_charge":370.12,"discounted_cash":203.57,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Comp Sys Arch Fem","code_information":[{"code":"SUP106192","type":"CDM"},{"code":"270","type":"RC"}],"standard_charges":[{"gross_charge":323.58,"discounted_cash":177.97,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"},{"gross_charge":316.3,"discounted_cash":173.96,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Cushion Waffle Bari","code_information":[{"code":"SUP106193","type":"CDM"},{"code":"270","type":"RC"}],"standard_charges":[{"gross_charge":167.91,"discounted_cash":92.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."},{"gross_charge":167.58,"discounted_cash":92.17,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."},{"gross_charge":168.35,"discounted_cash":92.59,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Cushion Waffle Standard","code_information":[{"code":"SUP106194","type":"CDM"},{"code":"272","type":"RC"}],"standard_charges":[{"gross_charge":122.16,"discounted_cash":67.19,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."},{"gross_charge":122.39,"discounted_cash":67.31,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."},{"gross_charge":122.35,"discounted_cash":67.29,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Drsg Trak Kt Lg","code_information":[{"code":"SUP106195","type":"CDM"},{"code":"272","type":"RC"}],"standard_charges":[{"gross_charge":250.92,"discounted_cash":138.01,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"},{"gross_charge":245.27,"discounted_cash":134.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."},{"gross_charge":245.64,"discounted_cash":135.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Drsg Trak Kt Sm","code_information":[{"code":"SUP106196","type":"CDM"},{"code":"272","type":"RC"}],"standard_charges":[{"gross_charge":173.13,"discounted_cash":95.22,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Pad Intelli Flo Back","code_information":[{"code":"SUP106197","type":"CDM"},{"code":"272","type":"RC"}],"standard_charges":[{"gross_charge":131.7,"discounted_cash":72.44,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"},{"gross_charge":128.74,"discounted_cash":70.81,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Pad Intelli Flo Knee","code_information":[{"code":"SUP106198","type":"CDM"},{"code":"270","type":"RC"}],"standard_charges":[{"gross_charge":178.26,"discounted_cash":98.04,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"},{"gross_charge":174.25,"discounted_cash":95.84,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Pad Intelli Flo Shield Xlg","code_information":[{"code":"SUP106199","type":"CDM"},{"code":"270","type":"RC"}],"standard_charges":[{"gross_charge":253.19,"discounted_cash":139.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Polar Care Kodiak Sys","code_information":[{"code":"SUP106200","type":"CDM"},{"code":"270","type":"RC"}],"standard_charges":[{"gross_charge":480.26,"discounted_cash":264.14,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"},{"gross_charge":469.46,"discounted_cash":258.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Sheet Comfort W Hdndl Xl","code_information":[{"code":"SUP106201","type":"CDM"},{"code":"272","type":"RC"}],"standard_charges":[{"gross_charge":243.52,"discounted_cash":133.94,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."},{"gross_charge":243.06,"discounted_cash":133.68,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Sheet Fitted Xxl 50X80","code_information":[{"code":"SUP106202","type":"CDM"},{"code":"272","type":"RC"}],"standard_charges":[{"gross_charge":126.03,"discounted_cash":69.32,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"},{"gross_charge":123.2,"discounted_cash":67.76,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Stapler Lin Reload Leg 60Mm 4.8Mm","code_information":[{"code":"SUP106203","type":"CDM"},{"code":"272","type":"RC"}],"standard_charges":[{"gross_charge":406.46,"discounted_cash":223.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Walker Boot Maxtrax Lg","code_information":[{"code":"SUP106204","type":"CDM"},{"code":"270","type":"RC"}],"standard_charges":[{"gross_charge":109.21,"discounted_cash":60.07,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."},{"gross_charge":108.77,"discounted_cash":59.82,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Walker Boot Maxtrax Md","code_information":[{"code":"SUP106205","type":"CDM"},{"code":"270","type":"RC"}],"standard_charges":[{"gross_charge":109.05,"discounted_cash":59.98,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."},{"gross_charge":108.92,"discounted_cash":59.91,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."},{"gross_charge":109.77,"discounted_cash":60.37,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Wedge Foam 30 Reg","code_information":[{"code":"SUP106206","type":"CDM"},{"code":"272","type":"RC"}],"standard_charges":[{"gross_charge":154.41,"discounted_cash":84.93,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"},{"gross_charge":151.74,"discounted_cash":83.46,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Wedge Foam 30 Xl","code_information":[{"code":"SUP106207","type":"CDM"},{"code":"272","type":"RC"}],"standard_charges":[{"gross_charge":258.86,"discounted_cash":142.37,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"},{"gross_charge":253.46,"discounted_cash":139.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Kit Cath Mult Lum Cvc Pwr Inj 7Fr","code_information":[{"code":"SUP106209","type":"CDM"},{"code":"272","type":"RC"},{"code":"C1751","type":"HCPCS"}],"standard_charges":[{"gross_charge":364.45,"discounted_cash":200.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"},{"gross_charge":357.05,"discounted_cash":196.38,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."},{"gross_charge":356.26,"discounted_cash":195.94,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Walker Boot Maxtrax Sm","code_information":[{"code":"SUP106210","type":"CDM"},{"code":"270","type":"RC"}],"standard_charges":[{"gross_charge":108.77,"discounted_cash":59.82,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Tray Urology","code_information":[{"code":"SUP106211","type":"CDM"},{"code":"272","type":"RC"}],"standard_charges":[{"gross_charge":581.31,"discounted_cash":319.72,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Tourniquet Combat Applic","code_information":[{"code":"SUP106212","type":"CDM"},{"code":"272","type":"RC"}],"standard_charges":[{"gross_charge":135.12,"discounted_cash":74.32,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Cpap Flow Safe Sm Adult","code_information":[{"code":"SUP106213","type":"CDM"},{"code":"272","type":"RC"}],"standard_charges":[{"gross_charge":214.58,"discounted_cash":118.02,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Cpap Flow Safe Ii Lg Adult","code_information":[{"code":"SUP106214","type":"CDM"},{"code":"272","type":"RC"}],"standard_charges":[{"gross_charge":221.4,"discounted_cash":121.77,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"},{"gross_charge":216.42,"discounted_cash":119.03,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."},{"gross_charge":217.07,"discounted_cash":119.39,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Cpap Flow Safe Ii Sm Adult","code_information":[{"code":"SUP106215","type":"CDM"},{"code":"272","type":"RC"}],"standard_charges":[{"gross_charge":213.44,"discounted_cash":117.39,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Needles Io","code_information":[{"code":"SUP106217","type":"CDM"},{"code":"272","type":"RC"}],"standard_charges":[{"gross_charge":484.79,"discounted_cash":266.63,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Handpiece Irrigation","code_information":[{"code":"SUP106218","type":"CDM"},{"code":"272","type":"RC"}],"standard_charges":[{"gross_charge":145.33,"discounted_cash":79.93,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Kit Cath Art Line 18Ga Lf","code_information":[{"code":"SUP106219","type":"CDM"},{"code":"272","type":"RC"}],"standard_charges":[{"gross_charge":211.18,"discounted_cash":116.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"},{"gross_charge":206.43,"discounted_cash":113.54,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Stabilizer Pelvic","code_information":[{"code":"SUP106220","type":"CDM"},{"code":"272","type":"RC"}],"standard_charges":[{"gross_charge":354.23,"discounted_cash":194.83,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"},{"gross_charge":346.27,"discounted_cash":190.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Pack Rhinonasal Anterior","code_information":[{"code":"SUP106221","type":"CDM"},{"code":"272","type":"RC"}],"standard_charges":[{"gross_charge":136.25,"discounted_cash":74.94,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"},{"gross_charge":133.18,"discounted_cash":73.25,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Pack Rhinonsal Posterior","code_information":[{"code":"SUP106222","type":"CDM"},{"code":"272","type":"RC"}],"standard_charges":[{"gross_charge":147.6,"discounted_cash":81.18,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"},{"gross_charge":144.28,"discounted_cash":79.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Splint Speed Traction","code_information":[{"code":"SUP106224","type":"CDM"},{"code":"272","type":"RC"}],"standard_charges":[{"gross_charge":289.51,"discounted_cash":159.23,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"},{"gross_charge":283.0,"discounted_cash":155.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Splint Metacarpal Adult Rt","code_information":[{"code":"SUP106225","type":"CDM"},{"code":"270","type":"RC"}],"standard_charges":[{"gross_charge":111.27,"discounted_cash":61.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"},{"gross_charge":108.77,"discounted_cash":59.82,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Splint Thumbwrist Med Lg Lt","code_information":[{"code":"SUP106226","type":"CDM"},{"code":"270","type":"RC"}],"standard_charges":[{"gross_charge":164.26,"discounted_cash":90.34,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."},{"gross_charge":164.5,"discounted_cash":90.48,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Splint Thumbwrist Sm Med Rt","code_information":[{"code":"SUP106227","type":"CDM"},{"code":"270","type":"RC"}],"standard_charges":[{"gross_charge":168.18,"discounted_cash":92.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."},{"gross_charge":167.58,"discounted_cash":92.17,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Tray Cath Ic Temp Sensor","code_information":[{"code":"SUP106228","type":"CDM"},{"code":"272","type":"RC"}],"standard_charges":[{"gross_charge":141.92,"discounted_cash":78.06,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"},{"gross_charge":138.82,"discounted_cash":76.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."},{"gross_charge":139.53,"discounted_cash":76.74,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Tube Gastro Ball 22Fr","code_information":[{"code":"SUP106230","type":"CDM"},{"code":"270","type":"RC"}],"standard_charges":[{"gross_charge":195.27,"discounted_cash":107.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"},{"gross_charge":190.89,"discounted_cash":104.99,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Supplies Hypothermia Tx","code_information":[{"code":"SUP106231","type":"CDM"},{"code":"272","type":"RC"}],"standard_charges":[{"gross_charge":2963.27,"discounted_cash":1629.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Kit Cath Presep Cv Oximetry 8.5Fr","code_information":[{"code":"SUP106232","type":"CDM"},{"code":"272","type":"RC"}],"standard_charges":[{"gross_charge":1503.22,"discounted_cash":826.77,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Cartridge Nxstage Disp","code_information":[{"code":"SUP106233","type":"CDM"},{"code":"272","type":"RC"}],"standard_charges":[{"gross_charge":643.74,"discounted_cash":354.06,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"},{"gross_charge":630.16,"discounted_cash":346.59,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Pack Thoracic","code_information":[{"code":"SUP106234","type":"CDM"},{"code":"272","type":"RC"}],"standard_charges":[{"gross_charge":204.36,"discounted_cash":112.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Tubing Flrtrac W 84 Press Line","code_information":[{"code":"SUP106238","type":"CDM"},{"code":"272","type":"RC"}],"standard_charges":[{"gross_charge":1143.31,"discounted_cash":628.82,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"},{"gross_charge":1117.6,"discounted_cash":614.68,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Screening Kit Neonatal","code_information":[{"code":"SUP106239","type":"CDM"},{"code":"271","type":"RC"}],"standard_charges":[{"gross_charge":592.65,"discounted_cash":325.96,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"},{"gross_charge":580.27,"discounted_cash":319.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."},{"gross_charge":580.66,"discounted_cash":319.36,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Trach Tube Inner Cannula","code_information":[{"code":"SUP106240","type":"CDM"},{"code":"272","type":"RC"},{"code":"A4623","type":"HCPCS"}],"standard_charges":[{"gross_charge":254.32,"discounted_cash":139.88,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Trach Tube Xlt Non Cuff Prox 6 7 8","code_information":[{"code":"SUP106241","type":"CDM"},{"code":"272","type":"RC"},{"code":"A7520","type":"HCPCS"}],"standard_charges":[{"gross_charge":308.82,"discounted_cash":169.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Sling Ultra Md","code_information":[{"code":"SUP106242","type":"CDM"},{"code":"274","type":"RC"},{"code":"L3761","type":"HCPCS"}],"standard_charges":[{"gross_charge":198.69,"discounted_cash":109.28,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"},{"gross_charge":194.68,"discounted_cash":107.07,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."},{"gross_charge":194.22,"discounted_cash":106.82,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Boot Rooke Classic Lg","code_information":[{"code":"SUP106243","type":"CDM"},{"code":"274","type":"RC"},{"code":"L4386","type":"HCPCS"}],"standard_charges":[{"gross_charge":328.11,"discounted_cash":180.46,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Boot Rooke Classic Md","code_information":[{"code":"SUP106244","type":"CDM"},{"code":"271","type":"RC"}],"standard_charges":[{"gross_charge":328.11,"discounted_cash":180.46,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Trach Speaking Vlv Wo 02 Port","code_information":[{"code":"SUP106245","type":"CDM"},{"code":"274","type":"RC"},{"code":"L8501","type":"HCPCS"}],"standard_charges":[{"gross_charge":173.71,"discounted_cash":95.54,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Kit Oxygen Heated High Flow","code_information":[{"code":"SUP106246","type":"CDM"},{"code":"270","type":"RC"}],"standard_charges":[{"gross_charge":284.97,"discounted_cash":156.73,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"},{"gross_charge":279.28,"discounted_cash":153.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."},{"gross_charge":280.7,"discounted_cash":154.38,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Spacer Adult","code_information":[{"code":"SUP106247","type":"CDM"},{"code":"272","type":"RC"}],"standard_charges":[{"gross_charge":111.21,"discounted_cash":61.17,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."},{"gross_charge":111.18,"discounted_cash":61.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."},{"gross_charge":110.98,"discounted_cash":61.04,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Spacer Child","code_information":[{"code":"SUP106248","type":"CDM"},{"code":"272","type":"RC"}],"standard_charges":[{"gross_charge":113.53,"discounted_cash":62.44,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"},{"gross_charge":110.98,"discounted_cash":61.04,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Glidescope Bflex 5.0","code_information":[{"code":"SUP106249","type":"CDM"},{"code":"272","type":"RC"}],"standard_charges":[{"gross_charge":1060.42,"discounted_cash":583.23,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"},{"gross_charge":1036.58,"discounted_cash":570.12,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Kiwi W Pro Cup","code_information":[{"code":"SUP106251","type":"CDM"},{"code":"272","type":"RC"}],"standard_charges":[{"gross_charge":147.6,"discounted_cash":81.18,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"},{"gross_charge":144.28,"discounted_cash":79.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Kiwi W Omni Cup","code_information":[{"code":"SUP106252","type":"CDM"},{"code":"272","type":"RC"}],"standard_charges":[{"gross_charge":110.12,"discounted_cash":60.57,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"},{"gross_charge":108.0,"discounted_cash":59.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."},{"gross_charge":107.65,"discounted_cash":59.21,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Bell Cup Mystic Mitysoft","code_information":[{"code":"SUP106253","type":"CDM"},{"code":"272","type":"RC"}],"standard_charges":[{"gross_charge":131.7,"discounted_cash":72.44,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"},{"gross_charge":129.01,"discounted_cash":70.96,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Brace Knee Hng Neoprene 2Xl","code_information":[{"code":"SUP106255","type":"CDM"},{"code":"271","type":"RC"}],"standard_charges":[{"gross_charge":273.62,"discounted_cash":150.49,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"},{"gross_charge":270.55,"discounted_cash":148.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Cath Tlum 5Fr Lf Pic Max Solo","code_information":[{"code":"SUP106279","type":"CDM"},{"code":"272","type":"RC"}],"standard_charges":[{"gross_charge":975.27,"discounted_cash":536.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Tube Feeding Retention System","code_information":[{"code":"SUP106358","type":"CDM"},{"code":"271","type":"RC"}],"standard_charges":[{"gross_charge":274.76,"discounted_cash":151.12,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Cassette Purge Impella Cntrl","code_information":[{"code":"SUP106369","type":"CDM"},{"code":"272","type":"RC"}],"standard_charges":[{"gross_charge":2753.24,"discounted_cash":1514.28,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Kt Arwy King Lt","code_information":[{"code":"SUP106376","type":"CDM"},{"code":"272","type":"RC"}],"standard_charges":[{"gross_charge":219.12,"discounted_cash":120.52,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Dilator Set S Curve","code_information":[{"code":"SUP106377","type":"CDM"},{"code":"272","type":"RC"}],"standard_charges":[{"gross_charge":653.97,"discounted_cash":359.68,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Equip Bariatric","code_information":[{"code":"SUP106648","type":"CDM"},{"code":"270","type":"RC"}],"standard_charges":[{"gross_charge":381.49,"discounted_cash":209.82,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"},{"gross_charge":373.29,"discounted_cash":205.31,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Tray Coude Advance  Sil 16Fr","code_information":[{"code":"SUP106649","type":"CDM"},{"code":"272","type":"RC"}],"standard_charges":[{"gross_charge":161.09,"discounted_cash":88.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."},{"gross_charge":160.93,"discounted_cash":88.51,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Cath Intub Ain 19Frx56Cm","code_information":[{"code":"SUP106650","type":"CDM"},{"code":"272","type":"RC"}],"standard_charges":[{"gross_charge":172.57,"discounted_cash":94.91,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"},{"gross_charge":168.69,"discounted_cash":92.78,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Wire Glide .035X150","code_information":[{"code":"SUP106651","type":"CDM"},{"code":"272","type":"RC"},{"code":"C1769","type":"HCPCS"}],"standard_charges":[{"gross_charge":195.27,"discounted_cash":107.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Wire Guide Nicor Ang .035X150","code_information":[{"code":"SUP106652","type":"CDM"},{"code":"272","type":"RC"},{"code":"C1769","type":"HCPCS"}],"standard_charges":[{"gross_charge":288.38,"discounted_cash":158.61,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Boot Rooke Classic Petite","code_information":[{"code":"SUP106810","type":"CDM"},{"code":"274","type":"RC"},{"code":"L4386","type":"HCPCS"}],"standard_charges":[{"gross_charge":316.76,"discounted_cash":174.22,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Boot Rooke Classic","code_information":[{"code":"SUP106811","type":"CDM"},{"code":"274","type":"RC"},{"code":"L4386","type":"HCPCS"}],"standard_charges":[{"gross_charge":316.76,"discounted_cash":174.22,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Boot Rooke Classic Sm","code_information":[{"code":"SUP106812","type":"CDM"},{"code":"274","type":"RC"},{"code":"L4386","type":"HCPCS"}],"standard_charges":[{"gross_charge":316.76,"discounted_cash":174.22,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Boot Rooke Classic Xsm","code_information":[{"code":"SUP106813","type":"CDM"},{"code":"274","type":"RC"},{"code":"L4386","type":"HCPCS"}],"standard_charges":[{"gross_charge":316.76,"discounted_cash":174.22,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Patient Positioner Standard Z Flo 16In","code_information":[{"code":"SUP106888","type":"CDM"},{"code":"270","type":"RC"}],"standard_charges":[{"gross_charge":545.47,"discounted_cash":300.01,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"},{"gross_charge":533.2,"discounted_cash":293.26,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Patient Positioner Small Fluidized","code_information":[{"code":"SUP106889","type":"CDM"},{"code":"270","type":"RC"}],"standard_charges":[{"gross_charge":182.56,"discounted_cash":100.41,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"},{"gross_charge":178.79,"discounted_cash":98.33,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Tray Thal Quick Chest Tube 10Frx20Cm","code_information":[{"code":"SUP107038","type":"CDM"},{"code":"272","type":"RC"},{"code":"C1729","type":"HCPCS"}],"standard_charges":[{"gross_charge":549.51,"discounted_cash":302.23,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"},{"gross_charge":537.16,"discounted_cash":295.44,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Wire Nitinol .014 X 80Cm","code_information":[{"code":"SUP107045","type":"CDM"},{"code":"272","type":"RC"},{"code":"C1769","type":"HCPCS"}],"standard_charges":[{"gross_charge":231.12,"discounted_cash":127.12,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Drsg Silicone 3X3","code_information":[{"code":"SUP107414","type":"CDM"},{"code":"272","type":"RC"}],"standard_charges":[{"gross_charge":179.39,"discounted_cash":98.66,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Kit Cpr Infant Anytime","code_information":[{"code":"SUP107439","type":"CDM"},{"code":"272","type":"RC"}],"standard_charges":[{"gross_charge":1077.45,"discounted_cash":592.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"},{"gross_charge":1053.75,"discounted_cash":579.56,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Inst Crpl Tnl Sx-One Microknife Disp","code_information":[{"code":"SUP107594","type":"CDM"},{"code":"272","type":"RC"}],"standard_charges":[{"gross_charge":2753.24,"discounted_cash":1514.28,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Sys Jada 2002 Hemorage Vac Vlv Blu Kt","code_information":[{"code":"SUP107734","type":"CDM"},{"code":"272","type":"RC"}],"standard_charges":[{"gross_charge":3158.56,"discounted_cash":1737.21,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"},{"gross_charge":3087.55,"discounted_cash":1698.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Slng Orth Givmohr Fm C100-140 Lb Sm Arm","code_information":[{"code":"SUP107761","type":"CDM"},{"code":"270","type":"RC"}],"standard_charges":[{"gross_charge":382.61,"discounted_cash":210.44,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Slng Orth Givmohr C135-185 Lb Med L13-14","code_information":[{"code":"SUP107762","type":"CDM"},{"code":"270","type":"RC"}],"standard_charges":[{"gross_charge":382.61,"discounted_cash":210.44,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Slng Orth Givmohr Fm C180-235 Lb Lg Arm","code_information":[{"code":"SUP107763","type":"CDM"},{"code":"270","type":"RC"}],"standard_charges":[{"gross_charge":382.61,"discounted_cash":210.44,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"},{"gross_charge":374.01,"discounted_cash":205.71,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Slng Orth Givmohr Fm Ovr C235 Xl Arm Elb","code_information":[{"code":"SUP107764","type":"CDM"},{"code":"270","type":"RC"}],"standard_charges":[{"gross_charge":382.61,"discounted_cash":210.44,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Boot Hl Std Z-Flx Air Fluidize Rip Stp","code_information":[{"code":"SUP107971","type":"CDM"},{"code":"270","type":"RC"}],"standard_charges":[{"gross_charge":138.88,"discounted_cash":76.38,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."},{"gross_charge":138.68,"discounted_cash":76.27,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Chest Compression System","code_information":[{"code":"SUP108091","type":"CDM"},{"code":"272","type":"RC"}],"standard_charges":[{"gross_charge":141.92,"discounted_cash":78.06,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Tube Trach Cuff 5Mm","code_information":[{"code":"SUP108092","type":"CDM"},{"code":"272","type":"RC"}],"standard_charges":[{"gross_charge":214.58,"discounted_cash":118.02,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Tube Trach Uncuf 6Mm","code_information":[{"code":"SUP108093","type":"CDM"},{"code":"272","type":"RC"}],"standard_charges":[{"gross_charge":214.58,"discounted_cash":118.02,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Valve Speaker Phonate","code_information":[{"code":"SUP108094","type":"CDM"},{"code":"272","type":"RC"}],"standard_charges":[{"gross_charge":118.08,"discounted_cash":64.94,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Tube Trach 7.5Mm","code_information":[{"code":"SUP108095","type":"CDM"},{"code":"272","type":"RC"}],"standard_charges":[{"gross_charge":155.54,"discounted_cash":85.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Cath Art Line 7Fr Fem","code_information":[{"code":"SUP108096","type":"CDM"},{"code":"272","type":"RC"}],"standard_charges":[{"gross_charge":264.54,"discounted_cash":145.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"},{"gross_charge":259.33,"discounted_cash":142.63,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Tube Trach Uncuf 7Mm","code_information":[{"code":"SUP108097","type":"CDM"},{"code":"272","type":"RC"}],"standard_charges":[{"gross_charge":214.58,"discounted_cash":118.02,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Tray Thal Quick Chest Tube 24Frx41Cm","code_information":[{"code":"SUP108400","type":"CDM"},{"code":"278","type":"RC"},{"code":"C1729","type":"HCPCS"}],"standard_charges":[{"gross_charge":577.9,"discounted_cash":317.84,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Blade Lopro S2.5 Single Use Glidescope","code_information":[{"code":"SUP108401","type":"CDM"},{"code":"272","type":"RC"}],"standard_charges":[{"gross_charge":179.39,"discounted_cash":98.66,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Glidescope Bflex 3.8","code_information":[{"code":"SUP108402","type":"CDM"},{"code":"272","type":"RC"}],"standard_charges":[{"gross_charge":832.22,"discounted_cash":457.72,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"},{"gross_charge":813.51,"discounted_cash":447.43,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Glidescope Bflex 5.8","code_information":[{"code":"SUP108403","type":"CDM"},{"code":"272","type":"RC"}],"standard_charges":[{"gross_charge":961.64,"discounted_cash":528.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Blade Miller Laryngoscope S0","code_information":[{"code":"SUP108404","type":"CDM"},{"code":"272","type":"RC"}],"standard_charges":[{"gross_charge":179.39,"discounted_cash":98.66,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Blade Miller Laryngoscope S1","code_information":[{"code":"SUP108405","type":"CDM"},{"code":"272","type":"RC"}],"standard_charges":[{"gross_charge":179.39,"discounted_cash":98.66,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"},{"gross_charge":175.35,"discounted_cash":96.44,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Cath Balloon Dil Pulmonary","code_information":[{"code":"SUP108615","type":"CDM"},{"code":"272","type":"RC"},{"code":"C1726","type":"HCPCS"}],"standard_charges":[{"gross_charge":825.89,"discounted_cash":454.24,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Forceps Biopsy Mini","code_information":[{"code":"SUP108616","type":"CDM"},{"code":"272","type":"RC"}],"standard_charges":[{"gross_charge":1399.95,"discounted_cash":769.97,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Sizing Device Tracheobr Stent","code_information":[{"code":"SUP108617","type":"CDM"},{"code":"272","type":"RC"}],"standard_charges":[{"gross_charge":731.32,"discounted_cash":402.23,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Needle Knife Endoscopic","code_information":[{"code":"SUP108618","type":"CDM"},{"code":"272","type":"RC"}],"standard_charges":[{"gross_charge":2120.27,"discounted_cash":1166.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Needle Biopsy Asp Electromag","code_information":[{"code":"SUP108619","type":"CDM"},{"code":"272","type":"RC"}],"standard_charges":[{"gross_charge":2169.76,"discounted_cash":1193.37,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Forceps Biopsy Electromag","code_information":[{"code":"SUP108620","type":"CDM"},{"code":"272","type":"RC"}],"standard_charges":[{"gross_charge":1541.82,"discounted_cash":848.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Sheath Guide Endoscope Disposable","code_information":[{"code":"SUP108621","type":"CDM"},{"code":"272","type":"RC"}],"standard_charges":[{"gross_charge":451.98,"discounted_cash":248.59,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Tissue Marker Implantable Any Type","code_information":[{"code":"SUP108622","type":"CDM"},{"code":"278","type":"RC"},{"code":"A4648","type":"HCPCS"}],"standard_charges":[{"gross_charge":340.91,"discounted_cash":187.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"},{"gross_charge":333.25,"discounted_cash":183.29,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Stent Tracheobronchial Covered","code_information":[{"code":"SUP108623","type":"CDM"},{"code":"278","type":"RC"},{"code":"C1874","type":"HCPCS"}],"standard_charges":[{"gross_charge":7240.59,"discounted_cash":3982.32,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Sling Patient Lift W/Head Support Lg Disp","code_information":[{"code":"SUP108640","type":"CDM"},{"code":"272","type":"RC"}],"standard_charges":[{"gross_charge":186.95,"discounted_cash":102.82,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"},{"gross_charge":183.19,"discounted_cash":100.75,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Sling Lft Xl Head Supp Brthbl Disp","code_information":[{"code":"SUP108641","type":"CDM"},{"code":"272","type":"RC"}],"standard_charges":[{"gross_charge":190.25,"discounted_cash":104.64,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"},{"gross_charge":186.36,"discounted_cash":102.5,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Apr Ewrst Sp Clip Medium-Large","code_information":[{"code":"SUP108783","type":"CDM"},{"code":"272","type":"RC"}],"standard_charges":[{"gross_charge":138.57,"discounted_cash":76.21,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Fcp Ewrst Sp Md Biplr","code_information":[{"code":"SUP108784","type":"CDM"},{"code":"272","type":"RC"}],"standard_charges":[{"gross_charge":1136.02,"discounted_cash":624.81,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"},{"gross_charge":1110.47,"discounted_cash":610.76,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Scsr Lapscp Jaw Opn Dvnc Ewrst Ptts 22D","code_information":[{"code":"SUP108785","type":"CDM"},{"code":"272","type":"RC"}],"standard_charges":[{"gross_charge":675.23,"discounted_cash":371.38,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Fcp Lapscp 1Cm Dvnc Xi Ewrst Blk Dmd Mic","code_information":[{"code":"SUP108786","type":"CDM"},{"code":"272","type":"RC"}],"standard_charges":[{"gross_charge":692.83,"discounted_cash":381.06,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Fcp Lapscp Rpsb 10 Use 30.99Cm 8Mm Dvnc","code_information":[{"code":"SUP108787","type":"CDM"},{"code":"272","type":"RC"}],"standard_charges":[{"gross_charge":703.82,"discounted_cash":387.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Scsr Lapscp 31.75Cm 8Mm Dvnc Xi Hot Shr","code_information":[{"code":"SUP108788","type":"CDM"},{"code":"272","type":"RC"}],"standard_charges":[{"gross_charge":1108.52,"discounted_cash":609.69,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"},{"gross_charge":1088.24,"discounted_cash":598.53,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Fcp Lapscp 31.75Cm 8Mm Resano Dvnc Xi","code_information":[{"code":"SUP108789","type":"CDM"},{"code":"272","type":"RC"}],"standard_charges":[{"gross_charge":762.11,"discounted_cash":419.16,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hook Lapscp 8Mm Ewrst Perm Caut Grsp Frc","code_information":[{"code":"SUP108790","type":"CDM"},{"code":"272","type":"RC"}],"standard_charges":[{"gross_charge":415.69,"discounted_cash":228.63,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"},{"gross_charge":415.69,"discounted_cash":228.63,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Eltrd Esurg Spat 32.26Cm 8Mm Dvnc Ewrst","code_information":[{"code":"SUP108791","type":"CDM"},{"code":"272","type":"RC"}],"standard_charges":[{"gross_charge":415.69,"discounted_cash":228.63,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Drvr Ndl 31.75Cm 8Mm Dvnc Xi Ewrst Mega","code_information":[{"code":"SUP108792","type":"CDM"},{"code":"272","type":"RC"}],"standard_charges":[{"gross_charge":762.11,"discounted_cash":419.16,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"},{"gross_charge":750.12,"discounted_cash":412.57,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Fcp Lapscp 32.77Cm 8Mm Dvnc Xi Ewrst 75D","code_information":[{"code":"SUP108793","type":"CDM"},{"code":"272","type":"RC"}],"standard_charges":[{"gross_charge":762.11,"discounted_cash":419.16,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Grspr Lapscp 32.26Cm 8Mm Dvnc Xi Ewrst","code_information":[{"code":"SUP108794","type":"CDM"},{"code":"272","type":"RC"}],"standard_charges":[{"gross_charge":831.39,"discounted_cash":457.26,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Rtrctr Lapscp 33.27Cm 8Mm Dvnc Xi Ewrst","code_information":[{"code":"SUP108795","type":"CDM"},{"code":"272","type":"RC"}],"standard_charges":[{"gross_charge":1213.0,"discounted_cash":667.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Rtrctr Lapscp Dual 33.27Cm 8Mm Dvnc Xi Ewrst","code_information":[{"code":"SUP108796","type":"CDM"},{"code":"272","type":"RC"}],"standard_charges":[{"gross_charge":1213.0,"discounted_cash":667.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Rtrctr Lapscp 4.5Cm Ewrst 0-65D Sm Med","code_information":[{"code":"SUP108797","type":"CDM"},{"code":"272","type":"RC"}],"standard_charges":[{"gross_charge":831.39,"discounted_cash":457.26,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Grspr Lapscp 32.77Cm 8Mm Dvnc Xi Ewrst","code_information":[{"code":"SUP108798","type":"CDM"},{"code":"272","type":"RC"}],"standard_charges":[{"gross_charge":762.11,"discounted_cash":419.16,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"},{"gross_charge":749.26,"discounted_cash":412.09,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Apr Clip 31.75Cm Dvnc Xi Ewrst 8Mm Sm W","code_information":[{"code":"SUP108799","type":"CDM"},{"code":"272","type":"RC"}],"standard_charges":[{"gross_charge":96.77,"discounted_cash":53.22,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Stplr 30Mm Ewrst Rpsb Str Tip Full Wrst","code_information":[{"code":"SUP108800","type":"CDM"},{"code":"272","type":"RC"}],"standard_charges":[{"gross_charge":470.68,"discounted_cash":258.87,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Stplr 30Mm Dvnc Xi Ewrst Rpsb Crv Tip","code_information":[{"code":"SUP108801","type":"CDM"},{"code":"272","type":"RC"}],"standard_charges":[{"gross_charge":499.27,"discounted_cash":274.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"},{"gross_charge":492.54,"discounted_cash":270.9,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Drvr Ndl 31.50Cm 8Mm Dvnc Xi Ewrst 30D","code_information":[{"code":"SUP108802","type":"CDM"},{"code":"272","type":"RC"}],"standard_charges":[{"gross_charge":589.45,"discounted_cash":324.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"},{"gross_charge":579.07,"discounted_cash":318.49,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Fcp Lapscp 32.51Cm 8Mm Dvnc Xi Ewrst 30D","code_information":[{"code":"SUP108803","type":"CDM"},{"code":"272","type":"RC"}],"standard_charges":[{"gross_charge":433.29,"discounted_cash":238.31,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"},{"gross_charge":423.55,"discounted_cash":232.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Fcp Lapscp 32.77Cm 8Mm Cadiere Dvnc Xi","code_information":[{"code":"SUP108804","type":"CDM"},{"code":"272","type":"RC"}],"standard_charges":[{"gross_charge":520.17,"discounted_cash":286.09,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"},{"gross_charge":512.37,"discounted_cash":281.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Fcp Lapscp 33.53Cm 8Mm Dvnc Xi Prograsp","code_information":[{"code":"SUP108805","type":"CDM"},{"code":"272","type":"RC"}],"standard_charges":[{"gross_charge":520.17,"discounted_cash":286.09,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"},{"gross_charge":510.56,"discounted_cash":280.81,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Fcp Lapscp Dvnc Xi Ewrst Mic Biplr","code_information":[{"code":"SUP108806","type":"CDM"},{"code":"272","type":"RC"}],"standard_charges":[{"gross_charge":1005.15,"discounted_cash":552.83,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Fcp Lapscp 32.77Cm 8Mm Dvnc Xi Md Ewrst","code_information":[{"code":"SUP108807","type":"CDM"},{"code":"272","type":"RC"}],"standard_charges":[{"gross_charge":813.8,"discounted_cash":447.59,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"},{"gross_charge":798.37,"discounted_cash":439.1,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Grspr Cbr","code_information":[{"code":"SUP108808","type":"CDM"},{"code":"272","type":"RC"}],"standard_charges":[{"gross_charge":623.54,"discounted_cash":342.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Fcp Lapscp 32.77Cm 8Mm Dvnc Xi Ewrst 45D","code_information":[{"code":"SUP108809","type":"CDM"},{"code":"272","type":"RC"}],"standard_charges":[{"gross_charge":692.83,"discounted_cash":381.06,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"},{"gross_charge":679.9,"discounted_cash":373.94,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Drvr Ndl 31.50Cm 8Mm Suturecut Ewrst","code_information":[{"code":"SUP108810","type":"CDM"},{"code":"272","type":"RC"}],"standard_charges":[{"gross_charge":589.45,"discounted_cash":324.2,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"},{"gross_charge":579.51,"discounted_cash":318.73,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Drvr Ndl 1.4Cm Mega Sut Cut Ewrst 0-35D","code_information":[{"code":"SUP108811","type":"CDM"},{"code":"272","type":"RC"}],"standard_charges":[{"gross_charge":605.95,"discounted_cash":333.27,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"},{"gross_charge":595.21,"discounted_cash":327.37,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Dsct Lapscp Ewrst Dvnc Xi 45D Crv Biplr","code_information":[{"code":"SUP108812","type":"CDM"},{"code":"272","type":"RC"}],"standard_charges":[{"gross_charge":935.86,"discounted_cash":514.72,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"},{"gross_charge":914.82,"discounted_cash":503.15,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Grspr Lapscp Ewrst Dvnc Xi Lng Biplr","code_information":[{"code":"SUP108813","type":"CDM"},{"code":"272","type":"RC"}],"standard_charges":[{"gross_charge":1005.15,"discounted_cash":552.83,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"},{"gross_charge":993.85,"discounted_cash":546.62,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Fcp Esurg 8Mm Ewrst Biplr Nonster Lf","code_information":[{"code":"SUP108814","type":"CDM"},{"code":"272","type":"RC"}],"standard_charges":[{"gross_charge":813.8,"discounted_cash":447.59,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"},{"gross_charge":800.07,"discounted_cash":440.04,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Molnlycke Tortoise Turn & Position System","code_information":[{"code":"SUP108891","type":"CDM"},{"code":"272","type":"RC"}],"standard_charges":[{"gross_charge":463.32,"discounted_cash":254.83,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Sys Dlv Ftl Plw Balln Cephalic Elev","code_information":[{"code":"SUP109040","type":"CDM"},{"code":"272","type":"RC"}],"standard_charges":[{"gross_charge":1844.7,"discounted_cash":1014.58,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Cath Embolectomy 5Fr 80Cm","code_information":[{"code":"SUP11037","type":"CDM"},{"code":"272","type":"RC"}],"standard_charges":[{"gross_charge":164.63,"discounted_cash":90.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Kit Camino Olm","code_information":[{"code":"SUP13848","type":"CDM"},{"code":"272","type":"RC"}],"standard_charges":[{"gross_charge":2791.84,"discounted_cash":1535.51,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Needle Ebus","code_information":[{"code":"SUP14686","type":"CDM"},{"code":"272","type":"RC"}],"standard_charges":[{"gross_charge":591.65,"discounted_cash":325.41,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Pack Ob","code_information":[{"code":"SUP14995","type":"CDM"},{"code":"272","type":"RC"}],"standard_charges":[{"gross_charge":141.92,"discounted_cash":78.06,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"},{"gross_charge":138.97,"discounted_cash":76.43,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."},{"gross_charge":138.98,"discounted_cash":76.44,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Set Chest Tube Thal-Quick 14Frx41Cm","code_information":[{"code":"SUP16705","type":"CDM"},{"code":"272","type":"RC"}],"standard_charges":[{"gross_charge":549.51,"discounted_cash":302.23,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Tray Thoracentesis Disp","code_information":[{"code":"SUP18364","type":"CDM"},{"code":"278","type":"RC"},{"code":"C1729","type":"HCPCS"}],"standard_charges":[{"gross_charge":189.16,"discounted_cash":104.04,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Tray Umbilical Vessel Insert","code_information":[{"code":"SUP18368","type":"CDM"},{"code":"272","type":"RC"}],"standard_charges":[{"gross_charge":295.18,"discounted_cash":162.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"},{"gross_charge":288.55,"discounted_cash":158.7,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Tube Blakemore","code_information":[{"code":"SUP18404","type":"CDM"},{"code":"272","type":"RC"}],"standard_charges":[{"gross_charge":597.19,"discounted_cash":328.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Forcep Disp Biospy","code_information":[{"code":"SUP24625","type":"CDM"},{"code":"272","type":"RC"}],"standard_charges":[{"gross_charge":175.96,"discounted_cash":96.78,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Walker Folding","code_information":[{"code":"SUP27181","type":"CDM"},{"code":"271","type":"RC"},{"code":"E0135","type":"HCPCS"}],"standard_charges":[{"gross_charge":188.47,"discounted_cash":103.66,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"},{"gross_charge":184.76,"discounted_cash":101.62,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Guidewire","code_information":[{"code":"SUP27486","type":"CDM"},{"code":"272","type":"RC"},{"code":"C1769","type":"HCPCS"}],"standard_charges":[{"gross_charge":148.73,"discounted_cash":81.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Cannula Escp 11Ga Ivas Acc Lf","code_information":[{"code":"SUP27956","type":"CDM"},{"code":"272","type":"RC"}],"standard_charges":[{"gross_charge":163.4,"discounted_cash":89.87,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Flexima Apd Reg Cath Sys 12Frx25Cm","code_information":[{"code":"SUP27976","type":"CDM"},{"code":"272","type":"RC"},{"code":"C1729","type":"HCPCS"}],"standard_charges":[{"gross_charge":246.18,"discounted_cash":135.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Cath Baln Extractor Micrvs","code_information":[{"code":"SUP28006","type":"CDM"},{"code":"272","type":"RC"}],"standard_charges":[{"gross_charge":46.55,"discounted_cash":25.6,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"},{"gross_charge":45.5,"discounted_cash":25.02,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Electrode Quik Combo Peds","code_information":[{"code":"SUP28456","type":"CDM"},{"code":"272","type":"RC"}],"standard_charges":[{"gross_charge":147.6,"discounted_cash":81.18,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Extractor Mityvac","code_information":[{"code":"SUP28473","type":"CDM"},{"code":"270","type":"RC"}],"standard_charges":[{"gross_charge":1444.17,"discounted_cash":794.29,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"},{"gross_charge":1411.7,"discounted_cash":776.44,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Kit Chest Tube 28.0 X 41Cm","code_information":[{"code":"SUP28776","type":"CDM"},{"code":"272","type":"RC"}],"standard_charges":[{"gross_charge":558.59,"discounted_cash":307.22,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Kit Indeflator","code_information":[{"code":"SUP28798","type":"CDM"},{"code":"272","type":"RC"}],"standard_charges":[{"gross_charge":160.09,"discounted_cash":88.05,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Electrode Quik Combo","code_information":[{"code":"SUP28916","type":"CDM"},{"code":"272","type":"RC"}],"standard_charges":[{"gross_charge":102.3,"discounted_cash":56.26,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."},{"gross_charge":102.46,"discounted_cash":56.35,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."},{"gross_charge":102.1,"discounted_cash":56.16,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Hemostat Disposable","code_information":[{"code":"SUP30657","type":"CDM"},{"code":"272","type":"RC"}],"standard_charges":[{"gross_charge":219.12,"discounted_cash":120.52,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"},{"gross_charge":214.19,"discounted_cash":117.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Bed Szwz Mattress Evolu A","code_information":[{"code":"SUP30767","type":"CDM"},{"code":"270","type":"RC"}],"standard_charges":[{"gross_charge":91.96,"discounted_cash":50.58,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Tube Trach Dic Shiley 6.0","code_information":[{"code":"SUP30800","type":"CDM"},{"code":"272","type":"RC"},{"code":"A4623","type":"HCPCS"}],"standard_charges":[{"gross_charge":147.6,"discounted_cash":81.18,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Cannula Inner Shiley Disp 8Mm","code_information":[{"code":"SUP30806","type":"CDM"},{"code":"272","type":"RC"}],"standard_charges":[{"gross_charge":147.6,"discounted_cash":81.18,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Blanket Warming Bair Hugger","code_information":[{"code":"SUP31285","type":"CDM"},{"code":"270","type":"RC"}],"standard_charges":[{"gross_charge":158.95,"discounted_cash":87.42,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Boot Cradle","code_information":[{"code":"SUP31297","type":"CDM"},{"code":"270","type":"RC"}],"standard_charges":[{"gross_charge":173.71,"discounted_cash":95.54,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Kit Breast Pump","code_information":[{"code":"SUP31328","type":"CDM"},{"code":"270","type":"RC"}],"standard_charges":[{"gross_charge":145.33,"discounted_cash":79.93,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"},{"gross_charge":142.06,"discounted_cash":78.13,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Tube Trach Dic Shiley 4.0","code_information":[{"code":"SUP31423","type":"CDM"},{"code":"272","type":"RC"}],"standard_charges":[{"gross_charge":157.81,"discounted_cash":86.8,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Cath Dual Lumen Picc Line 5Fr","code_information":[{"code":"SUP31582","type":"CDM"},{"code":"272","type":"RC"},{"code":"C1751","type":"HCPCS"}],"standard_charges":[{"gross_charge":858.32,"discounted_cash":472.08,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Cath Embolectomy 4.0Fr","code_information":[{"code":"SUP31702","type":"CDM"},{"code":"272","type":"RC"}],"standard_charges":[{"gross_charge":165.76,"discounted_cash":91.17,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Cath Pressure Intrauterine","code_information":[{"code":"SUP31945","type":"CDM"},{"code":"272","type":"RC"}],"standard_charges":[{"gross_charge":254.32,"discounted_cash":139.88,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"},{"gross_charge":248.76,"discounted_cash":136.82,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."},{"gross_charge":248.85,"discounted_cash":136.87,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Kit Craniotomy Od 5.31 Mm","code_information":[{"code":"SUP32526","type":"CDM"},{"code":"272","type":"RC"}],"standard_charges":[{"gross_charge":804.97,"discounted_cash":442.73,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Drsg Gauze Surgicel 2 X 14","code_information":[{"code":"SUP32629","type":"CDM"},{"code":"272","type":"RC"}],"standard_charges":[{"gross_charge":189.16,"discounted_cash":104.04,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"},{"gross_charge":304.34,"discounted_cash":167.39,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."},{"gross_charge":225.42,"discounted_cash":123.98,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Kit Chest Tube 20.0X41Cm","code_information":[{"code":"SUP33603","type":"CDM"},{"code":"272","type":"RC"}],"standard_charges":[{"gross_charge":549.51,"discounted_cash":302.23,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"},{"gross_charge":537.16,"discounted_cash":295.44,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Kit Pneumothorax","code_information":[{"code":"SUP33702","type":"CDM"},{"code":"278","type":"RC"},{"code":"C1729","type":"HCPCS"}],"standard_charges":[{"gross_charge":497.08,"discounted_cash":273.39,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"},{"gross_charge":485.9,"discounted_cash":267.24,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."},{"gross_charge":455.09,"discounted_cash":250.3,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Heart Hugger","code_information":[{"code":"SUP34127","type":"CDM"},{"code":"270","type":"RC"}],"standard_charges":[{"gross_charge":332.66,"discounted_cash":182.96,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"},{"gross_charge":325.18,"discounted_cash":178.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Pack Basic","code_information":[{"code":"SUP34167","type":"CDM"},{"code":"270","type":"RC"}],"standard_charges":[{"gross_charge":139.65,"discounted_cash":76.81,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Heart Hugger Large","code_information":[{"code":"SUP34177","type":"CDM"},{"code":"270","type":"RC"}],"standard_charges":[{"gross_charge":332.66,"discounted_cash":182.96,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"},{"gross_charge":325.18,"discounted_cash":178.85,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Tube Endotrach Cuffed 08.5Mm","code_information":[{"code":"SUP35902","type":"CDM"},{"code":"272","type":"RC"}],"standard_charges":[{"gross_charge":181.65,"discounted_cash":99.91,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Tube Trach W/O Cuff Non Fen #6","code_information":[{"code":"SUP36087","type":"CDM"},{"code":"272","type":"RC"}],"standard_charges":[{"gross_charge":228.2,"discounted_cash":125.51,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Tube Trach W/O Cuff Non Fen #8","code_information":[{"code":"SUP36088","type":"CDM"},{"code":"272","type":"RC"}],"standard_charges":[{"gross_charge":214.58,"discounted_cash":118.02,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Tube Tracheal Exchanger","code_information":[{"code":"SUP37636","type":"CDM"},{"code":"272","type":"RC"},{"code":"C1769","type":"HCPCS"}],"standard_charges":[{"gross_charge":666.44,"discounted_cash":366.54,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Tube Trach Fen W/O Cuff #10","code_information":[{"code":"SUP42832","type":"CDM"},{"code":"272","type":"RC"}],"standard_charges":[{"gross_charge":135.12,"discounted_cash":74.32,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Drain Chest Dry Suction","code_information":[{"code":"SUP45230","type":"CDM"},{"code":"272","type":"RC"}],"standard_charges":[{"gross_charge":121.49,"discounted_cash":66.82,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"},{"gross_charge":119.0,"discounted_cash":65.45,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Ndl Biop Quik Core 18Gax20Cm","code_information":[{"code":"SUP45428","type":"CDM"},{"code":"272","type":"RC"}],"standard_charges":[{"gross_charge":167.7,"discounted_cash":92.24,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Kit Bone Cmnt Vertaplex Hv Autoplex Wo","code_information":[{"code":"SUP45771","type":"CDM"},{"code":"278","type":"RC"},{"code":"C1713","type":"HCPCS"}],"standard_charges":[{"gross_charge":2086.57,"discounted_cash":1147.61,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Brush Cytology","code_information":[{"code":"SUP46204","type":"CDM"},{"code":"272","type":"RC"}],"standard_charges":[{"gross_charge":1513.22,"discounted_cash":832.27,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Drsg Wound Vac Canister","code_information":[{"code":"SUP49907","type":"CDM"},{"code":"270","type":"RC"}],"standard_charges":[{"gross_charge":197.66,"discounted_cash":108.71,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."},{"gross_charge":197.55,"discounted_cash":108.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Kit Suction Oral Care","code_information":[{"code":"SUP50859","type":"CDM"},{"code":"272","type":"RC"}],"standard_charges":[{"gross_charge":119.21,"discounted_cash":65.57,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"},{"gross_charge":116.84,"discounted_cash":64.26,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Tube Blakemore 16 Fr","code_information":[{"code":"SUP52796","type":"CDM"},{"code":"272","type":"RC"}],"standard_charges":[{"gross_charge":850.09,"discounted_cash":467.55,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Set System Drainage Csf","code_information":[{"code":"SUP54168","type":"CDM"},{"code":"272","type":"RC"}],"standard_charges":[{"gross_charge":665.32,"discounted_cash":365.93,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Basket Ercp","code_information":[{"code":"SUP56669","type":"CDM"},{"code":"272","type":"RC"}],"standard_charges":[{"gross_charge":731.32,"discounted_cash":402.23,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Kit Bone Biopsy Ivas 11Ga Lf","code_information":[{"code":"SUP59042","type":"CDM"},{"code":"272","type":"RC"}],"standard_charges":[{"gross_charge":237.58,"discounted_cash":130.67,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Kit Cath Ventricular Lg Disp","code_information":[{"code":"SUP59427","type":"CDM"},{"code":"272","type":"RC"}],"standard_charges":[{"gross_charge":552.92,"discounted_cash":304.11,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Kit Cranial Access","code_information":[{"code":"SUP60593","type":"CDM"},{"code":"272","type":"RC"}],"standard_charges":[{"gross_charge":1021.82,"discounted_cash":562.0,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Seal Floseal Matrix Hmst","code_information":[{"code":"SUP60833","type":"CDM"},{"code":"272","type":"RC"}],"standard_charges":[{"gross_charge":1223.92,"discounted_cash":673.16,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Ndl Biop Quik Core 18Gax15Cm","code_information":[{"code":"SUP62664","type":"CDM"},{"code":"272","type":"RC"}],"standard_charges":[{"gross_charge":167.7,"discounted_cash":92.24,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Ndl Biop Quik Core 18Gax19Cm","code_information":[{"code":"SUP62687","type":"CDM"},{"code":"272","type":"RC"}],"standard_charges":[{"gross_charge":167.7,"discounted_cash":92.24,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"St Dil Ureth S Crv","code_information":[{"code":"SUP63491","type":"CDM"},{"code":"272","type":"RC"}],"standard_charges":[{"gross_charge":630.12,"discounted_cash":346.57,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Ndl Biop Quik Core 18Gax9.0Cm","code_information":[{"code":"SUP64963","type":"CDM"},{"code":"272","type":"RC"}],"standard_charges":[{"gross_charge":167.7,"discounted_cash":92.24,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Kit Oxygen Heat High Flow Vapotherm","code_information":[{"code":"SUP68579","type":"CDM"},{"code":"270","type":"RC"}],"standard_charges":[{"gross_charge":359.91,"discounted_cash":197.95,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Blade Ultraguide Tfr","code_information":[{"code":"SUP68887","type":"CDM"},{"code":"272","type":"RC"}],"standard_charges":[{"gross_charge":1296.58,"discounted_cash":713.12,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Gwire Amplatz","code_information":[{"code":"SUP69244","type":"CDM"},{"code":"272","type":"RC"},{"code":"C1769","type":"HCPCS"}],"standard_charges":[{"gross_charge":501.83,"discounted_cash":276.01,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Gwire Super Stiff","code_information":[{"code":"SUP69257","type":"CDM"},{"code":"272","type":"RC"},{"code":"C1769","type":"HCPCS"}],"standard_charges":[{"gross_charge":136.25,"discounted_cash":74.94,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Glidescope Bflex 2.8","code_information":[{"code":"SUP69717","type":"CDM"},{"code":"272","type":"RC"}],"standard_charges":[{"gross_charge":832.22,"discounted_cash":457.72,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"},{"gross_charge":813.51,"discounted_cash":447.43,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Probe Plasma","code_information":[{"code":"SUP70597","type":"CDM"},{"code":"272","type":"RC"}],"standard_charges":[{"gross_charge":654.34,"discounted_cash":359.89,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Nasopore Firm 4Cm","code_information":[{"code":"SUP72211","type":"CDM"},{"code":"272","type":"RC"}],"standard_charges":[{"gross_charge":389.42,"discounted_cash":214.18,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"},{"gross_charge":380.67,"discounted_cash":209.37,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Protct Heel Prevalon","code_information":[{"code":"SUP73816","type":"CDM"},{"code":"271","type":"RC"}],"standard_charges":[{"gross_charge":173.71,"discounted_cash":95.54,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"},{"gross_charge":169.8,"discounted_cash":93.39,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Tray Paracentesis Quik Tap","code_information":[{"code":"SUP75233","type":"CDM"},{"code":"272","type":"RC"}],"standard_charges":[{"gross_charge":215.72,"discounted_cash":118.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Tray Power Picc Sgl 4Fr","code_information":[{"code":"SUP75235","type":"CDM"},{"code":"278","type":"RC"},{"code":"C1751","type":"HCPCS"}],"standard_charges":[{"gross_charge":820.87,"discounted_cash":451.48,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Tray Thoracic Vent Tru Close","code_information":[{"code":"SUP76738","type":"CDM"},{"code":"272","type":"RC"}],"standard_charges":[{"gross_charge":850.39,"discounted_cash":467.71,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Cannula Inner Shiley Trach Xlt 8","code_information":[{"code":"SUP78815","type":"CDM"},{"code":"272","type":"RC"},{"code":"C1894","type":"HCPCS"}],"standard_charges":[{"gross_charge":182.79,"discounted_cash":100.53,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Gauze Quikclot","code_information":[{"code":"SUP80499","type":"CDM"},{"code":"272","type":"RC"}],"standard_charges":[{"gross_charge":195.27,"discounted_cash":107.4,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"St Tube Chst Thal-Quik 12Fr X 22Cm","code_information":[{"code":"SUP81711","type":"CDM"},{"code":"272","type":"RC"},{"code":"C1729","type":"HCPCS"}],"standard_charges":[{"gross_charge":549.51,"discounted_cash":302.23,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Tube Mic Gastrotomy 20","code_information":[{"code":"SUP82630","type":"CDM"},{"code":"272","type":"RC"}],"standard_charges":[{"gross_charge":131.7,"discounted_cash":72.44,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Seal Floseal Matrix Hmsta 5.0Ml","code_information":[{"code":"SUP82708","type":"CDM"},{"code":"272","type":"RC"}],"standard_charges":[{"gross_charge":445.06,"discounted_cash":244.78,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"},{"gross_charge":435.05,"discounted_cash":239.28,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Drsg Nsl Ant Rapid Rhino 7.5Cm Rr750","code_information":[{"code":"SUP83385","type":"CDM"},{"code":"272","type":"RC"}],"standard_charges":[{"gross_charge":156.68,"discounted_cash":86.17,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Guide Locatable Bronchoscopy","code_information":[{"code":"SUP83727","type":"CDM"},{"code":"272","type":"RC"}],"standard_charges":[{"gross_charge":3654.39,"discounted_cash":2009.91,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Collar Vista With Pads","code_information":[{"code":"SUP85268","type":"CDM"},{"code":"270","type":"RC"}],"standard_charges":[{"gross_charge":188.47,"discounted_cash":103.66,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"},{"gross_charge":184.23,"discounted_cash":101.33,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Drsg Abthera","code_information":[{"code":"SUP85698","type":"CDM"},{"code":"272","type":"RC"}],"standard_charges":[{"gross_charge":1176.23,"discounted_cash":646.93,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hypothermia Pad Lg","code_information":[{"code":"SUP86203","type":"CDM"},{"code":"271","type":"RC"}],"standard_charges":[{"gross_charge":1226.2,"discounted_cash":674.41,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Hypothermia Pad Univ","code_information":[{"code":"SUP86204","type":"CDM"},{"code":"271","type":"RC"}],"standard_charges":[{"gross_charge":3042.94,"discounted_cash":1673.62,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"}]},{"description":"Boot Wlk Med","code_information":[{"code":"SUP86305","type":"CDM"},{"code":"270","type":"RC"}],"standard_charges":[{"gross_charge":112.09,"discounted_cash":61.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Boot Wlk Sm","code_information":[{"code":"SUP86306","type":"CDM"},{"code":"270","type":"RC"}],"standard_charges":[{"gross_charge":114.67,"discounted_cash":63.07,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"},{"gross_charge":112.09,"discounted_cash":61.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Boot Wlk Lg","code_information":[{"code":"SUP86307","type":"CDM"},{"code":"270","type":"RC"}],"standard_charges":[{"gross_charge":114.67,"discounted_cash":63.07,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380"},{"gross_charge":112.09,"discounted_cash":61.65,"setting":"both","billing_class":"facility","additional_generic_notes":"Gross Charge Type: Gfdl Default Fsc 2380 | Price is variable based on underlying billing methodology - especially, for drug and supply items."}]},{"description":"Evasc rpr a-unilac ndgft rpt","code_information":[{"code":"34704","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":9356.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0}]}]},{"description":"Tcat dlvr enhncd fixj dev","code_information":[{"code":"34712","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Endoven ther chem adhes sbsq","code_information":[{"code":"36483","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Nrv rpr w/nrv algrft 1st","code_information":[{"code":"64912","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":16752.93,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8680.28,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":16752.93,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6510.21,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8853.88,"additional_payer_notes":"APC"}]}]},{"description":"Fna bx w/ct gdn 1st les","code_information":[{"code":"10009","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":525.32,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":700.42,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1351.81,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":525.32,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":714.43,"additional_payer_notes":"APC"}]}]},{"description":"Punch bx skin ea sep/addl","code_information":[{"code":"11105","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Insj picc rs&i 5 yr+","code_information":[{"code":"36573","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1167.76,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1557.01,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3005.03,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1167.76,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1588.15,"additional_payer_notes":"APC"}]}]},{"description":"Hemicrt intrclry algrft prtl","code_information":[{"code":"20933","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Rmvl pg compnt wcs","code_information":[{"code":"0518T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2772.2,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3696.26,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7133.79,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2772.2,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3770.19,"additional_payer_notes":"APC"}]}]},{"description":"Mnl prep&insj imed rx dev","code_information":[{"code":"20702","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Evasc rpr n/a a-iliac ndgft","code_information":[{"code":"34718","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":9356.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0}]}]},{"description":"Rmvl i-artic rx delivery dev","code_information":[{"code":"20705","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Grfg autol fat lipo 50 cc/<","code_information":[{"code":"15771","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2628.85,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3505.13,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6764.9,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2628.85,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3575.23,"additional_payer_notes":"APC"}]}]},{"description":"Cysto rx balo cath urtl strx","code_information":[{"code":"52284","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3977.55,"maximum":10235.57,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5303.4,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":10235.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3977.55,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5409.47,"additional_payer_notes":"APC"}]}]},{"description":"Ire abltj 1+tumors open","code_information":[{"code":"0601T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5257.0,"maximum":20292.15,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10514.07,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5257.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":20292.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7885.55,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10724.35,"additional_payer_notes":"APC"}]}]},{"description":"Impltj oi implt skl tc esp","code_information":[{"code":"69716","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":24508.8,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12698.86,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":24508.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9524.15,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12952.84,"additional_payer_notes":"APC"}]}]},{"description":"R&l hrt cath chd nml nt cnj","code_information":[{"code":"93596","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2404.97,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3206.62,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6188.79,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2404.97,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3270.76,"additional_payer_notes":"APC"}]}]},{"description":"Perq trluml angp nt/recr coa","code_information":[{"code":"33897","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":9356.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0}]}]},{"description":"Tcat plmt&rmvl cepd perq","code_information":[{"code":"33370","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Njx pst chmbr eye medication","code_information":[{"code":"0699T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1712.02,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2282.69,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4405.59,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1712.02,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2328.34,"additional_payer_notes":"APC"}]}]},{"description":"Blind myocar trpl bon marrow","code_information":[{"code":"C9782","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":44873.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16942.93,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":44873.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":44873.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":44873.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":32699.86,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12707.2,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":43285.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17281.79,"additional_payer_notes":"APC"}]}]},{"description":"Rpr aa hrn 1st 3-10 rdc","code_information":[{"code":"49593","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":12358.4,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6403.32,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":12358.4,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4802.49,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6531.38,"additional_payer_notes":"APC"}]}]},{"description":"Perq p-art revsc 1 nm nt bi","code_information":[{"code":"33901","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":27583.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11418.47,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":22037.64,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8563.85,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":27583.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11646.84,"additional_payer_notes":"APC"}]}]},{"description":"Rpr parastomal hrna ncr/strn","code_information":[{"code":"49622","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":17314.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0}]}]},{"description":"Rpr aa hrn 1st < 3 ncr/strn","code_information":[{"code":"49592","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4484.77,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5979.69,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5257.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11540.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4484.77,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6099.28,"additional_payer_notes":"APC"}]}]},{"description":"Tcat rmvl 2chmbr ldls pm rv","code_information":[{"code":"0800T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2342.32,"maximum":8657.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3123.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6027.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2342.32,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3185.56,"additional_payer_notes":"APC"}]}]},{"description":"Revj/rmvl ins ptn subq","code_information":[{"code":"0818T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2593.52,"maximum":8657.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3458.03,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6674.0,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2593.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3527.19,"additional_payer_notes":"APC"}]}]},{"description":"Rlcj pg wcs lv trnsmtr only","code_information":[{"code":"0863T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1530.61,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2040.81,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3938.76,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1530.61,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2081.63,"additional_payer_notes":"APC"}]}]},{"description":"Tcat rmv 1chmbr ldls pm ra","code_information":[{"code":"0824T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2342.32,"maximum":8657.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3123.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6027.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2342.32,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3185.56,"additional_payer_notes":"APC"}]}]},{"description":"Insj phrnc nrv stim sys","code_information":[{"code":"33276","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8923.0,"maximum":84083.89,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":43566.78,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":10765.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":8923.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":10765.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":84083.89,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":32675.09,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":51942.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":44438.12,"additional_payer_notes":"APC"}]}]},{"description":"Rlcj pg wcs lv battery only","code_information":[{"code":"0862T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1530.61,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2040.81,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3938.76,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1530.61,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2081.63,"additional_payer_notes":"APC"}]}]},{"description":"App skn cl ssp agrft t/a/l 1","code_information":[{"code":"15015","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1530.61,"maximum":4106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2040.81,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3938.76,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1530.61,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2081.63,"additional_payer_notes":"APC"}]}]},{"description":"Insj perm ccm-d sys dual ld","code_information":[{"code":"0918T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6138.95,"maximum":15797.56,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8185.27,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":15797.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6138.95,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8348.97,"additional_payer_notes":"APC"}]}]},{"description":"Plmt bone marrow smplg port","code_information":[{"code":"0901T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5512.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0}]}]},{"description":"Ablt trurl prst8 tis trnsdcr","code_information":[{"code":"55882","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8923.0,"maximum":25186.06,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13049.77,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":10765.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":8923.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":10765.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":25186.06,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9787.33,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13310.77,"additional_payer_notes":"APC"}]}]},{"description":"Thrc fascial pln blk bi nfs","code_information":[{"code":"64469","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5512.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0}]}]},{"description":"Opn exc/dstr ntra-abd 5 cm/<","code_information":[{"code":"49186","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Anosc sbmcsl njx bulking agt","code_information":[{"code":"0963T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":887.71,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1183.61,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2284.37,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":887.71,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1207.28,"additional_payer_notes":"APC"}]}]},{"description":"Tranal ins tmp clrc anst dev","code_information":[{"code":"0967T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":887.71,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1183.61,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2284.37,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":887.71,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1207.28,"additional_payer_notes":"APC"}]}]},{"description":"Transport portable EKG","code_information":[{"code":"R0076","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":111.08,"maximum":114.66,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":114.66},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":111.08},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":114.66}]}]},{"description":"Radiation treatment delivery","code_information":[{"code":"G6010","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":660.14,"maximum":683.76,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":683.76},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":660.14},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":683.76}]}]},{"description":"Stereoscopic x-ray guidance","code_information":[{"code":"G6002","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":183.68,"maximum":190.24,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":190.24},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":183.68},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":190.24}]}]},{"description":"Colon ca scrn not hi rsk ind","code_information":[{"code":"G0121","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":689.87,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":919.83,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":1322.11},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1276.45},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":1322.11},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1775.27,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":689.87,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":938.23,"additional_payer_notes":"APC"}]}]},{"description":"Nuclear rx intra-articular","code_information":[{"code":"79440","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":168.24,"maximum":445.43,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":230.79,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":174.26},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":168.24},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":174.26},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":445.43,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":173.1,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":235.41,"additional_payer_notes":"APC"}]}]},{"description":"Rp loclzj tum spect 2 areas","code_information":[{"code":"78831","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":960.41,"maximum":2471.46,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1280.55,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":2150.31},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2076.04},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":2150.31},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2471.46,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":960.41,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1306.16,"additional_payer_notes":"APC"}]}]},{"description":"Iv inj ra drug dx study","code_information":[{"code":"78808","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":155.22,"maximum":763.16,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":395.42,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":160.74},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":155.22},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":160.74},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":763.16,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":296.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":403.33,"additional_payer_notes":"APC"}]}]},{"description":"Urinary bladder retention","code_information":[{"code":"78730","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":237.15,"maximum":245.63,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":245.63},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":237.15},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":245.63}]}]},{"description":"CSF leakage imaging","code_information":[{"code":"78650","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":960.41,"maximum":2471.46,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1280.55,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":1072.37},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1035.36},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":1072.37},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2471.46,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":960.41,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1306.16,"additional_payer_notes":"APC"}]}]},{"description":"Brain image 4+ views","code_information":[{"code":"78605","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":402.79,"maximum":1036.52,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":537.06,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":617.53},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":596.21},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":617.53},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1036.52,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":402.79,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":547.8,"additional_payer_notes":"APC"}]}]},{"description":"Heart first pass add-on","code_information":[{"code":"78496","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":68.42,"maximum":70.88,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":70.88},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":68.42},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":70.88}]}]},{"description":"Heart infarct image (3D)","code_information":[{"code":"78469","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":402.79,"maximum":1036.52,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":537.06,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":651.99},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":629.45},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":651.99},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1036.52,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":402.79,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":547.8,"additional_payer_notes":"APC"}]}]},{"description":"Ht muscle image planar sing","code_information":[{"code":"78453","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":880.89,"maximum":2471.46,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1280.55,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":912.38},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":880.89},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":912.38},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2471.46,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":960.41,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1306.16,"additional_payer_notes":"APC"}]}]},{"description":"Myocrd img pet rst/strs w/ct","code_information":[{"code":"78430","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1060.78,"maximum":2729.74,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1414.38,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":1669.88},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1644.58},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":1669.88},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2729.74,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1060.78,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1442.66,"additional_payer_notes":"APC"}]}]},{"description":"Bone imaging multiple areas","code_information":[{"code":"78305","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":296.56,"maximum":763.16,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":395.42,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":681.52},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":657.99},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":681.52},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":763.16,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":296.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":403.33,"additional_payer_notes":"APC"}]}]},{"description":"Gastric emptying imag study","code_information":[{"code":"78264","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":296.56,"maximum":1067.45,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":395.42,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":1067.45},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1030.6},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":1067.45},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":763.16,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":296.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":403.33,"additional_payer_notes":"APC"}]}]},{"description":"Hepatobiliary system imaging","code_information":[{"code":"78226","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":296.56,"maximum":1056.38,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":395.42,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":1056.38},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1019.92},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":1056.38},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":763.16,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":296.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":403.33,"additional_payer_notes":"APC"}]}]},{"description":"Red cell sequestration","code_information":[{"code":"78140","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":296.56,"maximum":763.16,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":395.42,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":377.55},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":364.52},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":377.55},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":763.16,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":296.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":403.33,"additional_payer_notes":"APC"}]}]},{"description":"Bone marrow imaging mult","code_information":[{"code":"78103","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":296.56,"maximum":763.16,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":395.42,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":666.76},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":643.74},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":666.76},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":763.16,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":296.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":403.33,"additional_payer_notes":"APC"}]}]},{"description":"Thyroid met imaging/studies","code_information":[{"code":"78016","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":296.56,"maximum":875.48,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":395.42,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":875.48},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":845.23},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":875.48},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":763.16,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":296.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":403.33,"additional_payer_notes":"APC"}]}]},{"description":"Hdr rdncl ntrstl/icav brchtx","code_information":[{"code":"77772","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":516.67,"maximum":2190.76,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":688.89,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":2190.76},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2115.11},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":2190.76},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1329.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":516.67,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":702.67,"additional_payer_notes":"APC"}]}]},{"description":"Infuse radioactive materials","code_information":[{"code":"77750","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":286.12,"maximum":736.29,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":381.5,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":390.58},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":377.1},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":390.58},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":736.29,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":286.12,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":389.13,"additional_payer_notes":"APC"}]}]},{"description":"Proton trmt simple w/comp","code_information":[{"code":"77522","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":927.1,"maximum":3195.73,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1236.13,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3195.73},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3147.35},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3195.73},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2385.73,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":927.1,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1260.85,"additional_payer_notes":"APC"}]}]},{"description":"Neutron beam tx complex","code_information":[{"code":"77423","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":324.23,"maximum":1054.79,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":546.52,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":335.81},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":324.23},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":335.81},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1054.79,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":409.89,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":557.46,"additional_payer_notes":"APC"}]}]},{"description":"Ntsty modul rad tx dlvr smpl","code_information":[{"code":"77385","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1148.5,"maximum":1189.56,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":1189.56},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1148.5},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":1189.56}]}]},{"description":"Radiation treatment aid(s)","code_information":[{"code":"77333","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":31.6,"maximum":256.58,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":132.94,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":32.72},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":31.6},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":32.72},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":256.58,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":99.71,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":135.6,"additional_payer_notes":"APC"}]}]},{"description":"Telethx isodose plan simple","code_information":[{"code":"77306","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":256.86,"maximum":714.78,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":370.35,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":266.05},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":256.86},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":266.05},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":714.78,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":277.76,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":377.76,"additional_payer_notes":"APC"}]}]},{"description":"Radiation therapy planning","code_information":[{"code":"77263","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":562.52,"maximum":582.65,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":582.65},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":562.52},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":582.65}]}]},{"description":"Dxa bone density study","code_information":[{"code":"77085","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":77.56,"maximum":199.58,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":103.41,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":139.8},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":134.97},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":139.8},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":199.58,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":77.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":105.48,"additional_payer_notes":"APC"}]}]},{"description":"X-rays bone survey limited","code_information":[{"code":"77074","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":77.56,"maximum":199.58,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":103.41,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":142.25},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":137.35},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":142.25},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":199.58,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":77.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":105.48,"additional_payer_notes":"APC"}]}]},{"description":"X-Ray of Mammary Duct","code_information":[{"code":"77053","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":133.79,"maximum":455.49,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":236.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":138.57},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":133.79},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":138.57},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":455.49,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":177.0,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":240.72,"additional_payer_notes":"APC"}]}]},{"description":"CT Guide for Tissue Ablation","code_information":[{"code":"77013","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1150.22,"maximum":1191.36,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":1191.36},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1150.22},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":1191.36}]}]},{"description":"Dx ntrop epcr us chd img acq","code_information":[{"code":"76988","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":169.27,"maximum":182.89,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":182.89},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":169.27},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":182.89}]}]},{"description":"Us bone density measure","code_information":[{"code":"76977","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":13.78,"maximum":199.58,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":103.41,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":14.27},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":13.78},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":14.27},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":199.58,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":77.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":105.48,"additional_payer_notes":"APC"}]}]},{"description":"Us guide tissue ablation","code_information":[{"code":"76940","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":209.52,"maximum":217.01,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":217.01},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":209.52},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":217.01}]}]},{"description":"Us xtr non-vasc complete","code_information":[{"code":"76881","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":77.56,"maximum":289.95,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":103.41,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":289.95},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":279.95},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":289.95},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":199.58,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":77.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":105.48,"additional_payer_notes":"APC"}]}]},{"description":"Echo exam of fetal heart","code_information":[{"code":"76828","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":77.56,"maximum":199.58,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":103.41,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":86.87},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":83.87},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":86.87},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":199.58,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":77.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":105.48,"additional_payer_notes":"APC"}]}]},{"description":"Transvaginal us obstetric","code_information":[{"code":"76817","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":77.56,"maximum":205.03,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":103.41,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":205.03},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":197.94},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":205.03},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":199.58,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":77.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":105.48,"additional_payer_notes":"APC"}]}]},{"description":"Ob us >/= 14 wks sngl fetus","code_information":[{"code":"76805","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":77.56,"maximum":317.01,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":103.41,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":317.01},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":306.06},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":317.01},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":199.58,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":77.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":105.48,"additional_payer_notes":"APC"}]}]},{"description":"Us exam abdom complete","code_information":[{"code":"76700","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":77.56,"maximum":285.01,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":103.41,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":285.01},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":275.17},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":285.01},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":199.58,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":77.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":105.48,"additional_payer_notes":"APC"}]}]},{"description":"Echo exam of eye thickness","code_information":[{"code":"76514","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":17.34,"maximum":55.21,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":28.61,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":17.95},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":17.34},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":17.95},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":55.21,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21.46,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":29.18,"additional_payer_notes":"APC"}]}]},{"description":"Fluoroscopic procedure","code_information":[{"code":"76496","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":64.56,"maximum":166.13,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":86.08,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":136.17},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":134.11},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":136.17},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":166.13,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":64.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":87.8,"additional_payer_notes":"APC"}]}]},{"description":"Cine/video x-rays","code_information":[{"code":"76120","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":77.56,"maximum":221.02,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":103.41,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":221.02},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":213.4},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":221.02},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":199.58,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":77.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":105.48,"additional_payer_notes":"APC"}]}]},{"description":"Mr sfty mplt&/fb asmt stf ea","code_information":[{"code":"76015","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":146.84,"maximum":160.19,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":160.19},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":146.84},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":160.19}]}]},{"description":"Xray place prox ext thor ao","code_information":[{"code":"75958","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":664.33,"maximum":688.09,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":688.09},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":664.33},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":688.09}]}]},{"description":"Vein x-ray liver","code_information":[{"code":"75891","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":297.74,"maximum":6027.57,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3123.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":308.41},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":297.74},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":308.41},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6027.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2342.32,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3185.56,"additional_payer_notes":"APC"}]}]},{"description":"Vein x-ray adrenal glands","code_information":[{"code":"75842","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":351.92,"maximum":364.52,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":364.52},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":351.92},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":364.52}]}]},{"description":"Vein x-ray spleen/liver","code_information":[{"code":"75810","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1343.62,"maximum":6027.57,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3123.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":1364.27},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1343.62},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":1364.27},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6027.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2342.32,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3185.56,"additional_payer_notes":"APC"}]}]},{"description":"Artery x-rays lung","code_information":[{"code":"75746","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":318.65,"maximum":6027.57,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3123.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":330.03},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":318.65},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":330.03},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6027.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2342.32,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3185.56,"additional_payer_notes":"APC"}]}]},{"description":"Artery x-rays arm/leg","code_information":[{"code":"75710","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":356.66,"maximum":6027.57,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3123.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":369.42},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":356.66},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":369.42},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6027.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2342.32,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3185.56,"additional_payer_notes":"APC"}]}]},{"description":"Ct angio hrt w/3d image","code_information":[{"code":"75574","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":258.81,"maximum":1031.04,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":345.07,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":1031.04},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":995.44},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":1031.04},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":665.99,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":258.81,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":351.98,"additional_payer_notes":"APC"}]}]},{"description":"Cardiac mri for morph","code_information":[{"code":"75557","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":177.0,"maximum":693.61,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":236.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":693.61},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":669.65},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":693.61},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":455.49,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":177.0,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":240.72,"additional_payer_notes":"APC"}]}]},{"description":"X-ray urethra/bladder","code_information":[{"code":"74455","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":177.0,"maximum":455.49,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":236.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":223.49},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":215.78},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":223.49},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":455.49,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":177.0,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":240.72,"additional_payer_notes":"APC"}]}]},{"description":"Contrst x-ray urinary tract","code_information":[{"code":"74410","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":130.12,"maximum":334.84,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":173.49,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":287.47},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":277.56},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":287.47},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":334.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":130.12,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":176.96,"additional_payer_notes":"APC"}]}]},{"description":"X-ray bile duct endoscopy","code_information":[{"code":"74328","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":274.59,"maximum":284.42,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":284.42},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":274.59},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":284.42}]}]},{"description":"Ct colonography dx w/dye","code_information":[{"code":"74262","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":130.12,"maximum":1426.59,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":173.49,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":1426.59},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1377.32},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":1426.59},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":334.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":130.12,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":176.96,"additional_payer_notes":"APC"}]}]},{"description":"Cine/vid x-ray throat/esoph","code_information":[{"code":"74230","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":130.12,"maximum":346.55,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":173.49,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":346.55},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":334.59},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":346.55},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":334.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":130.12,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":176.96,"additional_payer_notes":"APC"}]}]},{"description":"Mri abdomen w/o dye","code_information":[{"code":"74181","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":177.0,"maximum":892.46,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":236.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":892.46},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":861.64},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":892.46},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":455.49,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":177.0,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":240.72,"additional_payer_notes":"APC"}]}]},{"description":"Ct abdomen w/o dye","code_information":[{"code":"74150","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":77.56,"maximum":307.17,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":103.41,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":307.17},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":296.56},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":307.17},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":199.58,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":77.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":105.48,"additional_payer_notes":"APC"}]}]},{"description":"Mri jnt of lwr extre w/o dye","code_information":[{"code":"73721","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":177.0,"maximum":577.41,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":236.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":577.41},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":557.47},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":577.41},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":455.49,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":177.0,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":240.72,"additional_payer_notes":"APC"}]}]},{"description":"X-ray exam of toe(s)","code_information":[{"code":"73660","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":64.56,"maximum":166.13,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":86.08,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":73.35},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":70.8},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":73.35},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":166.13,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":64.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":87.8,"additional_payer_notes":"APC"}]}]},{"description":"X-ray exam of lower leg","code_information":[{"code":"73590","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":64.56,"maximum":166.13,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":86.08,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":68.41},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":66.04},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":68.41},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":166.13,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":64.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":87.8,"additional_payer_notes":"APC"}]}]},{"description":"Contrast x-ray of hip","code_information":[{"code":"73525","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":241.91,"maximum":665.99,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":345.07,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":250.56},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":241.91},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":250.56},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":665.99,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":258.81,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":351.98,"additional_payer_notes":"APC"}]}]},{"description":"Mri joint upr extr w/o&w/dye","code_information":[{"code":"73223","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":258.81,"maximum":1241.98,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":345.07,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":1241.98},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1199.1},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":1241.98},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":665.99,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":258.81,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":351.98,"additional_payer_notes":"APC"}]}]},{"description":"Ct upper extremity w/dye","code_information":[{"code":"73201","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":258.81,"maximum":665.99,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":345.07,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":564.38},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":544.9},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":564.38},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":665.99,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":258.81,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":351.98,"additional_payer_notes":"APC"}]}]},{"description":"X-ray exam of arm infant","code_information":[{"code":"73092","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":62.49,"maximum":199.58,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":103.41,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":64.73},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":62.49},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":64.73},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":199.58,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":77.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":105.48,"additional_payer_notes":"APC"}]}]},{"description":"X-ray exam of shoulder","code_information":[{"code":"73030","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":63.69,"maximum":166.13,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":86.08,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":65.95},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":63.69},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":65.95},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":166.13,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":64.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":87.8,"additional_payer_notes":"APC"}]}]},{"description":"Myelography thoracic spine","code_information":[{"code":"72255","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":168.24,"maximum":1496.49,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":775.38,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":174.26},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":168.24},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":174.26},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1496.49,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":581.54,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":790.89,"additional_payer_notes":"APC"}]}]},{"description":"Mri Pelvis W/O Dye","code_information":[{"code":"72195","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":177.0,"maximum":1036.45,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":236.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":1036.45},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1000.66},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":1036.45},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":455.49,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":177.0,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":240.72,"additional_payer_notes":"APC"}]}]},{"description":"Mri lumbar spine w/o & w/dye","code_information":[{"code":"72158","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":258.81,"maximum":903.55,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":345.07,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":903.55},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":872.35},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":903.55},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":665.99,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":258.81,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":351.98,"additional_payer_notes":"APC"}]}]},{"description":"Mri neck spine w/o dye","code_information":[{"code":"72141","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":177.0,"maximum":511.47,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":236.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":511.47},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":493.8},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":511.47},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":455.49,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":177.0,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":240.72,"additional_payer_notes":"APC"}]}]},{"description":"Ct neck spine w/dye","code_information":[{"code":"72126","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":258.81,"maximum":665.99,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":345.07,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":576.7},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":556.76},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":576.7},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":665.99,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":258.81,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":351.98,"additional_payer_notes":"APC"}]}]},{"description":"X-ray exam entire spi 2/3 vw","code_information":[{"code":"72082","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":77.56,"maximum":199.58,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":103.41,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":158.26},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":152.8},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":158.26},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":199.58,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":77.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":105.48,"additional_payer_notes":"APC"}]}]},{"description":"X-ray exam neck spine 2-3 vw","code_information":[{"code":"72040","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":64.56,"maximum":166.13,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":86.08,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":74.57},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":72.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":74.57},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":166.13,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":64.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":87.8,"additional_payer_notes":"APC"}]}]},{"description":"Ct thorax w/o & w/dye","code_information":[{"code":"71270","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":130.12,"maximum":707.16,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":173.49,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":707.16},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":682.72},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":707.16},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":334.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":130.12,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":176.96,"additional_payer_notes":"APC"}]}]},{"description":"X-ray exam ribs uni 2 views","code_information":[{"code":"71100","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":64.56,"maximum":166.13,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":86.08,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":73.35},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":70.8},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":73.35},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":166.13,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":64.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":87.8,"additional_payer_notes":"APC"}]}]},{"description":"Fmri brain by phys/psych","code_information":[{"code":"70555","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":177.0,"maximum":2119.42,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":236.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":2119.42},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2046.23},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":2119.42},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":455.49,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":177.0,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":240.72,"additional_payer_notes":"APC"}]}]},{"description":"Mr angiograph head w/o&w/dye","code_information":[{"code":"70546","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":258.81,"maximum":1749.01,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":345.07,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":1749.01},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1688.63},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":1749.01},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":665.99,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":258.81,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":351.98,"additional_payer_notes":"APC"}]}]},{"description":"Ct sft tsue nck w/o & w/dye","code_information":[{"code":"70492","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":130.12,"maximum":704.68,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":173.49,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":704.68},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":680.34},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":704.68},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":334.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":130.12,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":176.96,"additional_payer_notes":"APC"}]}]},{"description":"Ct orbit/ear/fossa w/o dye","code_information":[{"code":"70480","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":77.56,"maximum":580.38,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":103.41,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":580.38},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":560.35},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":580.38},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":199.58,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":77.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":105.48,"additional_payer_notes":"APC"}]}]},{"description":"X-ray exam of neck","code_information":[{"code":"70360","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":64.56,"maximum":166.13,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":86.08,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":67.2},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":64.88},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":67.2},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":166.13,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":64.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":87.8,"additional_payer_notes":"APC"}]}]},{"description":"X-ray exam of teeth","code_information":[{"code":"70310","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":94.58,"maximum":455.49,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":236.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":97.96},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":94.58},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":97.96},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":455.49,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":177.0,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":240.72,"additional_payer_notes":"APC"}]}]},{"description":"X-ray exam of eye sockets","code_information":[{"code":"70190","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":64.56,"maximum":166.13,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":86.08,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":83.18},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":80.32},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":83.18},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":166.13,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":64.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":87.8,"additional_payer_notes":"APC"}]}]},{"description":"X-ray exam of jaw 4/> views","code_information":[{"code":"70110","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":77.56,"maximum":199.58,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":103.41,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":85.63},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":82.68},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":85.63},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":199.58,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":77.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":105.48,"additional_payer_notes":"APC"}]}]},{"description":"Pulm tiss vntj alys w/ct","code_information":[{"code":"0808T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":111.71,"maximum":412.19,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":213.57,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":121.86},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":111.71},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":121.86},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":412.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":160.18,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":217.84,"additional_payer_notes":"APC"}]}]},{"description":"Auto alys xst ct std vrt fx","code_information":[{"code":"0691T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":30.5,"maximum":31.49,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":31.49},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":30.5},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":31.49}]}]},{"description":"Ct breast w/3d uni c-/c+","code_information":[{"code":"0635T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":130.12,"maximum":524.67,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":173.49,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":524.67},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":508.26},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":524.67},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":334.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":130.12,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":176.96,"additional_payer_notes":"APC"}]}]},{"description":"Rem oct rta techl sprt min 8","code_information":[{"code":"0605T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1702.14,"maximum":1728.3,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":1728.3},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1702.14},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":1728.3}]}]},{"description":"Ct scan f/biomchn ct alys","code_information":[{"code":"0558T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":64.56,"maximum":419.16,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":86.08,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":419.16},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":412.81},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":419.16},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":166.13,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":64.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":87.8,"additional_payer_notes":"APC"}]}]},{"description":"Oct mid ear i&r unilateral","code_information":[{"code":"0485T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":27.71,"maximum":130.77,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":36.94,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":130.77},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":128.8},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":130.77},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":71.3,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27.71,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":37.68,"additional_payer_notes":"APC"}]}]},{"description":"RSA lower extr exam","code_information":[{"code":"0350T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":64.56,"maximum":579.32,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":86.08,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":579.32},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":570.55},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":579.32},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":166.13,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":64.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":87.8,"additional_payer_notes":"APC"}]}]},{"description":"Fna w/o image","code_information":[{"code":"10021","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":301.57,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":402.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":776.03,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":301.57,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":410.13,"additional_payer_notes":"APC"}]}]},{"description":"Remove foreign body","code_information":[{"code":"10121","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1225.21,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1633.61,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3152.87,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1225.21,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1666.28,"additional_payer_notes":"APC"}]}]},{"description":"Debride genit/per/abdom wall","code_information":[{"code":"11006","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2654.0,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0}]}]},{"description":"Deb subq tissue add-on","code_information":[{"code":"11045","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Shave skin lesion 0.5 cm/<","code_information":[{"code":"11300","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":301.57,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":402.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":776.03,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":301.57,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":410.13,"additional_payer_notes":"APC"}]}]},{"description":"Shave skin lesion 0.5 cm/<","code_information":[{"code":"11310","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":148.84,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":198.45,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":383.01,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":148.84,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":202.42,"additional_payer_notes":"APC"}]}]},{"description":"Exc tr-ext b9+marg 3.1-4 cm","code_information":[{"code":"11404","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1225.21,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1633.61,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3152.87,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1225.21,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1666.28,"additional_payer_notes":"APC"}]}]},{"description":"Exc face-mm b9+marg 0.5 cm/<","code_information":[{"code":"11440","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":525.32,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":700.42,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1351.81,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":525.32,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":714.43,"additional_payer_notes":"APC"}]}]},{"description":"Removal sweat gland lesion","code_information":[{"code":"11462","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2154.81,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2873.08,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5545.05,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2154.81,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2930.54,"additional_payer_notes":"APC"}]}]},{"description":"Exc tr-ext mal+marg 3.1-4 cm","code_information":[{"code":"11604","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":525.32,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":700.42,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1351.81,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":525.32,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":714.43,"additional_payer_notes":"APC"}]}]},{"description":"Exc f/e/e/n/l mal+mrg 0.5cm<","code_information":[{"code":"11640","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":525.32,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":700.42,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1351.81,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":525.32,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":714.43,"additional_payer_notes":"APC"}]}]},{"description":"Debride nail 6 or more","code_information":[{"code":"11721","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":43.76,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":58.35,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":112.62,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":43.76,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":59.52,"additional_payer_notes":"APC"}]}]},{"description":"Excision of nail fold toe","code_information":[{"code":"11765","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":301.57,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":402.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":776.03,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":301.57,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":410.13,"additional_payer_notes":"APC"}]}]},{"description":"Correct skin color ea 20.0cm","code_information":[{"code":"11922","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Remove contraceptive capsule","code_information":[{"code":"11976","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":525.32,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":700.42,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1351.81,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":525.32,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":714.43,"additional_payer_notes":"APC"}]}]},{"description":"Rpr s/n/a/gen/trk12.6-20.0cm","code_information":[{"code":"12005","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":301.57,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":402.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":776.03,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":301.57,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":410.13,"additional_payer_notes":"APC"}]}]},{"description":"Rpr fe/e/en/l/m 20.1-30.0 cm","code_information":[{"code":"12017","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":301.57,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":402.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":776.03,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":301.57,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":410.13,"additional_payer_notes":"APC"}]}]},{"description":"Evasc rpr ilio-iliac ndgft","code_information":[{"code":"34707","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6019.0,"maximum":7398.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":7398.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6019.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":7398.0}]}]},{"description":"Opn ax/subcla art expos","code_information":[{"code":"34715","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Esphg tot w/laps moblj","code_information":[{"code":"43286","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5257.0,"maximum":6462.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5257.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6462.0}]}]},{"description":"Remove drug implant","code_information":[{"code":"G0517","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":331.39,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":441.86,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":852.79,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":331.39,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":450.7,"additional_payer_notes":"APC"}]}]},{"description":"Insj subq car rhythm mntr","code_information":[{"code":"33285","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6138.95,"maximum":27583.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8185.27,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":15797.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6138.95,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":27583.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8348.97,"additional_payer_notes":"APC"}]}]},{"description":"Punch bx skin single lesion","code_information":[{"code":"11104","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":301.57,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":402.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":776.03,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":301.57,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":410.13,"additional_payer_notes":"APC"}]}]},{"description":"Rplcmt a-valve tlcj autol pv","code_information":[{"code":"33440","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":9356.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0}]}]},{"description":"Fna bx w/fluor gdn 1st les","code_information":[{"code":"10007","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":525.32,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":700.42,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1351.81,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":525.32,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":714.43,"additional_payer_notes":"APC"}]}]},{"description":"Esw integ wnd hlg ea addl","code_information":[{"code":"0513T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Grfg autol soft tiss dir exc","code_information":[{"code":"15769","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2628.85,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3505.13,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6764.9,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2628.85,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3575.23,"additional_payer_notes":"APC"}]}]},{"description":"Expl n/flwd surg uxtr art","code_information":[{"code":"35702","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3388.0,"maximum":4106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0}]}]},{"description":"Evasc rpr a-iliac ndgft","code_information":[{"code":"34717","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":9356.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0}]}]},{"description":"Ndl insj w/o njx 1 or 2 musc","code_information":[{"code":"20560","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":21.46,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":28.61,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":55.21,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21.46,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":29.18,"additional_payer_notes":"APC"}]}]},{"description":"Rmvl&rplcmt ss impl dfb pg","code_information":[{"code":"0614T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":54996.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22001.33,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":54996.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":54996.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":54996.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":42462.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16501.0,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":51942.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22441.36,"additional_payer_notes":"APC"}]}]},{"description":"Mag ctrld capsule endoscopy","code_information":[{"code":"0651T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":672.83,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":897.11,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1731.42,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":672.83,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":915.05,"additional_payer_notes":"APC"}]}]},{"description":"Excl laa thrscp any method","code_information":[{"code":"33269","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8923.0,"maximum":10765.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":10765.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":8923.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":10765.0}]}]},{"description":"Transorl lwr esophgl myotomy","code_information":[{"code":"43497","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":11589.23,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6004.78,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11589.23,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4503.59,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6124.88,"additional_payer_notes":"APC"}]}]},{"description":"Rev/rplct hpglsl nstm ary pg","code_information":[{"code":"64583","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":27583.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11021.34,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":21271.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8266.01,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":27583.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11241.77,"additional_payer_notes":"APC"}]}]},{"description":"Evasc st rpr thrc/aa x crsg","code_information":[{"code":"33895","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":9356.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0}]}]},{"description":"Tprnl balo cntnc dev bi","code_information":[{"code":"53451","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8923.0,"maximum":27583.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13049.77,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":10765.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":8923.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":10765.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":25186.06,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9787.33,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":27583.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13310.77,"additional_payer_notes":"APC"}]}]},{"description":"Impl oi implt sk tc esp>=100","code_information":[{"code":"69729","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":24508.8,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12698.86,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":24508.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9524.15,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12952.84,"additional_payer_notes":"APC"}]}]},{"description":"Tot disc arthrp 2ntrspc lmbr","code_information":[{"code":"22860","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8923.0,"maximum":10765.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":10765.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":8923.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":10765.0}]}]},{"description":"Laps surg prst8ect smpl stot","code_information":[{"code":"55867","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":20292.15,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10514.07,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":20292.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7885.55,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10724.35,"additional_payer_notes":"APC"}]}]},{"description":"Rpr parastomal hernia rdc","code_information":[{"code":"49621","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":17314.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0}]}]},{"description":"Tcat rmv&rpl2chmb ldls pm rv","code_information":[{"code":"0803T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8923.0,"maximum":36770.21,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19051.92,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":10765.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":8923.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":10765.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":36770.21,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14288.94,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":27583.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19432.96,"additional_payer_notes":"APC"}]}]},{"description":"Rmvl phrnc nrv stim transvns","code_information":[{"code":"33279","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2593.52,"maximum":8657.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3458.03,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6674.0,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2593.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3527.19,"additional_payer_notes":"APC"}]}]},{"description":"Low ntsty eswt corpus cvrnsm","code_information":[{"code":"0864T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":185.35,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":247.13,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":476.96,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":185.35,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":252.07,"additional_payer_notes":"APC"}]}]},{"description":"Rmvl phrnc nrv stim pg only","code_information":[{"code":"33280","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2593.52,"maximum":8657.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3458.03,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6674.0,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2593.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3527.19,"additional_payer_notes":"APC"}]}]},{"description":"Tcat rmv&rpl1chmb ldls pm ra","code_information":[{"code":"0825T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8923.0,"maximum":36770.21,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19051.92,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":10765.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":8923.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":10765.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":36770.21,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14288.94,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":27583.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19432.96,"additional_payer_notes":"APC"}]}]},{"description":"Rmv sk-mnt crnl nstm pg/rcvr","code_information":[{"code":"61892","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":8657.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Rpr intst excl anrect fist","code_information":[{"code":"C9796","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2059.07,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2745.43,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5298.68,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2059.07,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2800.34,"additional_payer_notes":"APC"}]}]},{"description":"Cathj rmvl dev ischmc rmdlg","code_information":[{"code":"53866","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":185.35,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":247.13,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":476.96,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":185.35,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":252.07,"additional_payer_notes":"APC"}]}]},{"description":"Prepj skn cll ssp agrft ea","code_information":[{"code":"15014","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5512.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0}]}]},{"description":"Thrc fascial pln blk uni njx","code_information":[{"code":"64466","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5512.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0}]}]},{"description":"Rmvl perm ccm-d sys 1 dfb ld","code_information":[{"code":"0921T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2772.2,"maximum":7133.79,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3696.26,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7133.79,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2772.2,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3770.19,"additional_payer_notes":"APC"}]}]},{"description":"App skn cll ssp f/n/g/hf 1st","code_information":[{"code":"15017","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1530.61,"maximum":4106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2040.81,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3938.76,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1530.61,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2081.63,"additional_payer_notes":"APC"}]}]},{"description":"App skn cll ssp f/n/g/hf ea","code_information":[{"code":"15018","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5512.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0}]}]},{"description":"Rmv/rplc magnet coil assem","code_information":[{"code":"0959T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1225.21,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1633.61,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3152.87,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1225.21,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1666.28,"additional_payer_notes":"APC"}]}]},{"description":"Ablt b9 brst tum perq lsr ea","code_information":[{"code":"0970T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2904.59,"maximum":7474.49,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3872.79,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7474.49,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2904.59,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3950.25,"additional_payer_notes":"APC"}]}]},{"description":"Radiation tx delivery imrt","code_information":[{"code":"G6015","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1150.59,"maximum":1191.75,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":1191.75},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1150.59},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":1191.75}]}]},{"description":"Radiation treatment delivery","code_information":[{"code":"G6007","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1009.47,"maximum":1045.57,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":1045.57},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1009.47},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":1045.57}]}]},{"description":"Recon, CTA for surg plan","code_information":[{"code":"G0288","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":118.01,"maximum":122.24,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":122.24},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":118.01},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":122.24}]}]},{"description":"Coronavirus vaccine 5","code_information":[{"code":"91304","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":0.01,"maximum":439.79,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":0.01},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":0.01},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":177.69},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":0.01},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":306.92},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":306.92},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":306.92},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":298.85},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":439.79}]}]},{"description":"Nuclear rx intracav admin","code_information":[{"code":"79200","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":173.1,"maximum":445.43,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":230.79,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":202.07},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":195.07},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":202.07},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":445.43,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":173.1,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":235.41,"additional_payer_notes":"APC"}]}]},{"description":"Pet image w/ct skull-thigh","code_information":[{"code":"78815","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1060.78,"maximum":2928.5,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1414.38,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":2928.5},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2884.18},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":2928.5},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2729.74,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1060.78,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1442.66,"additional_payer_notes":"APC"}]}]},{"description":"Tumor imaging whole body","code_information":[{"code":"78802","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":402.79,"maximum":1036.52,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":537.06,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":1014.54},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":979.5},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":1014.54},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1036.52,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":402.79,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":547.8,"additional_payer_notes":"APC"}]}]},{"description":"K flow/funct image w/drug","code_information":[{"code":"78708","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":397.3,"maximum":1036.52,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":537.06,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":411.51},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":397.3},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":411.51},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1036.52,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":402.79,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":547.8,"additional_payer_notes":"APC"}]}]},{"description":"Cerebrospinal fluid scan","code_information":[{"code":"78630","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":402.79,"maximum":1092.08,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":537.06,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":1092.08},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1054.35},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":1092.08},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1036.52,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":402.79,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":547.8,"additional_payer_notes":"APC"}]}]},{"description":"Lung perf&ventilat diferentl","code_information":[{"code":"78598","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":402.79,"maximum":1036.52,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":537.06,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":950.54},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":917.72},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":950.54},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1036.52,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":402.79,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":547.8,"additional_payer_notes":"APC"}]}]},{"description":"Heart image (pet) single","code_information":[{"code":"78491","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1060.78,"maximum":2729.74,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1414.38,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":1305.3},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1285.53},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":1305.3},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2729.74,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1060.78,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1442.66,"additional_payer_notes":"APC"}]}]},{"description":"Heart muscle imaging (PET)","code_information":[{"code":"78459","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":960.41,"maximum":2471.46,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1280.55,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":1256.24},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1237.23},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":1256.24},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2471.46,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":960.41,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1306.16,"additional_payer_notes":"APC"}]}]},{"description":"Vascular flow imaging","code_information":[{"code":"78445","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":296.56,"maximum":763.16,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":395.42,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":542.46},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":523.72},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":542.46},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":763.16,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":296.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":403.33,"additional_payer_notes":"APC"}]}]},{"description":"Non-imaging heart function","code_information":[{"code":"78414","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":171.27,"maximum":1036.52,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":537.06,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":177.39},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":171.27},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":177.39},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1036.52,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":402.79,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":547.8,"additional_payer_notes":"APC"}]}]},{"description":"Meckels divert exam","code_information":[{"code":"78290","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":296.56,"maximum":1073.6,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":395.42,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":1073.6},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1036.53},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":1073.6},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":763.16,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":296.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":403.33,"additional_payer_notes":"APC"}]}]},{"description":"Esophageal motility study","code_information":[{"code":"78258","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":296.56,"maximum":763.16,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":395.42,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":663.07},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":640.16},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":663.07},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":763.16,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":296.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":403.33,"additional_payer_notes":"APC"}]}]},{"description":"Liver imaging with flow","code_information":[{"code":"78202","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":402.79,"maximum":1036.52,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":537.06,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":635.98},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":614.02},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":635.98},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1036.52,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":402.79,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":547.8,"additional_payer_notes":"APC"}]}]},{"description":"Red cell mass multiple","code_information":[{"code":"78121","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":295.58,"maximum":1036.52,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":537.06,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":306.16},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":295.58},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":306.16},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1036.52,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":402.79,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":547.8,"additional_payer_notes":"APC"}]}]},{"description":"Parathyrd planar w/spect&ct","code_information":[{"code":"78072","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":402.79,"maximum":1207.75,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":537.06,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":1207.75},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1166.05},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":1207.75},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1036.52,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":402.79,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":547.8,"additional_payer_notes":"APC"}]}]},{"description":"Thyroid imaging w/blood flow","code_information":[{"code":"78013","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":296.56,"maximum":763.16,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":395.42,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":616.28},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":595.02},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":616.28},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":763.16,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":296.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":403.33,"additional_payer_notes":"APC"}]}]},{"description":"Hdr rdncl skn surf brachytx","code_information":[{"code":"77768","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":286.12,"maximum":968.49,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":381.5,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":968.49},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":935.04},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":968.49},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":736.29,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":286.12,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":389.13,"additional_payer_notes":"APC"}]}]},{"description":"Hyperthermia treatment","code_information":[{"code":"77610","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":409.89,"maximum":3149.77,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":546.52,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3149.77},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3040.99},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3149.77},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1054.79,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":409.89,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":557.46,"additional_payer_notes":"APC"}]}]},{"description":"Io radiation tx management","code_information":[{"code":"77469","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1093.87,"maximum":1132.98,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":1132.98},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1093.87},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":1132.98}]}]},{"description":"Radiation treatment delivery","code_information":[{"code":"77407","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":286.12,"maximum":736.29,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":381.5,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":686.21},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":662.54},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":686.21},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":736.29,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":286.12,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":389.13,"additional_payer_notes":"APC"}]}]},{"description":"Srs multisource","code_information":[{"code":"77371","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4103.08,"maximum":14060.2,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7285.08,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4249.84},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4103.08},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4249.84},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":14060.2,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5463.81,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7430.78,"additional_payer_notes":"APC"}]}]},{"description":"Special teletx port plan","code_information":[{"code":"77321","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":145.66,"maximum":714.78,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":370.35,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":150.86},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":145.66},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":150.86},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":714.78,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":277.76,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":377.76,"additional_payer_notes":"APC"}]}]},{"description":"3-d radiotherapy plan","code_information":[{"code":"77295","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":897.03,"maximum":2642.28,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1369.06,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":929.12},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":897.03},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":929.12},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2642.28,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1026.79,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1396.44,"additional_payer_notes":"APC"}]}]},{"description":"Tbs i&r fx rsk qhp","code_information":[{"code":"77092","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":37.25,"maximum":37.81,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":37.81},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":37.25},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":37.81}]}]},{"description":"Dxa bone density axial","code_information":[{"code":"77080","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":77.56,"maximum":199.58,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":103.41,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":106.57},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":102.88},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":106.57},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":199.58,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":77.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":105.48,"additional_payer_notes":"APC"}]}]},{"description":"X-Ray Stress View","code_information":[{"code":"77071","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":64.56,"maximum":167.47,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":86.08,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":167.47},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":161.67},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":167.47},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":166.13,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":64.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":87.8,"additional_payer_notes":"APC"}]}]},{"description":"Mri breast c- bilateral","code_information":[{"code":"77047","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":177.0,"maximum":607.17,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":236.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":607.17},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":592.09},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":607.17},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":455.49,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":177.0,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":240.72,"additional_payer_notes":"APC"}]}]},{"description":"Fluoroguide for Spine Inject","code_information":[{"code":"77003","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":186.06,"maximum":192.72,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":192.72},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":186.06},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":192.72}]}]},{"description":"Use ea addl target lesion","code_information":[{"code":"76983","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":114.24,"maximum":117.15,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":117.15},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":114.24},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":117.15}]}]},{"description":"Echo guide ova aspiration","code_information":[{"code":"76948","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":132.59,"maximum":137.34,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":137.34},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":132.59},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":137.34}]}]},{"description":"Echo guide for heart biopsy","code_information":[{"code":"76932","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":182.67,"maximum":189.21,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":189.21},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":182.67},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":189.21}]}]},{"description":"Us exam scrotum","code_information":[{"code":"76870","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":77.56,"maximum":199.58,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":103.41,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":122.56},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":118.34},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":122.56},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":199.58,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":77.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":105.48,"additional_payer_notes":"APC"}]}]},{"description":"Echo exam of fetal heart","code_information":[{"code":"76825","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":405.35,"maximum":1043.1,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":540.46,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":669.72},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":646.59},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":669.72},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1043.1,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":405.35,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":551.27,"additional_payer_notes":"APC"}]}]},{"description":"Ob us nuchal meas add-on","code_information":[{"code":"76814","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":100.52,"maximum":104.11,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":104.11},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":100.52},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":104.11}]}]},{"description":"Us exam spinal canal","code_information":[{"code":"76800","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":77.56,"maximum":281.31,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":103.41,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":281.31},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":271.62},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":281.31},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":199.58,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":77.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":105.48,"additional_payer_notes":"APC"}]}]},{"description":"Us exam chest","code_information":[{"code":"76604","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":77.56,"maximum":211.18,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":103.41,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":211.18},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":203.89},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":211.18},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":199.58,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":77.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":105.48,"additional_payer_notes":"APC"}]}]},{"description":"Ophth us quant a only","code_information":[{"code":"76511","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":77.56,"maximum":199.58,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":103.41,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":166.87},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":161.12},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":166.87},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":199.58,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":77.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":105.48,"additional_payer_notes":"APC"}]}]},{"description":"CAT scan follow-up study","code_information":[{"code":"76380","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":64.56,"maximum":331.79,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":86.08,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":331.79},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":320.33},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":331.79},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":166.13,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":64.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":87.8,"additional_payer_notes":"APC"}]}]},{"description":"X-ray exam of fistula","code_information":[{"code":"76080","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":94.58,"maximum":1043.1,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":540.46,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":97.96},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":94.58},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":97.96},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1043.1,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":405.35,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":551.27,"additional_payer_notes":"APC"}]}]},{"description":"Fluoroscope examination","code_information":[{"code":"76000","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":127.84,"maximum":455.49,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":236.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":132.41},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":127.84},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":132.41},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":455.49,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":177.0,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":240.72,"additional_payer_notes":"APC"}]}]},{"description":"Remove cva lumen obstruct","code_information":[{"code":"75902","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":175.36,"maximum":181.64,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":181.64},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":175.36},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":181.64}]}]},{"description":"Vein x-ray liver w/hemodynam","code_information":[{"code":"75885","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":295.36,"maximum":6027.57,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3123.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":305.93},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":295.36},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":305.93},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6027.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2342.32,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3185.56,"additional_payer_notes":"APC"}]}]},{"description":"Vein x-ray kidney","code_information":[{"code":"75831","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":283.5,"maximum":6027.57,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3123.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":293.62},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":283.5},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":293.62},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6027.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2342.32,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3185.56,"additional_payer_notes":"APC"}]}]},{"description":"Lymph vessel x-ray trunk","code_information":[{"code":"75805","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":760.95,"maximum":6027.57,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3123.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":772.63},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":760.95},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":772.63},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6027.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2342.32,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3185.56,"additional_payer_notes":"APC"}]}]},{"description":"Artery x-rays pelvis","code_information":[{"code":"75736","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":348.37,"maximum":10622.5,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5503.89,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":360.82},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":348.37},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":360.82},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":10622.5,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4127.91,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5613.96,"additional_payer_notes":"APC"}]}]},{"description":"X-ray aorta leg arteries","code_information":[{"code":"75630","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":273.99,"maximum":6027.57,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3123.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":283.8},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":273.99},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":283.8},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6027.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2342.32,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3185.56,"additional_payer_notes":"APC"}]}]},{"description":"Ct hrt w/o dye w/ca test","code_information":[{"code":"75571","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":64.56,"maximum":245.63,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":86.08,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":245.63},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":237.15},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":245.63},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":166.13,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":64.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":87.8,"additional_payer_notes":"APC"}]}]},{"description":"X-ray female genital tract","code_information":[{"code":"74740","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":177.0,"maximum":455.49,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":236.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":191.49},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":184.86},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":191.49},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":455.49,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":177.0,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":240.72,"additional_payer_notes":"APC"}]}]},{"description":"X-ray male genital tract","code_information":[{"code":"74440","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":177.0,"maximum":455.49,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":236.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":216.09},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":208.63},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":216.09},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":455.49,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":177.0,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":240.72,"additional_payer_notes":"APC"}]}]},{"description":"X-ray guide gi dilation","code_information":[{"code":"74360","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":299.06,"maximum":309.77,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":309.77},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":299.06},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":309.77}]}]},{"description":"Contrast x-ray gallbladder","code_information":[{"code":"74290","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":130.12,"maximum":334.84,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":173.49,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":185.34},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":178.93},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":185.34},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":334.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":130.12,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":176.96,"additional_payer_notes":"APC"}]}]},{"description":"X-ray exam of small bowel","code_information":[{"code":"74250","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":130.12,"maximum":334.84,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":173.49,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":275.19},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":265.66},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":275.19},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":334.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":130.12,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":176.96,"additional_payer_notes":"APC"}]}]},{"description":"Contrst x-ray exam of throat","code_information":[{"code":"74210","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":130.12,"maximum":334.84,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":173.49,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":205.03},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":197.94},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":205.03},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":334.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":130.12,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":176.96,"additional_payer_notes":"APC"}]}]},{"description":"Ct abd & pelvis w/o contrast","code_information":[{"code":"74176","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":177.0,"maximum":455.49,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":236.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":384.71},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":371.42},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":384.71},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":455.49,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":177.0,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":240.72,"additional_payer_notes":"APC"}]}]},{"description":"X-ray exam abdomen 2 views","code_information":[{"code":"74019","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":71.86,"maximum":199.58,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":103.41,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":74.44},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":71.86},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":74.44},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":199.58,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":77.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":105.48,"additional_payer_notes":"APC"}]}]},{"description":"Mri Lower Extremity W/O Dye","code_information":[{"code":"73718","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":177.0,"maximum":1021.69,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":236.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":1021.69},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":986.41},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":1021.69},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":455.49,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":177.0,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":240.72,"additional_payer_notes":"APC"}]}]},{"description":"X-ray exam of foot","code_information":[{"code":"73620","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":60.11,"maximum":166.13,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":86.08,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":62.25},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":60.11},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":62.25},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":166.13,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":64.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":87.8,"additional_payer_notes":"APC"}]}]},{"description":"X-ray exam knee 4 or more","code_information":[{"code":"73564","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":77.56,"maximum":199.58,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":103.41,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":96.72},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":93.39},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":96.72},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":199.58,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":77.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":105.48,"additional_payer_notes":"APC"}]}]},{"description":"X-ray exam hips bi 2 views","code_information":[{"code":"73521","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":77.56,"maximum":199.58,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":103.41,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":96.72},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":93.39},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":96.72},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":199.58,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":77.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":105.48,"additional_payer_notes":"APC"}]}]},{"description":"Mri uppr extremity w/o&w/dye","code_information":[{"code":"73220","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":258.81,"maximum":1347.81,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":345.07,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":1347.81},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1301.27},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":1347.81},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":665.99,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":258.81,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":351.98,"additional_payer_notes":"APC"}]}]},{"description":"X-ray exam of hand","code_information":[{"code":"73130","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":64.56,"maximum":166.13,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":86.08,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":74.57},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":72.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":74.57},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":166.13,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":64.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":87.8,"additional_payer_notes":"APC"}]}]},{"description":"X-ray exam of elbow","code_information":[{"code":"73080","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":64.56,"maximum":166.13,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":86.08,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":75.8},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":73.17},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":75.8},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":166.13,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":64.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":87.8,"additional_payer_notes":"APC"}]}]},{"description":"X-ray exam of collar bone","code_information":[{"code":"73000","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":62.49,"maximum":166.13,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":86.08,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":64.73},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":62.49},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":64.73},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":166.13,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":64.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":87.8,"additional_payer_notes":"APC"}]}]},{"description":"X-ray exam si joints 3/> vws","code_information":[{"code":"72202","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":76.74,"maximum":199.58,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":103.41,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":79.5},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":76.74},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":79.5},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":199.58,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":77.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":105.48,"additional_payer_notes":"APC"}]}]},{"description":"Ct pelvis w/o dye","code_information":[{"code":"72192","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":77.56,"maximum":312.09,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":103.41,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":312.09},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":301.32},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":312.09},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":199.58,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":77.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":105.48,"additional_payer_notes":"APC"}]}]},{"description":"Mri lumbar spine w/dye","code_information":[{"code":"72149","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":258.81,"maximum":792.78,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":345.07,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":792.78},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":765.4},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":792.78},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":665.99,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":258.81,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":351.98,"additional_payer_notes":"APC"}]}]},{"description":"Ct lumbar spine w/o dye","code_information":[{"code":"72131","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":77.56,"maximum":443.78,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":103.41,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":443.78},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":428.45},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":443.78},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":199.58,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":77.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":105.48,"additional_payer_notes":"APC"}]}]},{"description":"X-ray exam l-s spine bending","code_information":[{"code":"72114","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":77.56,"maximum":199.58,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":103.41,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":157.01},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":151.6},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":157.01},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":199.58,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":77.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":105.48,"additional_payer_notes":"APC"}]}]},{"description":"X-ray exam thorac spine4/>vw","code_information":[{"code":"72074","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":77.56,"maximum":199.58,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":103.41,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":96.72},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":93.39},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":96.72},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":199.58,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":77.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":105.48,"additional_payer_notes":"APC"}]}]},{"description":"Mri chest w/o & w/dye","code_information":[{"code":"71552","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":258.81,"maximum":1602.07,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":345.07,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":1602.07},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1546.74},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":1602.07},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":665.99,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":258.81,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":351.98,"additional_payer_notes":"APC"}]}]},{"description":"X-ray strenoclavic jt 3/>vws","code_information":[{"code":"71130","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":64.56,"maximum":166.13,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":86.08,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":84.41},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":81.49},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":84.41},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":166.13,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":64.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":87.8,"additional_payer_notes":"APC"}]}]},{"description":"X-ray exam chest 2 views","code_information":[{"code":"71046","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":64.56,"maximum":166.13,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":86.08,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":67.02},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":64.74},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":67.02},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":166.13,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":64.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":87.8,"additional_payer_notes":"APC"}]}]},{"description":"Mri brain stem w/dye","code_information":[{"code":"70552","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":258.81,"maximum":790.32,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":345.07,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":790.32},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":763.03},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":790.32},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":665.99,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":258.81,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":351.98,"additional_payer_notes":"APC"}]}]},{"description":"Mri orbt/fac/nck w/o &w/dye","code_information":[{"code":"70543","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":258.81,"maximum":1321.98,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":345.07,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":1321.98},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1276.33},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":1321.98},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":665.99,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":258.81,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":351.98,"additional_payer_notes":"APC"}]}]},{"description":"Ct maxillofacial w/o & w/dye","code_information":[{"code":"70488","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":130.12,"maximum":485.61,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":173.49,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":485.61},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":468.84},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":485.61},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":334.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":130.12,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":176.96,"additional_payer_notes":"APC"}]}]},{"description":"Ct head/brain w/o dye","code_information":[{"code":"70450","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":77.56,"maximum":250.56,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":103.41,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":250.56},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":241.91},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":250.56},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":199.58,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":77.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":105.48,"additional_payer_notes":"APC"}]}]},{"description":"Magnetic image jaw joint","code_information":[{"code":"70336","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":177.0,"maximum":848.17,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":236.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":848.17},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":818.88},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":848.17},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":455.49,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":177.0,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":240.72,"additional_payer_notes":"APC"}]}]},{"description":"X-ray exam of skull","code_information":[{"code":"70250","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":76.74,"maximum":199.58,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":103.41,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":79.5},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":76.74},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":79.5},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":199.58,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":77.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":105.48,"additional_payer_notes":"APC"}]}]},{"description":"X-ray exam of facial bones","code_information":[{"code":"70150","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":77.56,"maximum":199.58,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":103.41,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":95.5},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":92.2},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":95.5},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":199.58,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":77.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":105.48,"additional_payer_notes":"APC"}]}]},{"description":"Contrast x-ray of brain","code_information":[{"code":"70015","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":301.32,"maximum":1496.49,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":775.38,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":312.09},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":301.32},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":312.09},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1496.49,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":581.54,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":790.89,"additional_payer_notes":"APC"}]}]},{"description":"Aqmbf spect xers/strs & rest","code_information":[{"code":"0742T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":210.81,"maximum":227.75,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":227.75},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":210.81},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":227.75}]}]},{"description":"Quan mr alys tiss w/mri","code_information":[{"code":"0649T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":262.2,"maximum":1776.02,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":920.22,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":283.29},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":262.2},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":283.29},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1776.02,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":690.16,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":938.62,"additional_payer_notes":"APC"}]}]},{"description":"Mrs discogenic pain i&r","code_information":[{"code":"0612T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":99.14,"maximum":100.66,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":100.66},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":99.14},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":100.66}]}]},{"description":"Ncntc r-t fluor wnd img 1st","code_information":[{"code":"0598T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":160.18,"maximum":412.19,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":213.57,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":333.36},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":328.31},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":333.36},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":412.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":160.18,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":217.84,"additional_payer_notes":"APC"}]}]},{"description":"Insj wcs lv pg compnt","code_information":[{"code":"0517T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1188.31,"maximum":27583.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10338.17,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":1206.58},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1188.31},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":1206.58},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":19952.66,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7753.63,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":27583.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10544.93,"additional_payer_notes":"APC"}]}]},{"description":"Mrgfus strtctc les abltj","code_information":[{"code":"0398T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6315.17,"maximum":27583.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6519.05},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6315.17},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6519.05},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":27583.0}]}]},{"description":"Heart symp image plnr spect","code_information":[{"code":"0332T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":829.71,"maximum":2471.46,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1280.55,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":842.47},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":829.71},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":842.47},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2471.46,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":960.41,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1306.16,"additional_payer_notes":"APC"}]}]},{"description":"Drainage of skin abscess","code_information":[{"code":"10060","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":148.84,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":198.45,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":383.01,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":148.84,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":202.42,"additional_payer_notes":"APC"}]}]},{"description":"Complex drainage wound","code_information":[{"code":"10180","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2154.81,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2873.08,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5545.05,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2154.81,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2930.54,"additional_payer_notes":"APC"}]}]},{"description":"Debride skin musc at fx site","code_information":[{"code":"11011","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":525.32,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":700.42,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1351.81,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":525.32,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":714.43,"additional_payer_notes":"APC"}]}]},{"description":"Trim skin lesion","code_information":[{"code":"11055","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":148.84,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":198.45,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":383.01,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":148.84,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":202.42,"additional_payer_notes":"APC"}]}]},{"description":"Shave skin lesion >2.0 cm","code_information":[{"code":"11303","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":301.57,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":402.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":776.03,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":301.57,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":410.13,"additional_payer_notes":"APC"}]}]},{"description":"Shave skin lesion >2.0 cm","code_information":[{"code":"11313","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":301.57,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":402.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":776.03,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":301.57,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":410.13,"additional_payer_notes":"APC"}]}]},{"description":"Exc h-f-nk-sp b9+marg 0.6-1","code_information":[{"code":"11421","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":525.32,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":700.42,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1351.81,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":525.32,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":714.43,"additional_payer_notes":"APC"}]}]},{"description":"Exc face-mm b9+marg 2.1-3 cm","code_information":[{"code":"11443","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1225.21,"maximum":4106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1633.61,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3152.87,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1225.21,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1666.28,"additional_payer_notes":"APC"}]}]},{"description":"Removal sweat gland lesion","code_information":[{"code":"11471","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2154.81,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2873.08,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5545.05,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2154.81,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2930.54,"additional_payer_notes":"APC"}]}]},{"description":"Exc s/n/h/f/g mal+mrg 0.6-1","code_information":[{"code":"11621","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":525.32,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":700.42,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1351.81,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":525.32,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":714.43,"additional_payer_notes":"APC"}]}]},{"description":"Exc f/e/e/n/l mal+mrg 2.1-3","code_information":[{"code":"11643","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1225.21,"maximum":4106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1633.61,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3152.87,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1225.21,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1666.28,"additional_payer_notes":"APC"}]}]},{"description":"Drain blood from under nail","code_information":[{"code":"11740","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":98.7,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":131.6,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":253.99,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":98.7,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":134.23,"additional_payer_notes":"APC"}]}]},{"description":"Remove pilonidal cyst compl","code_information":[{"code":"11772","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2154.81,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2873.08,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5545.05,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2154.81,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2930.54,"additional_payer_notes":"APC"}]}]},{"description":"Tx contour defects 5.1-10cc","code_information":[{"code":"11952","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":548.27,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":731.02,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1410.87,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":548.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":745.64,"additional_payer_notes":"APC"}]}]},{"description":"Remove drug implant device","code_information":[{"code":"11982","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":331.39,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":441.86,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":852.79,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":331.39,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":450.7,"additional_payer_notes":"APC"}]}]},{"description":"Rpr f/e/e/n/l/m 2.5 cm/<","code_information":[{"code":"12011","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":148.84,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":198.45,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":383.01,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":148.84,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":202.42,"additional_payer_notes":"APC"}]}]},{"description":"Closure of split wound","code_information":[{"code":"12021","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":301.57,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":402.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":776.03,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":301.57,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":410.13,"additional_payer_notes":"APC"}]}]},{"description":"Evasc rpr a-biiliac rpt","code_information":[{"code":"34706","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":9356.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0}]}]},{"description":"Opn fem art expos cndt crtj","code_information":[{"code":"34714","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Laps pelvic lymphadec","code_information":[{"code":"38573","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":20292.15,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10514.07,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":20292.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7885.55,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10724.35,"additional_payer_notes":"APC"}]}]},{"description":"Insert drug del implant, >4","code_information":[{"code":"G0516","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":331.39,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":441.86,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":852.79,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":331.39,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":450.7,"additional_payer_notes":"APC"}]}]},{"description":"Insj picc rs&i <5 yr","code_information":[{"code":"36572","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":465.35,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":620.47,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1197.51,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":465.35,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":632.88,"additional_payer_notes":"APC"}]}]},{"description":"Trurl dstrj prst8 tiss rf wv","code_information":[{"code":"53854","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2614.94,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3486.59,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6729.12,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2614.94,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3556.32,"additional_payer_notes":"APC"}]}]},{"description":"Open bx/exc inguinofem nodes","code_information":[{"code":"38531","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2904.59,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3872.79,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7474.49,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2904.59,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3950.25,"additional_payer_notes":"APC"}]}]},{"description":"Intercalary algrft compl","code_information":[{"code":"20934","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Esw integ wnd hlg 1st wnd","code_information":[{"code":"0512T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":148.84,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":198.45,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":383.01,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":148.84,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":202.42,"additional_payer_notes":"APC"}]}]},{"description":"Exc ch wal tum w/lymphadec","code_information":[{"code":"21603","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":7398.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6019.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":7398.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Reexploration pelvic wound","code_information":[{"code":"49014","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Prcrd drg 6yr+ w/o cgen car","code_information":[{"code":"33017","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3388.0,"maximum":4106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0}]}]},{"description":"Grfg autol fat lipo ea addl","code_information":[{"code":"15772","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Non-blind interatrial shunt","code_information":[{"code":"C9760","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":54996.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26624.33,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":54996.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":54996.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":54996.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":51384.96,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19968.25,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":51942.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27156.82,"additional_payer_notes":"APC"}]}]},{"description":"Ire abltj 1+tum organ perq","code_information":[{"code":"0600T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5257.0,"maximum":20292.15,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10514.07,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5257.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":20292.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7885.55,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10724.35,"additional_payer_notes":"APC"}]}]},{"description":"Revj/rplcmt oi implt tc esp","code_information":[{"code":"69719","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":24508.8,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12698.86,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":24508.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9524.15,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12952.84,"additional_payer_notes":"APC"}]}]},{"description":"Rmvl oi implt skl tc esp","code_information":[{"code":"69727","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Excl laa open any method","code_information":[{"code":"33267","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8923.0,"maximum":10765.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":10765.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":8923.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":10765.0}]}]},{"description":"Litt icr 1 traj 1 smpl les","code_information":[{"code":"61736","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Njx b1 sub mtrl sbchdrl dfct","code_information":[{"code":"0707T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Rmv ntr oi imp sktc esp>=100","code_information":[{"code":"69728","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Rpr aa hrn rcr > 10 ncr/strn","code_information":[{"code":"49618","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5257.0,"maximum":17314.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5257.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0}]}]},{"description":"Impl absrb msh/prsth dly cls","code_information":[{"code":"15778","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":9356.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0}]}]},{"description":"Perq p-art revsc 1 nm nt uni","code_information":[{"code":"33900","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":27583.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11418.47,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":22037.64,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8563.85,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":27583.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11646.84,"additional_payer_notes":"APC"}]}]},{"description":"Egd flx trnsorl rmvl balo","code_information":[{"code":"43291","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":672.83,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":897.11,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1731.42,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":672.83,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":915.05,"additional_payer_notes":"APC"}]}]},{"description":"Blind/nonblind trans atrial","code_information":[{"code":"C9792","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7079.89,"maximum":27583.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9439.85,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":18218.91,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7079.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":27583.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9628.65,"additional_payer_notes":"APC"}]}]},{"description":"Egd vol adjmt bariatric balo","code_information":[{"code":"0813T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":672.83,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":897.11,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1731.42,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":672.83,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":915.05,"additional_payer_notes":"APC"}]}]},{"description":"Ins sk-mnt crnl nstm pg/rcvr","code_information":[{"code":"61889","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8923.0,"maximum":10765.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":10765.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":8923.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":10765.0}]}]},{"description":"Ins/rplmt eltrd ra spi nstim","code_information":[{"code":"0784T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":27583.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11021.34,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":21271.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8266.01,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":27583.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11241.77,"additional_payer_notes":"APC"}]}]},{"description":"Prq njx biod osteo matrl fem","code_information":[{"code":"0814T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8923.0,"maximum":10765.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":10765.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":8923.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":10765.0}]}]},{"description":"Nsl/sinus ndsc cryoabltj pnn","code_information":[{"code":"31243","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":15691.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Ins trurl ablt trnsdc thr us","code_information":[{"code":"51721","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":9356.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0}]}]},{"description":"Opn exc/dstr ntra-abd 5.1-10","code_information":[{"code":"49187","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Opn exc/dst ntra-abd 10.1-20","code_information":[{"code":"49188","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Rmvl perm ccm-d sys pg only","code_information":[{"code":"0919T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2772.2,"maximum":7133.79,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3696.26,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7133.79,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2772.2,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3770.19,"additional_payer_notes":"APC"}]}]},{"description":"Insj perm ccm-d sys pg&eltrd","code_information":[{"code":"0915T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8923.0,"maximum":59920.75,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":31047.02,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":10765.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":8923.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":10765.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":59920.75,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23285.27,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":31667.96,"additional_payer_notes":"APC"}]}]},{"description":"Vein mech throm w/intrvas us","code_information":[{"code":"C7564","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6019.0,"maximum":7398.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":7398.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6019.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":7398.0}]}]},{"description":"Slctv nzmtc dbrdmt s/n/hf 1","code_information":[{"code":"0975T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":301.57,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":402.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":776.03,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":301.57,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":410.13,"additional_payer_notes":"APC"}]}]},{"description":"Prt crn ch cr&tun elt s-sclp","code_information":[{"code":"0956T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5512.0,"maximum":51798.34,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26838.52,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":51798.34,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20128.89,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27375.29,"additional_payer_notes":"APC"}]}]},{"description":"Dlyd plmt xtn prosth ea addl","code_information":[{"code":"34711","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6019.0,"maximum":7398.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":7398.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6019.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":7398.0}]}]},{"description":"Endoven ther chem adhes 1st","code_information":[{"code":"36482","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4127.91,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5503.89,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":10622.5,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4127.91,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5613.96,"additional_payer_notes":"APC"}]}]},{"description":"Laps tot hyst resj mal","code_information":[{"code":"58575","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0}]}]},{"description":"Tangntl bx skin ea sep/addl","code_information":[{"code":"11103","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Tcat insj/rpl perm ldls pm","code_information":[{"code":"33274","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8923.0,"maximum":44873.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19051.92,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":10765.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":8923.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":10765.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":44873.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":44873.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":44873.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":36770.21,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14288.94,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":43285.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19432.96,"additional_payer_notes":"APC"}]}]},{"description":"Aortic hemiarch graft","code_information":[{"code":"33866","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Dilat xst trc new access rcs","code_information":[{"code":"50437","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2614.94,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3486.59,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6729.12,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2614.94,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3556.32,"additional_payer_notes":"APC"}]}]},{"description":"Fna bx w/mr gdn 1st les","code_information":[{"code":"10011","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":525.32,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":700.42,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1351.81,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":525.32,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":714.43,"additional_payer_notes":"APC"}]}]},{"description":"Rf abltj nrv nrvtg si jt","code_information":[{"code":"64625","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1448.59,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1931.46,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3727.72,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1448.59,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1970.09,"additional_payer_notes":"APC"}]}]},{"description":"As-aort grf f/aortic dsj","code_information":[{"code":"33858","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":9356.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0}]}]},{"description":"Int hrhc tranal dartlzj 2+","code_information":[{"code":"46948","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2059.07,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2745.43,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5298.68,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2059.07,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2800.34,"additional_payer_notes":"APC"}]}]},{"description":"As-aort grf f/ds oth/thn dsj","code_information":[{"code":"33859","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":9356.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0}]}]},{"description":"Ndl insj w/o njx 3+ musc","code_information":[{"code":"20561","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":21.46,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":28.61,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":55.21,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21.46,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":29.18,"additional_payer_notes":"APC"}]}]},{"description":"Cysto w/prst8 commissurotomy","code_information":[{"code":"0619T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0}]}]},{"description":"Elec impd spectrsc 1+skn les","code_information":[{"code":"0658T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":43.76,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":58.35,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":96.28},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":93.27},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":96.28},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":112.62,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":43.76,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":59.52,"additional_payer_notes":"APC"}]}]},{"description":"Excl laa opn oth px any meth","code_information":[{"code":"33268","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8923.0,"maximum":10765.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":10765.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":8923.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":10765.0}]}]},{"description":"Insj rx elut implt lac canal","code_information":[{"code":"68841","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1763.69,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2351.59,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4538.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1763.69,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2398.62,"additional_payer_notes":"APC"}]}]},{"description":"Lam factc/frmt arthrd lum ea","code_information":[{"code":"63053","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Tprnl balo cntnc dev rmvl ea","code_information":[{"code":"53453","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2614.94,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3486.59,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6729.12,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2614.94,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3556.32,"additional_payer_notes":"APC"}]}]},{"description":"Blind cor sinus reducer impl","code_information":[{"code":"C9783","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":27583.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11418.47,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":22037.64,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8563.85,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":27583.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11646.84,"additional_payer_notes":"APC"}]}]},{"description":"Insj bioprostc vlv fem vn","code_information":[{"code":"0744T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4127.91,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5503.89,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":10622.5,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4127.91,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5613.96,"additional_payer_notes":"APC"}]}]},{"description":"Rpr nsl vlv collapse w/rmdlg","code_information":[{"code":"30469","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Rpr aa hrn rcr < 3 ncr/strn","code_information":[{"code":"49614","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4484.77,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5979.69,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5257.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11540.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4484.77,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6099.28,"additional_payer_notes":"APC"}]}]},{"description":"Rpr aa hrn 1st > 10 ncr/strn","code_information":[{"code":"49596","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":17314.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0}]}]},{"description":"Tcat ins 2chmbr ldls pm rv","code_information":[{"code":"0797T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8923.0,"maximum":36770.21,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19051.92,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":10765.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":8923.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":10765.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":36770.21,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14288.94,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":27583.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19432.96,"additional_payer_notes":"APC"}]}]},{"description":"Sprchoroidal spc njx rx agt","code_information":[{"code":"67516","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":245.03,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":326.71,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":630.55,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":245.03,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":333.24,"additional_payer_notes":"APC"}]}]},{"description":"Opn insj/rplcmt ins ptn subq","code_information":[{"code":"0816T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8923.0,"maximum":37034.45,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19188.83,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":10765.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":8923.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":10765.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":37034.45,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14391.63,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":27583.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19572.61,"additional_payer_notes":"APC"}]}]},{"description":"Ins/rplcm prq eltrd ra pn ea","code_information":[{"code":"64597","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2334.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Rmvl pg wcs lv both compnt","code_information":[{"code":"0861T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2772.2,"maximum":8657.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3696.26,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7133.79,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2772.2,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3770.19,"additional_payer_notes":"APC"}]}]},{"description":"Tcat ins 1chmbr ldls pm ra","code_information":[{"code":"0823T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8923.0,"maximum":36770.21,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19051.92,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":10765.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":8923.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":10765.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":36770.21,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14288.94,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":27583.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19432.96,"additional_payer_notes":"APC"}]}]},{"description":"Prq tcat thr rx ntrc bal sep","code_information":[{"code":"0914T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5512.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0}]}]},{"description":"Insj perm ccm-d sys pg only","code_information":[{"code":"0916T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8923.0,"maximum":42462.57,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22001.33,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":10765.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":8923.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":10765.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":42462.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16501.0,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22441.36,"additional_payer_notes":"APC"}]}]},{"description":"Arthrp ntrcrpl/crp/mtcrp ssp","code_information":[{"code":"25448","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":6246.19,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Tcat impl wrls l atr prs snr","code_information":[{"code":"0933T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2404.97,"maximum":6188.79,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3206.62,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6188.79,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2404.97,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3270.76,"additional_payer_notes":"APC"}]}]},{"description":"Thrc fascial pln blk uni nfs","code_information":[{"code":"64467","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5512.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0}]}]},{"description":"Opn exc/dst ntra-abd 20.1-30","code_information":[{"code":"49189","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Cysto insj dev ischmc rmdlg","code_information":[{"code":"53865","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":18071.3,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9363.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":18071.3,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7022.52,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9550.63,"additional_payer_notes":"APC"}]}]},{"description":"Rpl s-sclp eltr ra rcvr&tlmt","code_information":[{"code":"0960T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5512.0,"maximum":51798.34,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26838.52,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":51798.34,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20128.89,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27375.29,"additional_payer_notes":"APC"}]}]},{"description":"I&cust prep jaw xpnsj 1arch","code_information":[{"code":"0964T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2459.51,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3279.35,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6329.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2459.51,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3344.94,"additional_payer_notes":"APC"}]}]},{"description":"Delivery comp imrt","code_information":[{"code":"G6016","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1148.5,"maximum":1189.56,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":1189.56},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1148.5},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":1189.56}]}]},{"description":"Radiation treatment delivery","code_information":[{"code":"G6008","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":667.26,"maximum":691.14,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":691.14},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":667.26},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":691.14}]}]},{"description":"Electromagntic tx for ulcers","code_information":[{"code":"G0329","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7.58,"maximum":33.09,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10.11,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":33.09},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":31.93},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":33.09},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":19.51,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7.58,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10.31,"additional_payer_notes":"APC"}]}]},{"description":"Colon CA screen;barium enema","code_information":[{"code":"G0106","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":540.13,"maximum":559.47,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":559.47},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":540.13},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":559.47}]}]},{"description":"Nuclr rx interstit colloid","code_information":[{"code":"79300","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":173.1,"maximum":445.43,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":230.79,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":181.83},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":175.53},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":181.83},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":445.43,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":173.1,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":235.41,"additional_payer_notes":"APC"}]}]},{"description":"Pet image w/ct full body","code_information":[{"code":"78816","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1060.78,"maximum":2954.05,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1414.38,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":2954.05},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2909.33},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":2954.05},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2729.74,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1060.78,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1442.66,"additional_payer_notes":"APC"}]}]},{"description":"Tumor imaging (3D)","code_information":[{"code":"78803","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":402.79,"maximum":1036.52,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":537.06,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":1034.22},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":998.52},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":1034.22},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1036.52,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":402.79,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":547.8,"additional_payer_notes":"APC"}]}]},{"description":"K flow/funct image multiple","code_information":[{"code":"78709","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":402.79,"maximum":1058.84,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":537.06,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":1058.84},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1022.29},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":1058.84},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1036.52,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":402.79,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":547.8,"additional_payer_notes":"APC"}]}]},{"description":"CSF ventriculography","code_information":[{"code":"78635","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":402.79,"maximum":1104.38,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":537.06,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":1104.38},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1066.23},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":1104.38},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1036.52,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":402.79,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":547.8,"additional_payer_notes":"APC"}]}]},{"description":"Brain image < 4 views","code_information":[{"code":"78600","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":296.56,"maximum":763.16,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":395.42,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":581.84},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":561.74},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":581.84},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":763.16,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":296.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":403.33,"additional_payer_notes":"APC"}]}]},{"description":"Heart image (pet) multiple","code_information":[{"code":"78492","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1060.78,"maximum":2729.74,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1414.38,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":1556.81},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1533.24},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":1556.81},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2729.74,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1060.78,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1442.66,"additional_payer_notes":"APC"}]}]},{"description":"Heart infarct image","code_information":[{"code":"78466","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":296.56,"maximum":763.16,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":395.42,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":567.08},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":547.5},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":567.08},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":763.16,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":296.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":403.33,"additional_payer_notes":"APC"}]}]},{"description":"Ht muscle image spect sing","code_information":[{"code":"78451","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":948.6,"maximum":2471.46,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1280.55,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":982.55},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":948.6},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":982.55},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2471.46,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":960.41,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1306.16,"additional_payer_notes":"APC"}]}]},{"description":"Cardiac shunt imaging","code_information":[{"code":"78428","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":296.56,"maximum":763.16,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":395.42,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":510.46},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":492.82},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":510.46},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":763.16,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":296.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":403.33,"additional_payer_notes":"APC"}]}]},{"description":"Leveen/shunt patency exam","code_information":[{"code":"78291","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":296.56,"maximum":763.16,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":395.42,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":751.66},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":725.71},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":751.66},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":763.16,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":296.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":403.33,"additional_payer_notes":"APC"}]}]},{"description":"Gastric mucosa imaging","code_information":[{"code":"78261","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":296.56,"maximum":767.68,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":395.42,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":767.68},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":741.17},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":767.68},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":763.16,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":296.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":403.33,"additional_payer_notes":"APC"}]}]},{"description":"Liver and spleen imaging","code_information":[{"code":"78215","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":296.56,"maximum":763.16,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":395.42,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":610.14},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":589.06},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":610.14},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":763.16,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":296.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":403.33,"additional_payer_notes":"APC"}]}]},{"description":"Blood volume","code_information":[{"code":"78122","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":263.54,"maximum":1036.52,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":537.06,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":272.94},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":263.54},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":272.94},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1036.52,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":402.79,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":547.8,"additional_payer_notes":"APC"}]}]},{"description":"Adrenal cortex & medulla img","code_information":[{"code":"78075","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":960.41,"maximum":2471.46,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1280.55,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":1404.16},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1355.68},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":1404.16},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2471.46,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":960.41,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1306.16,"additional_payer_notes":"APC"}]}]},{"description":"Thyroid imaging w/blood flow","code_information":[{"code":"78014","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":296.56,"maximum":776.28,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":395.42,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":776.28},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":749.49},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":776.28},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":763.16,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":296.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":403.33,"additional_payer_notes":"APC"}]}]},{"description":"Hdr rdncl ntrstl/icav brchtx","code_information":[{"code":"77770","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":516.67,"maximum":1329.56,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":688.89,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":762.25},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":735.94},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":762.25},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1329.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":516.67,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":702.67,"additional_payer_notes":"APC"}]}]},{"description":"Hyperthermia treatment","code_information":[{"code":"77615","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":409.89,"maximum":3310.96,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":546.52,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3310.96},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3196.6},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3310.96},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1054.79,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":409.89,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":557.46,"additional_payer_notes":"APC"}]}]},{"description":"Special radiation treatment","code_information":[{"code":"77470","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":160.61,"maximum":1054.79,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":546.52,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":166.37},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":160.61},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":166.37},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1054.79,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":409.89,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":557.46,"additional_payer_notes":"APC"}]}]},{"description":"Radiation treatment delivery","code_information":[{"code":"77412","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":409.89,"maximum":1054.79,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":546.52,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":961.89},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":928.67},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":961.89},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1054.79,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":409.89,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":557.46,"additional_payer_notes":"APC"}]}]},{"description":"Srs linear based","code_information":[{"code":"77372","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3586.5,"maximum":14060.2,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7285.08,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3714.78},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3586.5},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3714.78},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":14060.2,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5463.81,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7430.78,"additional_payer_notes":"APC"}]}]},{"description":"Special radiation dosimetry","code_information":[{"code":"77331","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":62.49,"maximum":256.58,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":132.94,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":64.73},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":62.49},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":64.73},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":256.58,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":99.71,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":135.6,"additional_payer_notes":"APC"}]}]},{"description":"Radiation therapy dose plan","code_information":[{"code":"77300","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":99.71,"maximum":256.58,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":132.94,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":118.88},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":114.78},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":118.88},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":256.58,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":99.71,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":135.6,"additional_payer_notes":"APC"}]}]},{"description":"Radiation therapy planning","code_information":[{"code":"77261","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":257.7,"maximum":266.91,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":266.91},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":257.7},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":266.91}]}]},{"description":"Dxa bone density/peripheral","code_information":[{"code":"77081","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":56.56,"maximum":166.13,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":86.08,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":58.57},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":56.56},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":58.57},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":166.13,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":64.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":87.8,"additional_payer_notes":"APC"}]}]},{"description":"X-Rays for Bone Age","code_information":[{"code":"77072","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":44.67,"maximum":199.58,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":103.41,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":46.27},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":44.67},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":46.27},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":199.58,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":77.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":105.48,"additional_payer_notes":"APC"}]}]},{"description":"Mri breast c-+ w/cad uni","code_information":[{"code":"77048","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":980.96,"maximum":1005.96,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":1005.96},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":980.96},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":1005.96}]}]},{"description":"CT Scan for Localization","code_information":[{"code":"77011","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":532.99,"maximum":552.08,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":552.08},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":532.99},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":552.08}]}]},{"description":"Dx intraop thoracic aorta us","code_information":[{"code":"76984","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":85.8,"maximum":92.7,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":92.7},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":85.8},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":92.7}]}]},{"description":"Echo guidance radiotherapy","code_information":[{"code":"76965","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":79.12,"maximum":81.96,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":81.96},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":79.12},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":81.96}]}]},{"description":"Echo guide for artery repair","code_information":[{"code":"76936","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":160.18,"maximum":599.57,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":213.57,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":599.57},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":578.85},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":599.57},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":412.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":160.18,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":217.84,"additional_payer_notes":"APC"}]}]},{"description":"Us transrectal","code_information":[{"code":"76872","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":77.56,"maximum":209.96,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":103.41,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":209.96},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":202.71},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":209.96},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":199.58,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":77.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":105.48,"additional_payer_notes":"APC"}]}]},{"description":"Intmd rpr n-hf/genit2.6-7.5","code_information":[{"code":"12042","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":301.57,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":402.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":776.03,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":301.57,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":410.13,"additional_payer_notes":"APC"}]}]},{"description":"Intmd rpr face/mm 7.6-12.5cm","code_information":[{"code":"12054","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":301.57,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":402.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":776.03,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":301.57,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":410.13,"additional_payer_notes":"APC"}]}]},{"description":"Cmplx rpr s/a/l 2.6-7.5 cm","code_information":[{"code":"13121","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":301.57,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":402.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":776.03,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":301.57,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":410.13,"additional_payer_notes":"APC"}]}]},{"description":"Late closure of wound","code_information":[{"code":"13160","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2628.85,"maximum":6764.9,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3505.13,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6764.9,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2628.85,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3575.23,"additional_payer_notes":"APC"}]}]},{"description":"Tis trnfr e/n/e/l10.1-30sqcm","code_information":[{"code":"14061","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1530.61,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2040.81,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3938.76,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1530.61,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2081.63,"additional_payer_notes":"APC"}]}]},{"description":"Harvest cultured skin graft","code_information":[{"code":"15040","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1530.61,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2040.81,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3938.76,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1530.61,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2081.63,"additional_payer_notes":"APC"}]}]},{"description":"Skn splt a-grft fac/nck/hf/g","code_information":[{"code":"15120","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2628.85,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3505.13,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6764.9,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2628.85,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3575.23,"additional_payer_notes":"APC"}]}]},{"description":"Cult skin graft t/a/l +%","code_information":[{"code":"15152","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Skin full grft face/genit/hf","code_information":[{"code":"15240","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1530.61,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2040.81,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3938.76,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1530.61,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2081.63,"additional_payer_notes":"APC"}]}]},{"description":"Skin sub graft face/nk/hf/g","code_information":[{"code":"15275","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":548.27,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":731.02,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1410.87,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":548.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":745.64,"additional_payer_notes":"APC"}]}]},{"description":"Delay flap trunk","code_information":[{"code":"15600","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2628.85,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3505.13,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6764.9,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2628.85,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3575.23,"additional_payer_notes":"APC"}]}]},{"description":"Muscle-skin graft leg","code_information":[{"code":"15738","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2628.85,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3505.13,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6764.9,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2628.85,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3575.23,"additional_payer_notes":"APC"}]}]},{"description":"Hair trnspl 1-15 punch grfts","code_information":[{"code":"15775","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":301.57,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":402.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":776.03,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":301.57,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":410.13,"additional_payer_notes":"APC"}]}]},{"description":"Abrasion lesions add-on","code_information":[{"code":"15787","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Revision of upper eyelid","code_information":[{"code":"15823","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1530.61,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2040.81,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3938.76,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1530.61,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2081.63,"additional_payer_notes":"APC"}]}]},{"description":"Excise excessive skin leg","code_information":[{"code":"15833","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2154.81,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2873.08,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5545.05,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2154.81,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2930.54,"additional_payer_notes":"APC"}]}]},{"description":"Nerve palsy muscle graft","code_information":[{"code":"15841","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2628.85,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3505.13,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6764.9,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2628.85,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3575.23,"additional_payer_notes":"APC"}]}]},{"description":"Suction lipectomy trunk","code_information":[{"code":"15877","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2628.85,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3505.13,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6764.9,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2628.85,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3575.23,"additional_payer_notes":"APC"}]}]},{"description":"Remove sacrum pressure sore","code_information":[{"code":"15935","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2628.85,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3505.13,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6764.9,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2628.85,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3575.23,"additional_payer_notes":"APC"}]}]},{"description":"Remove thigh pressure sore","code_information":[{"code":"15950","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1225.21,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1633.61,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3152.87,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1225.21,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1666.28,"additional_payer_notes":"APC"}]}]},{"description":"Dress/debrid p-thick burn s","code_information":[{"code":"16020","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":148.84,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":198.45,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":383.01,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":148.84,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":202.42,"additional_payer_notes":"APC"}]}]},{"description":"Destruction of skin lesions","code_information":[{"code":"17106","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":301.57,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":402.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":776.03,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":301.57,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":410.13,"additional_payer_notes":"APC"}]}]},{"description":"Exc face les sbq 2 cm/>","code_information":[{"code":"21012","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1225.21,"maximum":4106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1633.61,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3152.87,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1225.21,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1666.28,"additional_payer_notes":"APC"}]}]},{"description":"Excise max/zygoma b9 tumor","code_information":[{"code":"21030","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":11300.84,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Excise lwr jaw cyst w/repair","code_information":[{"code":"21047","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Prepare face/oral prosthesis","code_information":[{"code":"21077","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Mt bone graft microvasc","code_information":[{"code":"20957","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Sp bone algrft morsel add-on","code_information":[{"code":"20930","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Replantation foot complete","code_information":[{"code":"20838","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6779.0,"maximum":33471.73,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17342.86,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":33471.73,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13007.15,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":27583.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17689.72,"additional_payer_notes":"APC"}]}]},{"description":"Comp ext fixate strut change","code_information":[{"code":"20697","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1192.86,"maximum":4106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1590.48,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3069.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1192.86,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1622.29,"additional_payer_notes":"APC"}]}]},{"description":"Removal of fixation device","code_information":[{"code":"20665","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":331.39,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":441.86,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":852.79,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":331.39,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":450.7,"additional_payer_notes":"APC"}]}]},{"description":"Aspirate/inj ganglion cyst","code_information":[{"code":"20612","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":227.71,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":303.61,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":585.96,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":227.71,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":309.68,"additional_payer_notes":"APC"}]}]},{"description":"Inject trigger points 3/>","code_information":[{"code":"20553","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":227.71,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":303.61,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":585.96,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":227.71,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":309.68,"additional_payer_notes":"APC"}]}]},{"description":"Inject sinus tract for x-ray","code_information":[{"code":"20501","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Needle biopsy muscle","code_information":[{"code":"20206","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1225.21,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1633.61,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3152.87,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1225.21,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1666.28,"additional_payer_notes":"APC"}]}]},{"description":"Breast surgery procedure","code_information":[{"code":"19499","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2904.59,"maximum":13249.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3872.79,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":13249.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":10779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":13249.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7474.49,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2904.59,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3950.25,"additional_payer_notes":"APC"}]}]},{"description":"Plmt xtn prosth evasc rpr","code_information":[{"code":"34709","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6019.0,"maximum":7398.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":7398.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6019.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":7398.0}]}]},{"description":"Njx noncmpnd sclrsnt 1 vein","code_information":[{"code":"36465","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1530.61,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2040.81,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3938.76,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1530.61,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2081.63,"additional_payer_notes":"APC"}]}]},{"description":"Esphg thrsc moblj","code_information":[{"code":"43288","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5257.0,"maximum":6462.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5257.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6462.0}]}]},{"description":"Fna bx w/fluor gdn ea addl","code_information":[{"code":"10008","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Fna bx w/o img gdn ea addl","code_information":[{"code":"10004","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Fna bx w/us gdn ea addl","code_information":[{"code":"10006","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Tcat impl wrls p-art prs snr","code_information":[{"code":"33289","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8923.0,"maximum":54996.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":28370.97,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":10765.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":8923.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":10765.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":54996.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":54996.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":54996.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":54755.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21278.23,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":51942.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":28938.39,"additional_payer_notes":"APC"}]}]},{"description":"Rmvl & rplcmt pg compnt wcs","code_information":[{"code":"0519T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":19952.66,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10338.17,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":19952.66,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7753.63,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10544.93,"additional_payer_notes":"APC"}]}]},{"description":"Pericardiocentesis w/imaging","code_information":[{"code":"33016","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1167.76,"maximum":4106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1557.01,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3005.03,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1167.76,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1588.15,"additional_payer_notes":"APC"}]}]},{"description":"Expl n/flwd surg lxtr art","code_information":[{"code":"35703","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3388.0,"maximum":4106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0}]}]},{"description":"Dstrj nulyt agt gnclr nrv","code_information":[{"code":"64624","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1448.59,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1931.46,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3727.72,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1448.59,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1970.09,"additional_payer_notes":"APC"}]}]},{"description":"Prcrd drg 0-5yr or w/anomly","code_information":[{"code":"33018","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3388.0,"maximum":4106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0}]}]},{"description":"Xcapsl ctrc rmvl w/ecp","code_information":[{"code":"66988","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3066.31,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4088.41,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7890.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3066.31,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4170.17,"additional_payer_notes":"APC"}]}]},{"description":"Revasc lithotrip-stent-ather","code_information":[{"code":"C9767","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8923.0,"maximum":34994.75,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18131.99,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":10765.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":8923.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":10765.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":34994.75,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13599.0,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":27583.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18494.63,"additional_payer_notes":"APC"}]}]},{"description":"Scalp cool 1st meas&calbrj","code_information":[{"code":"0662T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5512.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0}]}]},{"description":"Dise eval slp do brth flx dx","code_information":[{"code":"42975","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1320.39,"maximum":4106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1760.51,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3397.79,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1320.39,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1795.72,"additional_payer_notes":"APC"}]}]},{"description":"R&l hrt cath chd abnl nt cnj","code_information":[{"code":"93597","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2404.97,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3206.62,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6188.79,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2404.97,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3270.76,"additional_payer_notes":"APC"}]}]},{"description":"Rmvl oi implt skl perq esp","code_information":[{"code":"69726","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"R hrt cath chd nml nt cnj","code_information":[{"code":"93593","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2404.97,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3206.62,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6188.79,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2404.97,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3270.76,"additional_payer_notes":"APC"}]}]},{"description":"Abltj b9 thyr ndul perq lasr","code_information":[{"code":"0673T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1225.21,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1633.61,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3152.87,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1225.21,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1666.28,"additional_payer_notes":"APC"}]}]},{"description":"Perq p-art revsc each addl","code_information":[{"code":"33904","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Prq av fstl crt uxtr sep acs","code_information":[{"code":"36837","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8923.0,"maximum":34994.75,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18131.99,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":10765.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":8923.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":10765.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":34994.75,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13599.0,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":27583.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18494.63,"additional_payer_notes":"APC"}]}]},{"description":"Rpr aa hrn rcr > 10 rdc","code_information":[{"code":"49617","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5257.0,"maximum":17314.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5257.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0}]}]},{"description":"Rmvl ninfct mesh hernia rpr","code_information":[{"code":"49623","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Prq tcat thrm ablt nrv p-art","code_information":[{"code":"0793T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8923.0,"maximum":34994.75,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18131.99,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":10765.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":8923.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":10765.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":34994.75,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13599.0,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":27583.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18494.63,"additional_payer_notes":"APC"}]}]},{"description":"Revj/rmvl nea pn w/int nstim","code_information":[{"code":"64598","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2593.52,"maximum":8657.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3458.03,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6674.0,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2593.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3527.19,"additional_payer_notes":"APC"}]}]},{"description":"Insj phrnc nrv stim transvns","code_information":[{"code":"33277","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2334.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Ins/rplcmt prq eltrd ra pn 1","code_information":[{"code":"64596","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":27583.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11021.34,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":21271.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8266.01,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":27583.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11241.77,"additional_payer_notes":"APC"}]}]},{"description":"Transcrv abltj utrn fibrd rf","code_information":[{"code":"58580","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5501.01,"maximum":15691.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7334.68,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":14155.93,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5501.01,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7481.37,"additional_payer_notes":"APC"}]}]},{"description":"Rev/rplcmt sk-mnt crnl nstm","code_information":[{"code":"61891","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8923.0,"maximum":58906.76,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":30521.64,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":10765.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":8923.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":10765.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":58906.76,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22891.23,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":27583.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":31132.07,"additional_payer_notes":"APC"}]}]},{"description":"Intraop ther estim pn ue ea","code_information":[{"code":"0883T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5512.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0}]}]},{"description":"Hrv skn cll ssp agrft ea add","code_information":[{"code":"15012","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5512.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0}]}]},{"description":"Rmvl int nstim sys vagus nrv","code_information":[{"code":"0910T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2593.52,"maximum":6674.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3458.03,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6674.0,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2593.52,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3527.19,"additional_payer_notes":"APC"}]}]},{"description":"Rpr aa hrn < 3 rdc w/ rmvl","code_information":[{"code":"C7565","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Rpos prv ccm-d trnsvns eltrd","code_information":[{"code":"0924T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":465.35,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":620.47,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1197.51,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":465.35,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":632.88,"additional_payer_notes":"APC"}]}]},{"description":"Rplcmt int nstim sys vgs nrv","code_information":[{"code":"0909T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":58906.76,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":30521.64,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":58906.76,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22891.23,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":31132.07,"additional_payer_notes":"APC"}]}]},{"description":"Prepj skn cll ssp agrft 1st","code_information":[{"code":"15013","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2654.0,"maximum":13547.63,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7019.5,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13547.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5264.62,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7159.89,"additional_payer_notes":"APC"}]}]},{"description":"Rev s-sclp eltr ra rcvr&tlmt","code_information":[{"code":"0957T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1192.86,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1590.48,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3069.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1192.86,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1622.29,"additional_payer_notes":"APC"}]}]},{"description":"Ablt mal brst tum pq lsr uni","code_information":[{"code":"0971T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2904.59,"maximum":7474.49,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3872.79,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7474.49,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2904.59,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3950.25,"additional_payer_notes":"APC"}]}]},{"description":"Evasc rpr ilio-iliac rpt","code_information":[{"code":"34708","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6019.0,"maximum":7398.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":7398.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6019.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":7398.0}]}]},{"description":"Opn ax/subcla art expos cndt","code_information":[{"code":"34716","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Esphg dstl 2/3 w/laps moblj","code_information":[{"code":"43287","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5257.0,"maximum":6462.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5257.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6462.0}]}]},{"description":"Remove w insert drug implant","code_information":[{"code":"G0518","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":331.39,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":441.86,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":852.79,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":331.39,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":450.7,"additional_payer_notes":"APC"}]}]},{"description":"Rplc gtube  revj gstrst trc","code_information":[{"code":"43763","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":185.35,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":247.13,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":476.96,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":185.35,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":252.07,"additional_payer_notes":"APC"}]}]},{"description":"Incal bx skn ea sep/addl","code_information":[{"code":"11107","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Njx cntrst kne arthg/ct/mri","code_information":[{"code":"27369","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Microwave bronch, 3d, ebus","code_information":[{"code":"C9751","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0}]}]},{"description":"Rmvl deep rx delivery device","code_information":[{"code":"20701","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Rmvl imed rx delivery device","code_information":[{"code":"20703","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Ther spi pnxr csf fluor/ct","code_information":[{"code":"62329","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":523.65,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":698.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1347.51,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":523.65,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":712.16,"additional_payer_notes":"APC"}]}]},{"description":"Njx aa&/strd gnclr nrv brnch","code_information":[{"code":"64454","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":523.65,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":698.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1347.51,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":523.65,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":712.16,"additional_payer_notes":"APC"}]}]},{"description":"Spine/lumbar disk surgery","code_information":[{"code":"C9757","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":24508.8,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12698.86,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":24508.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9524.15,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12952.84,"additional_payer_notes":"APC"}]}]},{"description":"Revasc intra lithotrip-stent","code_information":[{"code":"C9765","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":34994.75,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18131.99,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":34994.75,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13599.0,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":27583.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18494.63,"additional_payer_notes":"APC"}]}]},{"description":"Egd flx transnasal bx 1/ml","code_information":[{"code":"0653T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1423.51,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1898.01,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3663.16,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1423.51,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1935.97,"additional_payer_notes":"APC"}]}]},{"description":"Opn mpltj hpglsl nstm ary pg","code_information":[{"code":"64582","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8923.0,"maximum":58906.76,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":30521.64,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":10765.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":8923.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":10765.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":44873.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":44873.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":44873.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":58906.76,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22891.23,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":43285.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":31132.07,"additional_payer_notes":"APC"}]}]},{"description":"Rmvl hpglsl nstim ary pg","code_information":[{"code":"64584","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2534.21,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3378.94,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6521.36,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2534.21,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3446.52,"additional_payer_notes":"APC"}]}]},{"description":"Trml dstrj ios bvn ea addl","code_information":[{"code":"64629","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Xcpsl ctrc rmvl cplx insj 1+","code_information":[{"code":"66989","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3947.51,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5263.35,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":10158.27,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3947.51,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5368.62,"additional_payer_notes":"APC"}]}]},{"description":"Tprnl balo cntnc dev uni","code_information":[{"code":"53452","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":18071.3,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9363.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":18071.3,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7022.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9550.63,"additional_payer_notes":"APC"}]}]},{"description":"Perq p-art revsc 1 abnor bi","code_information":[{"code":"33903","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":27583.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11418.47,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":22037.64,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8563.85,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":27583.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11646.84,"additional_payer_notes":"APC"}]}]},{"description":"Removal sutr&stapl xreq anes","code_information":[{"code":"15854","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Perq p-art revsc 1 abnor uni","code_information":[{"code":"33902","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8923.0,"maximum":34994.75,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18131.99,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":10765.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":8923.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":10765.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":34994.75,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13599.0,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":27583.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18494.63,"additional_payer_notes":"APC"}]}]},{"description":"Rpr aa hrn 1st < 3 cm rdc","code_information":[{"code":"49591","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2656.06,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3541.41,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6834.92,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2656.06,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3612.24,"additional_payer_notes":"APC"}]}]},{"description":"Endo outlet restrict w/tube","code_information":[{"code":"C9785","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":20292.15,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10514.07,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":20292.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7885.55,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10724.35,"additional_payer_notes":"APC"}]}]},{"description":"Ant thrc vrt body tethrg <7","code_information":[{"code":"22836","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6779.0,"maximum":33471.73,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17342.86,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":33471.73,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13007.15,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17689.72,"additional_payer_notes":"APC"}]}]},{"description":"Rmv&rplcmt phrnc nrv stim pg","code_information":[{"code":"33287","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8923.0,"maximum":58906.76,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":30521.64,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":10765.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":8923.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":10765.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":58906.76,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22891.23,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":43285.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":31132.07,"additional_payer_notes":"APC"}]}]},{"description":"Nsl/sinus ndsc rf abltj pnn","code_information":[{"code":"31242","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":15691.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Opn insj/rplcmt ins ptn subf","code_information":[{"code":"0817T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8923.0,"maximum":37034.45,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19188.83,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":10765.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":8923.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":10765.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":37034.45,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14391.63,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":27583.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19572.61,"additional_payer_notes":"APC"}]}]},{"description":"Rmvl phrnc nrv stim sys","code_information":[{"code":"33278","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2593.52,"maximum":8657.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3458.03,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6674.0,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2593.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3527.19,"additional_payer_notes":"APC"}]}]},{"description":"Vasc emb/occ w/prs cath","code_information":[{"code":"C9797","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5512.0,"maximum":34994.75,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18131.99,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":34994.75,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13599.0,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18494.63,"additional_payer_notes":"APC"}]}]},{"description":"Rlcj skin pocket ccm-d pg","code_information":[{"code":"0925T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1530.61,"maximum":4106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2040.81,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3938.76,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1530.61,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2081.63,"additional_payer_notes":"APC"}]}]},{"description":"Rmvl perm ccm-d sys 1 pac ld","code_information":[{"code":"0920T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2772.2,"maximum":7133.79,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3696.26,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7133.79,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2772.2,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3770.19,"additional_payer_notes":"APC"}]}]},{"description":"Thrc fascial pln blk bi njx","code_information":[{"code":"64468","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5512.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0}]}]},{"description":"Cysto flx rmv&rplc urtl scaf","code_information":[{"code":"0942T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7022.52,"maximum":18071.3,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9363.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":10765.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":8923.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":10765.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":18071.3,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7022.52,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9550.63,"additional_payer_notes":"APC"}]}]},{"description":"Hrv skn cll ssp agrft 1st 25","code_information":[{"code":"15011","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1530.61,"maximum":4106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2040.81,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3938.76,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1530.61,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2081.63,"additional_payer_notes":"APC"}]}]},{"description":"Cysto w/rnl pel symp dnrvtj","code_information":[{"code":"0935T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2654.0,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0}]}]},{"description":"Tcat impl wrls ivc snr","code_information":[{"code":"0981T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5512.0,"maximum":34994.75,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18131.99,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":34994.75,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13599.0,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18494.63,"additional_payer_notes":"APC"}]}]},{"description":"Rmv s-sclp eltr ra rcvr&tlmt","code_information":[{"code":"0958T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Evac rpr a-biiliac ndgft","code_information":[{"code":"34705","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":9356.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0}]}]},{"description":"Perq access & clsr fem art","code_information":[{"code":"34713","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Dx bone marrow bx & aspir","code_information":[{"code":"38222","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2154.81,"maximum":5545.05,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2873.08,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5545.05,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2154.81,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2930.54,"additional_payer_notes":"APC"}]}]},{"description":"Nrv rpr w/nrv algrft ea addl","code_information":[{"code":"64913","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Osteoart algrft w/surf & b1","code_information":[{"code":"20932","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Incal bx skn single les","code_information":[{"code":"11106","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":548.27,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":731.02,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1410.87,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":548.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":745.64,"additional_payer_notes":"APC"}]}]},{"description":"Fna bx w/us gdn 1st les","code_information":[{"code":"10005","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":525.32,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":700.42,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1351.81,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":525.32,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":714.43,"additional_payer_notes":"APC"}]}]},{"description":"Tangntl bx skin single les","code_information":[{"code":"11102","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":301.57,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":402.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":776.03,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":301.57,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":410.13,"additional_payer_notes":"APC"}]}]},{"description":"Fna bx w/mr gdn ea addl","code_information":[{"code":"10012","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Mnl prep&insj dp rx dlvr dev","code_information":[{"code":"20700","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Grfg autol fat lipo 25 cc/<","code_information":[{"code":"15773","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1530.61,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2040.81,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3938.76,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1530.61,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2081.63,"additional_payer_notes":"APC"}]}]},{"description":"Prpertl pel pack hemrrg trma","code_information":[{"code":"49013","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Exc ch wal tum w/o lymphadec","code_information":[{"code":"21602","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":7398.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6019.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":7398.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Revasc intra lithotrip-ather","code_information":[{"code":"C9766","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":34994.75,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18131.99,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":34994.75,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13599.0,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":27583.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18494.63,"additional_payer_notes":"APC"}]}]},{"description":"Revasc intravasc lithotripsy","code_information":[{"code":"C9764","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6019.0,"maximum":22037.64,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11418.47,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":7398.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6019.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":7398.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":22037.64,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8563.85,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11646.84,"additional_payer_notes":"APC"}]}]},{"description":"L hrt cath chd nm/abn nt cnj","code_information":[{"code":"93595","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2404.97,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3206.62,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6188.79,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2404.97,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3270.76,"additional_payer_notes":"APC"}]}]},{"description":"Ndsc hrv uxtr art 1 sgm cab","code_information":[{"code":"33509","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Evasc st rpr thrc/aa acrs br","code_information":[{"code":"33894","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":9356.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0}]}]},{"description":"Lam facetc/frmt arthrd lum 1","code_information":[{"code":"63052","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Tprnl balo cntnc dev adjmt","code_information":[{"code":"53454","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":185.35,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":247.13,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":476.96,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":185.35,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":252.07,"additional_payer_notes":"APC"}]}]},{"description":"Arthro/shoul surg; w/spacer","code_information":[{"code":"C9781","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6779.0,"maximum":24508.8,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12698.86,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":24508.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9524.15,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12952.84,"additional_payer_notes":"APC"}]}]},{"description":"Removal sutr/stapl xreq anes","code_information":[{"code":"15853","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Rpr aa hrn 1st 3-10 ncr/strn","code_information":[{"code":"49594","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4484.77,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5979.69,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5257.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11540.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4484.77,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6099.28,"additional_payer_notes":"APC"}]}]},{"description":"Rpr aa hrn rcr 3-10 ncr/strn","code_information":[{"code":"49616","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5257.0,"maximum":17314.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5257.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0}]}]},{"description":"Prq av fstl crtj uxtr 1 acs","code_information":[{"code":"36836","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8923.0,"maximum":34994.75,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18131.99,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":10765.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":8923.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":10765.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":34994.75,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13599.0,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":27583.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18494.63,"additional_payer_notes":"APC"}]}]},{"description":"Instill pharm renal pelvis","code_information":[{"code":"C9789","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":907.99,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1210.66,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2336.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":907.99,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1234.87,"additional_payer_notes":"APC"}]}]},{"description":"Rev rplc/rmv thrc vrt tethrg","code_information":[{"code":"22838","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6779.0,"maximum":33471.73,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17342.86,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":33471.73,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13007.15,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17689.72,"additional_payer_notes":"APC"}]}]},{"description":"Ant thrc vrt body tethrg 8+","code_information":[{"code":"22837","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6779.0,"maximum":33471.73,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17342.86,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":33471.73,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13007.15,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17689.72,"additional_payer_notes":"APC"}]}]},{"description":"Reposg phrnc nrv stim trnsvn","code_information":[{"code":"33281","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2593.52,"maximum":8657.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3458.03,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6674.0,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2593.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3527.19,"additional_payer_notes":"APC"}]}]},{"description":"Arthrd si jt prq wo tfxj dev","code_information":[{"code":"27278","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8923.0,"maximum":33471.73,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17342.86,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":10765.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":8923.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":10765.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":33471.73,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13007.15,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":27583.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17689.72,"additional_payer_notes":"APC"}]}]},{"description":"Revj/rmvl nea spi w/nstim","code_information":[{"code":"0785T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2593.52,"maximum":8657.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3458.03,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6674.0,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2593.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3527.19,"additional_payer_notes":"APC"}]}]},{"description":"Rmvl&rplcmt perm ccm-d pg","code_information":[{"code":"0923T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8923.0,"maximum":42462.57,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22001.33,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":10765.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":8923.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":10765.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":42462.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16501.0,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22441.36,"additional_payer_notes":"APC"}]}]},{"description":"Opn imp int nstm sys vgs nrv","code_information":[{"code":"0908T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8923.0,"maximum":58906.76,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":30521.64,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":10765.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":8923.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":10765.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":58906.76,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22891.23,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":31132.07,"additional_payer_notes":"APC"}]}]},{"description":"Cysto flx rmvl urtl scaffold","code_information":[{"code":"0943T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1550.71,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2067.62,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3990.5,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1550.71,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2108.97,"additional_payer_notes":"APC"}]}]},{"description":"Insj perm ccm-d sys 1 lead","code_information":[{"code":"0917T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6138.95,"maximum":15797.56,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8185.27,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":15797.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6138.95,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8348.97,"additional_payer_notes":"APC"}]}]},{"description":"Imp extar knee shck absrb","code_information":[{"code":"C8003","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":33471.73,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17342.86,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":33471.73,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13007.15,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17689.72,"additional_payer_notes":"APC"}]}]},{"description":"Mrgfus strtctc ablt trgt icr","code_information":[{"code":"61715","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":21271.19,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11021.34,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":21271.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8266.01,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11241.77,"additional_payer_notes":"APC"}]}]},{"description":"Slctv nzmtc dbrdmt t/a/l 1st","code_information":[{"code":"0973T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":301.57,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":402.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":776.03,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":301.57,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":410.13,"additional_payer_notes":"APC"}]}]},{"description":"I&cst prp jw xpn dl arch fxd","code_information":[{"code":"0966T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2459.51,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3279.35,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6329.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2459.51,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3344.94,"additional_payer_notes":"APC"}]}]},{"description":"Cardiokymography","code_information":[{"code":"Q0035","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":27.71,"maximum":71.3,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":36.94,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":41.33},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":39.93},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":41.33},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":71.3,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27.71,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":37.68,"additional_payer_notes":"APC"}]}]},{"description":"Radiation treatment delivery","code_information":[{"code":"G6009","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":661.33,"maximum":684.99,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":684.99},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":661.33},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":684.99}]}]},{"description":"Echo guidance radiotherapy","code_information":[{"code":"G6001","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":73.17,"maximum":75.8,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":75.8},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":73.17},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":75.8}]}]},{"description":"Colon ca scrn; barium enema","code_information":[{"code":"G0120","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":540.13,"maximum":559.47,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":559.47},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":540.13},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":559.47}]}]},{"description":"Hematopoietic nuclear tx","code_information":[{"code":"79403","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":173.1,"maximum":445.43,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":230.79,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":284.02},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":274.21},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":284.02},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":445.43,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":173.1,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":235.41,"additional_payer_notes":"APC"}]}]},{"description":"Rp loclzj tum spect w/ct 1","code_information":[{"code":"78830","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":960.41,"maximum":2471.46,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1280.55,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":1449.23},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1399.2},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":1449.23},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2471.46,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":960.41,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1306.16,"additional_payer_notes":"APC"}]}]},{"description":"Tumor imaging whole body","code_information":[{"code":"78804","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":402.79,"maximum":1843.74,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":537.06,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":1843.74},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1780.08},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":1843.74},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1036.52,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":402.79,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":547.8,"additional_payer_notes":"APC"}]}]},{"description":"Kidney function study","code_information":[{"code":"78725","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":296.56,"maximum":763.16,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":395.42,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":319.7},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":308.65},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":319.7},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":763.16,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":296.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":403.33,"additional_payer_notes":"APC"}]}]},{"description":"CSF shunt evaluation","code_information":[{"code":"78645","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":402.79,"maximum":1056.38,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":537.06,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":1056.38},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1019.92},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":1056.38},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1036.52,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":402.79,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":547.8,"additional_payer_notes":"APC"}]}]},{"description":"Brain image w/flow < 4 views","code_information":[{"code":"78601","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":296.56,"maximum":763.16,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":395.42,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":676.61},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":653.22},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":676.61},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":763.16,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":296.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":403.33,"additional_payer_notes":"APC"}]}]},{"description":"Heart image spect","code_information":[{"code":"78494","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":296.56,"maximum":763.16,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":395.42,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":597.85},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":577.19},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":597.85},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":763.16,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":296.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":403.33,"additional_payer_notes":"APC"}]}]},{"description":"Heart infarct image (ef)","code_information":[{"code":"78468","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":402.79,"maximum":1036.52,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":537.06,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":568.3},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":548.68},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":568.3},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1036.52,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":402.79,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":547.8,"additional_payer_notes":"APC"}]}]},{"description":"Ht muscle image spect mult","code_information":[{"code":"78452","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":960.41,"maximum":2471.46,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1280.55,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":1412.27},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1363.51},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":1412.27},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2471.46,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":960.41,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1306.16,"additional_payer_notes":"APC"}]}]},{"description":"Myocrd img pet 1 std w/ct","code_information":[{"code":"78429","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1060.78,"maximum":2729.74,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1414.38,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":1393.53},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1372.43},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":1393.53},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2729.74,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1060.78,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1442.66,"additional_payer_notes":"APC"}]}]},{"description":"Bone imaging limited area","code_information":[{"code":"78300","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":296.56,"maximum":763.16,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":395.42,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":536.3},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":517.78},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":536.3},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":763.16,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":296.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":403.33,"additional_payer_notes":"APC"}]}]},{"description":"Gastroesophageal reflux exam","code_information":[{"code":"78262","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":296.56,"maximum":763.16,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":395.42,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":756.59},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":730.45},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":756.59},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":763.16,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":296.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":403.33,"additional_payer_notes":"APC"}]}]},{"description":"Liver & spleen image/flow","code_information":[{"code":"78216","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":296.56,"maximum":763.16,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":395.42,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":350.48},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":338.37},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":350.48},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":763.16,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":296.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":403.33,"additional_payer_notes":"APC"}]}]},{"description":"Red cell survival study","code_information":[{"code":"78130","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":296.56,"maximum":763.16,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":395.42,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":493.95},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":476.9},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":493.95},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":763.16,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":296.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":403.33,"additional_payer_notes":"APC"}]}]},{"description":"Bone marrow imaging ltd","code_information":[{"code":"78102","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":296.56,"maximum":763.16,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":395.42,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":511.68},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":494.01},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":511.68},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":763.16,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":296.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":403.33,"additional_payer_notes":"APC"}]}]},{"description":"Thyroid met imaging","code_information":[{"code":"78015","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":296.56,"maximum":763.16,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":395.42,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":671.67},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":648.48},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":671.67},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":763.16,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":296.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":403.33,"additional_payer_notes":"APC"}]}]},{"description":"Hdr rdncl ntrstl/icav brchtx","code_information":[{"code":"77771","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":516.67,"maximum":1388.39,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":688.89,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":1388.39},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1340.45},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":1388.39},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1329.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":516.67,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":702.67,"additional_payer_notes":"APC"}]}]},{"description":"Hyperthermia treatment","code_information":[{"code":"77620","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":409.89,"maximum":1054.79,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":546.52,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":1048.99},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1012.77},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":1048.99},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1054.79,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":409.89,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":557.46,"additional_payer_notes":"APC"}]}]},{"description":"Proton trmt simple w/o comp","code_information":[{"code":"77520","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":409.89,"maximum":3187.07,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":546.52,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3187.07},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3138.81},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3187.07},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1054.79,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":409.89,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":557.46,"additional_payer_notes":"APC"}]}]},{"description":"Radiology port images(s)","code_information":[{"code":"77417","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":36.35,"maximum":37.65,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":37.65},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":36.35},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":37.65}]}]},{"description":"SBRT Delivery","code_information":[{"code":"77373","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1326.43,"maximum":4720.72,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1768.58,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4720.72},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4557.69},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4720.72},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3413.36,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1326.43,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1803.95,"additional_payer_notes":"APC"}]}]},{"description":"Radiation treatment aid(s)","code_information":[{"code":"77332","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":99.71,"maximum":256.58,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":132.94,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":190.24},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":183.68},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":190.24},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":256.58,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":99.71,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":135.6,"additional_payer_notes":"APC"}]}]},{"description":"Radiotherapy dose plan imrt","code_information":[{"code":"77301","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1026.79,"maximum":5333.55,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1369.06,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5333.55},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5149.37},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5333.55},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2642.28,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1026.79,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1396.44,"additional_payer_notes":"APC"}]}]},{"description":"Radiation therapy planning","code_information":[{"code":"77262","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":384.77,"maximum":398.53,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":398.53},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":384.77},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":398.53}]}]},{"description":"Magnetic image bone marrow","code_information":[{"code":"77084","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":177.0,"maximum":1066.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":236.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":1066.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1029.18},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":1066.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":455.49,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":177.0,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":240.72,"additional_payer_notes":"APC"}]}]},{"description":"X-rays bone length studies","code_information":[{"code":"77073","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":72.0,"maximum":199.58,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":103.41,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":74.57},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":72.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":74.57},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":199.58,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":77.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":105.48,"additional_payer_notes":"APC"}]}]},{"description":"Mri breast c-+ w/cad bi","code_information":[{"code":"77049","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":976.14,"maximum":1001.04,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":1001.04},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":976.14},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":1001.04}]}]},{"description":"Ct scan for needle biopsy","code_information":[{"code":"77012","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":221.7,"maximum":229.65,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":229.65},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":221.7},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":229.65}]}]},{"description":"Dx intraop epicar car us chd","code_information":[{"code":"76987","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":267.25,"maximum":288.74,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":288.74},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":267.25},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":288.74}]}]},{"description":"GI endoscopic ultrasound","code_information":[{"code":"76975","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":177.0,"maximum":455.49,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":236.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":204.07},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":200.98},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":204.07},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":455.49,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":177.0,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":240.72,"additional_payer_notes":"APC"}]}]},{"description":"Us guide vascular access","code_information":[{"code":"76937","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":57.02,"maximum":59.07,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":59.07},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":57.02},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":59.07}]}]},{"description":"Echograp trans r pros study","code_information":[{"code":"76873","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":77.56,"maximum":310.86,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":103.41,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":310.86},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":300.12},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":310.86},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":199.58,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":77.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":105.48,"additional_payer_notes":"APC"}]}]},{"description":"Echo exam of fetal heart","code_information":[{"code":"76827","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":77.56,"maximum":199.58,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":103.41,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":163.16},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":157.54},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":163.16},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":199.58,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":77.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":105.48,"additional_payer_notes":"APC"}]}]},{"description":"Ob us follow-up per fetus","code_information":[{"code":"76816","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":77.56,"maximum":248.09,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":103.41,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":248.09},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":239.53},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":248.09},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":199.58,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":77.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":105.48,"additional_payer_notes":"APC"}]}]},{"description":"Ob us < 14 wks addl fetus","code_information":[{"code":"76802","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":74.86,"maximum":77.54,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":77.54},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":74.86},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":77.54}]}]},{"description":"Ultrasound breast limited","code_information":[{"code":"76642","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":64.56,"maximum":187.79,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":86.08,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":187.79},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":181.31},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":187.79},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":166.13,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":64.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":87.8,"additional_payer_notes":"APC"}]}]},{"description":"Echo exam of eye water bath","code_information":[{"code":"76513","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":77.56,"maximum":205.03,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":103.41,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":205.03},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":197.94},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":205.03},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":199.58,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":77.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":105.48,"additional_payer_notes":"APC"}]}]},{"description":"Mr elastography","code_information":[{"code":"76391","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":177.0,"maximum":625.67,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":236.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":625.67},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":610.14},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":625.67},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":455.49,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":177.0,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":240.72,"additional_payer_notes":"APC"}]}]},{"description":"X-ray exam of body section","code_information":[{"code":"76100","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":77.56,"maximum":208.71,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":103.41,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":208.71},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":201.51},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":208.71},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":199.58,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":77.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":105.48,"additional_payer_notes":"APC"}]}]},{"description":"Mr sfty implt&/fb asmt stf 1","code_information":[{"code":"76014","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":21.46,"maximum":55.21,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":28.61,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":33.27},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":30.5},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":33.27},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":55.21,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21.46,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":29.18,"additional_payer_notes":"APC"}]}]},{"description":"Xray endovasc thor ao repr","code_information":[{"code":"75957","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1000.51,"maximum":1036.3,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":1036.3},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1000.51},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":1036.3}]}]},{"description":"Vein x-ray liver w/hemodynam","code_information":[{"code":"75889","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":295.36,"maximum":6027.57,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3123.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":305.93},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":295.36},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":305.93},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6027.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2342.32,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3185.56,"additional_payer_notes":"APC"}]}]},{"description":"Vein x-ray adrenal gland","code_information":[{"code":"75840","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":303.67,"maximum":6027.57,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3123.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":314.56},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":303.67},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":314.56},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6027.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2342.32,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3185.56,"additional_payer_notes":"APC"}]}]},{"description":"Nonvascular shunt x-ray","code_information":[{"code":"75809","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":77.56,"maximum":260.38,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":103.41,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":260.38},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":251.4},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":260.38},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":199.58,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":77.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":105.48,"additional_payer_notes":"APC"}]}]},{"description":"Artery x-rays lungs","code_information":[{"code":"75743","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":294.18,"maximum":6027.57,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3123.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":304.72},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":294.18},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":304.72},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6027.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2342.32,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3185.56,"additional_payer_notes":"APC"}]}]},{"description":"Artery x-rays spine","code_information":[{"code":"75705","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":430.34,"maximum":10622.5,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5503.89,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":445.72},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":430.34},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":445.72},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":10622.5,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4127.91,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5613.96,"additional_payer_notes":"APC"}]}]},{"description":"Ct hrt w/3d image congen","code_information":[{"code":"75573","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":258.81,"maximum":907.24,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":345.07,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":907.24},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":875.92},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":907.24},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":665.99,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":258.81,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":351.98,"additional_payer_notes":"APC"}]}]},{"description":"X-ray exam of perineum","code_information":[{"code":"74775","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":177.0,"maximum":455.49,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":236.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":186.35},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":183.53},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":186.35},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":455.49,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":177.0,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":240.72,"additional_payer_notes":"APC"}]}]},{"description":"X-ray urethra/bladder","code_information":[{"code":"74450","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":177.0,"maximum":455.49,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":236.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":183.88},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":181.08},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":183.88},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":455.49,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":177.0,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":240.72,"additional_payer_notes":"APC"}]}]},{"description":"Contrst x-ray urinary tract","code_information":[{"code":"74400","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":130.12,"maximum":334.84,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":173.49,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":291.17},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":281.12},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":291.17},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":334.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":130.12,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":176.96,"additional_payer_notes":"APC"}]}]},{"description":"X-rays at surgery add-on","code_information":[{"code":"74301","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":65.08,"maximum":67.41,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":67.41},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":65.08},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":67.41}]}]},{"description":"Ct colonography dx","code_information":[{"code":"74261","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":77.56,"maximum":1254.29,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":103.41,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":1254.29},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1210.99},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":1254.29},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":199.58,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":77.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":105.48,"additional_payer_notes":"APC"}]}]},{"description":"X-ray xm esophagus 2cntrst","code_information":[{"code":"74221","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":130.12,"maximum":334.84,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":173.49,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":249.26},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":240.66},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":249.26},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":334.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":130.12,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":176.96,"additional_payer_notes":"APC"}]}]},{"description":"Ct abd & pelv 1/> regns","code_information":[{"code":"74178","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":258.81,"maximum":865.41,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":345.07,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":865.41},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":835.53},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":865.41},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":665.99,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":258.81,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":351.98,"additional_payer_notes":"APC"}]}]},{"description":"X-ray exam series abdomen","code_information":[{"code":"74022","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":77.56,"maximum":199.58,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":103.41,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":96.72},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":93.39},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":96.72},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":199.58,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":77.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":105.48,"additional_payer_notes":"APC"}]}]},{"description":"Mri lwr extremity w/o&w/dye","code_information":[{"code":"73720","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":258.81,"maximum":1357.67,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":345.07,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":1357.67},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1310.78},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":1357.67},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":665.99,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":258.81,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":351.98,"additional_payer_notes":"APC"}]}]},{"description":"X-ray exam of heel","code_information":[{"code":"73650","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":62.49,"maximum":166.13,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":86.08,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":64.73},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":62.49},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":64.73},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":166.13,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":64.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":87.8,"additional_payer_notes":"APC"}]}]},{"description":"Contrast x-ray of knee joint","code_information":[{"code":"73580","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":258.81,"maximum":665.99,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":345.07,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":298.56},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":288.24},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":298.56},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":665.99,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":258.81,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":351.98,"additional_payer_notes":"APC"}]}]},{"description":"X-ray exam hips bi 5/> views","code_information":[{"code":"73523","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":77.56,"maximum":199.58,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":103.41,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":138.57},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":133.79},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":138.57},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":199.58,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":77.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":105.48,"additional_payer_notes":"APC"}]}]},{"description":"Mri joint upr extrem w/dye","code_information":[{"code":"73222","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":581.54,"maximum":1496.49,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":775.38,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":1019.24},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":984.03},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":1019.24},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1496.49,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":581.54,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":790.89,"additional_payer_notes":"APC"}]}]},{"description":"Ct upper extremity w/o dye","code_information":[{"code":"73200","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":77.56,"maximum":441.31,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":103.41,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":441.31},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":426.08},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":441.31},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":199.58,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":77.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":105.48,"additional_payer_notes":"APC"}]}]},{"description":"X-ray exam of forearm","code_information":[{"code":"73090","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":56.56,"maximum":166.13,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":86.08,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":58.57},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":56.56},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":58.57},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":166.13,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":64.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":87.8,"additional_payer_notes":"APC"}]}]},{"description":"X-ray exam of shoulder","code_information":[{"code":"73020","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":49.43,"maximum":166.13,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":86.08,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":51.18},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":49.43},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":51.18},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":166.13,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":64.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":87.8,"additional_payer_notes":"APC"}]}]},{"description":"Myelography neck spine","code_information":[{"code":"72240","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":171.8,"maximum":1496.49,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":775.38,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":177.94},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":171.8},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":177.94},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1496.49,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":581.54,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":790.89,"additional_payer_notes":"APC"}]}]},{"description":"Ct pelvis w/o & w/dye","code_information":[{"code":"72194","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":130.12,"maximum":684.99,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":173.49,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":684.99},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":661.33},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":684.99},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":334.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":130.12,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":176.96,"additional_payer_notes":"APC"}]}]},{"description":"Mri chest spine w/o & w/dye","code_information":[{"code":"72157","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":258.81,"maximum":908.46,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":345.07,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":908.46},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":877.1},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":908.46},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":665.99,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":258.81,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":351.98,"additional_payer_notes":"APC"}]}]},{"description":"Ct lumbar spine w/o & w/dye","code_information":[{"code":"72133","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":130.12,"maximum":710.82,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":173.49,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":710.82},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":686.28},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":710.82},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":334.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":130.12,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":176.96,"additional_payer_notes":"APC"}]}]},{"description":"Ct neck spine w/o dye","code_information":[{"code":"72125","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":77.56,"maximum":448.69,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":103.41,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":448.69},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":433.21},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":448.69},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":199.58,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":77.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":105.48,"additional_payer_notes":"APC"}]}]},{"description":"X-ray exam entire spi 1 vw","code_information":[{"code":"72081","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":64.56,"maximum":166.13,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":86.08,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":86.87},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":83.87},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":86.87},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":166.13,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":64.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":87.8,"additional_payer_notes":"APC"}]}]},{"description":"X-ray exam of spine 1 view","code_information":[{"code":"72020","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":47.04,"maximum":166.13,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":86.08,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":48.73},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":47.04},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":48.73},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":166.13,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":64.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":87.8,"additional_payer_notes":"APC"}]}]},{"description":"Ct thorax w/dye","code_information":[{"code":"71260","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":130.12,"maximum":573.01,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":173.49,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":573.01},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":553.21},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":573.01},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":334.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":130.12,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":176.96,"additional_payer_notes":"APC"}]}]},{"description":"X-ray exam chest 4+ views","code_information":[{"code":"71048","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":77.56,"maximum":199.58,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":103.41,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":87.99},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":84.99},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":87.99},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":199.58,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":77.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":105.48,"additional_payer_notes":"APC"}]}]},{"description":"Fmri brain by tech","code_information":[{"code":"70554","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":177.0,"maximum":1183.63,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":236.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":1183.63},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1142.78},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":1183.63},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":455.49,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":177.0,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":240.72,"additional_payer_notes":"APC"}]}]},{"description":"Mr Angiography Head W/Dye","code_information":[{"code":"70545","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":258.81,"maximum":1125.06,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":345.07,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":1125.06},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1086.22},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":1125.06},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":665.99,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":258.81,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":351.98,"additional_payer_notes":"APC"}]}]},{"description":"Ct soft tissue neck w/dye","code_information":[{"code":"70491","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":130.12,"maximum":570.54,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":173.49,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":570.54},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":550.84},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":570.54},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":334.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":130.12,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":176.96,"additional_payer_notes":"APC"}]}]},{"description":"Ct head/brain w/o & w/dye","code_information":[{"code":"70470","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":130.12,"maximum":437.62,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":173.49,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":437.62},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":422.52},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":437.62},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":334.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":130.12,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":176.96,"additional_payer_notes":"APC"}]}]},{"description":"Panoramic x-ray of jaws","code_information":[{"code":"70355","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":30.4,"maximum":166.13,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":86.08,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":31.5},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":30.4},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":31.5},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":166.13,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":64.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":87.8,"additional_payer_notes":"APC"}]}]},{"description":"X-ray exam of teeth","code_information":[{"code":"70300","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":29.21,"maximum":166.13,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":86.08,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":30.25},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":29.21},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":30.25},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":166.13,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":64.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":87.8,"additional_payer_notes":"APC"}]}]},{"description":"X-ray exam of tear duct","code_information":[{"code":"70170","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":121.41,"maximum":455.49,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":236.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":123.27},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":121.41},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":123.27},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":455.49,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":177.0,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":240.72,"additional_payer_notes":"APC"}]}]},{"description":"X-ray exam of jaw <4views","code_information":[{"code":"70100","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":64.56,"maximum":166.13,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":86.08,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":80.72},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":77.94},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":80.72},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":166.13,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":64.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":87.8,"additional_payer_notes":"APC"}]}]},{"description":"Pulm tiss vntj alys prev ct","code_information":[{"code":"0807T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":111.71,"maximum":412.19,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":213.57,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":121.86},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":111.71},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":121.86},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":412.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":160.18,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":217.84,"additional_payer_notes":"APC"}]}]},{"description":"Quan us tis charac w/dx us","code_information":[{"code":"0690T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":131.1,"maximum":141.65,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":141.65},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":131.1},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":141.65}]}]},{"description":"Ct breast w/3d uni c+","code_information":[{"code":"0634T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":130.12,"maximum":502.24,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":173.49,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":502.24},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":486.53},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":502.24},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":334.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":130.12,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":176.96,"additional_payer_notes":"APC"}]}]},{"description":"Rem oct rta dev setup&educaj","code_information":[{"code":"0604T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":66.66,"maximum":67.69,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":67.69},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":66.66},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":67.69}]}]},{"description":"B1 str&fx rsk transmis data","code_information":[{"code":"0555T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":21.46,"maximum":140.41,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":28.61,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":140.41},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":138.29},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":140.41},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":55.21,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21.46,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":29.18,"additional_payer_notes":"APC"}]}]},{"description":"R-t spctrl alys prst8 tiss","code_information":[{"code":"0443T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":161.37,"maximum":2334.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":163.84},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":161.37},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":163.84},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"RSA upper extr exam","code_information":[{"code":"0349T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":77.56,"maximum":666.22,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":103.41,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":666.22},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":656.14},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":666.22},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":199.58,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":77.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":105.48,"additional_payer_notes":"APC"}]}]},{"description":"Guide cathet fluid drainage","code_information":[{"code":"10030","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":525.32,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":700.42,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1351.81,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":525.32,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":714.43,"additional_payer_notes":"APC"}]}]},{"description":"Drainage of hematoma/fluid","code_information":[{"code":"10140","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1225.21,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1633.61,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3152.87,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1225.21,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1666.28,"additional_payer_notes":"APC"}]}]},{"description":"Remove mesh from abd wall","code_information":[{"code":"11008","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2654.0,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0}]}]},{"description":"Deb musc/fascia add-on","code_information":[{"code":"11046","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Shave skin lesion 0.6-1.0 cm","code_information":[{"code":"11301","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":148.84,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":198.45,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":383.01,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":148.84,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":202.42,"additional_payer_notes":"APC"}]}]},{"description":"Shave skin lesion 0.6-1.0 cm","code_information":[{"code":"11311","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":148.84,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":198.45,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":383.01,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":148.84,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":202.42,"additional_payer_notes":"APC"}]}]},{"description":"Exc tr-ext b9+marg >4.0 cm","code_information":[{"code":"11406","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1225.21,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1633.61,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3152.87,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1225.21,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1666.28,"additional_payer_notes":"APC"}]}]},{"description":"Exc face-mm b9+marg 0.6-1 cm","code_information":[{"code":"11441","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":525.32,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":700.42,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1351.81,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":525.32,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":714.43,"additional_payer_notes":"APC"}]}]},{"description":"Removal sweat gland lesion","code_information":[{"code":"11463","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2154.81,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2873.08,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5545.05,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2154.81,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2930.54,"additional_payer_notes":"APC"}]}]},{"description":"Exc tr-ext mal+marg >4 cm","code_information":[{"code":"11606","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1225.21,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1633.61,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3152.87,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1225.21,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1666.28,"additional_payer_notes":"APC"}]}]},{"description":"Exc f/e/e/n/l mal+mrg 0.6-1","code_information":[{"code":"11641","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":525.32,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":700.42,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1351.81,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":525.32,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":714.43,"additional_payer_notes":"APC"}]}]},{"description":"Removal of nail plate","code_information":[{"code":"11730","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":148.84,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":198.45,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":383.01,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":148.84,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":202.42,"additional_payer_notes":"APC"}]}]},{"description":"Remove pilonidal cyst simple","code_information":[{"code":"11770","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2154.81,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2873.08,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5545.05,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2154.81,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2930.54,"additional_payer_notes":"APC"}]}]},{"description":"Tx contour defects 1 cc/<","code_information":[{"code":"11950","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":148.84,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":198.45,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":383.01,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":148.84,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":202.42,"additional_payer_notes":"APC"}]}]},{"description":"Implant hormone pellet(s)","code_information":[{"code":"11980","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":331.39,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":441.86,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":852.79,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":331.39,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":450.7,"additional_payer_notes":"APC"}]}]},{"description":"Rpr s/n/a/gen/trk20.1-30.0cm","code_information":[{"code":"12006","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":301.57,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":402.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":776.03,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":301.57,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":410.13,"additional_payer_notes":"APC"}]}]},{"description":"Rpr f/e/e/n/l/m >30.0 cm","code_information":[{"code":"12018","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":148.84,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":198.45,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":383.01,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":148.84,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":202.42,"additional_payer_notes":"APC"}]}]},{"description":"Intmd rpr s/tr/ext >30.0 cm","code_information":[{"code":"12037","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1530.61,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2040.81,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3938.76,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1530.61,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2081.63,"additional_payer_notes":"APC"}]}]},{"description":"Intmd rpr face/mm 2.6-5.0 cm","code_information":[{"code":"12052","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":301.57,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":402.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":776.03,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":301.57,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":410.13,"additional_payer_notes":"APC"}]}]},{"description":"Cmplx rpr trunk addl 5cm/<","code_information":[{"code":"13102","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Cmplx rpr e/n/e/l 2.6-7.5 cm","code_information":[{"code":"13152","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":548.27,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":731.02,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1410.87,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":548.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":745.64,"additional_payer_notes":"APC"}]}]},{"description":"Tis trnfr f/c/c/m/n/a/g/h/f","code_information":[{"code":"14041","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1530.61,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2040.81,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3938.76,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1530.61,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2081.63,"additional_payer_notes":"APC"}]}]},{"description":"Wound prep f/n/hf/g","code_information":[{"code":"15004","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":301.57,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":402.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":776.03,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":301.57,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":410.13,"additional_payer_notes":"APC"}]}]},{"description":"Epidrm a-grft face/nck/hf/g","code_information":[{"code":"15115","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1530.61,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2040.81,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3938.76,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1530.61,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2081.63,"additional_payer_notes":"APC"}]}]},{"description":"Cult skin grft t/arm/leg","code_information":[{"code":"15150","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1530.61,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2040.81,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3938.76,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1530.61,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2081.63,"additional_payer_notes":"APC"}]}]},{"description":"Skin full graft sclp/arm/leg","code_information":[{"code":"15220","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1530.61,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2040.81,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3938.76,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1530.61,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2081.63,"additional_payer_notes":"APC"}]}]},{"description":"Skin sub grft t/arm/lg child","code_information":[{"code":"15273","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1530.61,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2040.81,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3938.76,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1530.61,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2081.63,"additional_payer_notes":"APC"}]}]},{"description":"Pedcle fh/ch/ch/m/n/ax/g/h/f","code_information":[{"code":"15574","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1530.61,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2040.81,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3938.76,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1530.61,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2081.63,"additional_payer_notes":"APC"}]}]},{"description":"Muscle-skin graft trunk","code_information":[{"code":"15734","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2628.85,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3505.13,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6764.9,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2628.85,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3575.23,"additional_payer_notes":"APC"}]}]},{"description":"Composite skin graft","code_information":[{"code":"15760","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1530.61,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2040.81,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3938.76,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1530.61,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2081.63,"additional_payer_notes":"APC"}]}]},{"description":"Dermabrasion suprfl any site","code_information":[{"code":"15783","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":301.57,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":402.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":776.03,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":301.57,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":410.13,"additional_payer_notes":"APC"}]}]},{"description":"Revision of lower eyelid","code_information":[{"code":"15821","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1530.61,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2040.81,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3938.76,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1530.61,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2081.63,"additional_payer_notes":"APC"}]}]},{"description":"Exc Skin Abd","code_information":[{"code":"15830","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4925.89,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6567.85,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":7398.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6019.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":7398.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":12675.95,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4925.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6699.21,"additional_payer_notes":"APC"}]}]},{"description":"Excise excess skin & tissue","code_information":[{"code":"15839","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2154.81,"maximum":5545.05,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2873.08,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5545.05,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2154.81,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2930.54,"additional_payer_notes":"APC"}]}]},{"description":"Test for blood flow in graft","code_information":[{"code":"15860","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":331.39,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":441.86,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":852.79,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":331.39,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":450.7,"additional_payer_notes":"APC"}]}]},{"description":"Remove sacrum pressure sore","code_information":[{"code":"15933","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2154.81,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2873.08,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5545.05,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2154.81,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2930.54,"additional_payer_notes":"APC"}]}]},{"description":"Remove hip pressure sore","code_information":[{"code":"15945","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1530.61,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2040.81,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3938.76,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1530.61,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2081.63,"additional_payer_notes":"APC"}]}]},{"description":"Removal of pressure sore","code_information":[{"code":"15999","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":525.32,"maximum":13249.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":700.42,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":13249.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":10779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":13249.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1351.81,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":525.32,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":714.43,"additional_payer_notes":"APC"}]}]},{"description":"Destruct premalg les 2-14","code_information":[{"code":"17003","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Incision of jaw joint","code_information":[{"code":"21010","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2459.51,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3279.35,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6329.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2459.51,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3344.94,"additional_payer_notes":"APC"}]}]},{"description":"Excision of facial bone(s)","code_information":[{"code":"21026","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":11300.84,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Extensive jaw surgery","code_information":[{"code":"21045","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Mnpj of tmj w/anesth","code_information":[{"code":"21073","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1151.01,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1534.69,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2961.94,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1151.01,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1565.38,"additional_payer_notes":"APC"}]}]},{"description":"Bone/skin graft microvasc","code_information":[{"code":"20969","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Sp bone agrft local add-on","code_information":[{"code":"20936","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5512.0,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0}]}]},{"description":"Removal of bone for graft","code_information":[{"code":"20902","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":13851.98,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Replant forearm complete","code_information":[{"code":"20805","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6779.0,"maximum":33471.73,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17342.86,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":33471.73,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13007.15,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":27583.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17689.72,"additional_payer_notes":"APC"}]}]},{"description":"Removal of support implant","code_information":[{"code":"20680","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2154.81,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2873.08,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5545.05,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2154.81,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2930.54,"additional_payer_notes":"APC"}]}]},{"description":"Insert and remove bone pin","code_information":[{"code":"20650","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Drain/inj joint/bursa w/o us","code_information":[{"code":"20600","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":227.71,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":303.61,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":585.96,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":227.71,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":309.68,"additional_payer_notes":"APC"}]}]},{"description":"Removal of foreign body","code_information":[{"code":"20525","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2154.81,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2873.08,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5545.05,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2154.81,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2930.54,"additional_payer_notes":"APC"}]}]},{"description":"Bone biopsy trocar/needle","code_information":[{"code":"20225","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1225.21,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1633.61,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3152.87,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1225.21,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1666.28,"additional_payer_notes":"APC"}]}]},{"description":"Explore wound chest","code_information":[{"code":"20101","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1530.61,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2040.81,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3938.76,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1530.61,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2081.63,"additional_payer_notes":"APC"}]}]},{"description":"Breast reconstruction","code_information":[{"code":"19368","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6019.0,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":7398.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6019.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":7398.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0}]}]},{"description":"Immediate breast prosthesis","code_information":[{"code":"19340","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6019.0,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8084.38,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":7398.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6019.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":7398.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":15602.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6063.28,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8246.06,"additional_payer_notes":"APC"}]}]},{"description":"Mast radical","code_information":[{"code":"19305","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6019.0,"maximum":7398.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":7398.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6019.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":7398.0}]}]},{"description":"Perq dev breast add mr guide","code_information":[{"code":"19288","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Excision addl breast lesion","code_information":[{"code":"19126","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Bx breast add lesion mr imag","code_information":[{"code":"19086","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Drain breast lesion add-on","code_information":[{"code":"19001","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Mohs 1 stage t/a/l","code_information":[{"code":"17313","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":548.27,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":731.02,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1410.87,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":548.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":745.64,"additional_payer_notes":"APC"}]}]},{"description":"Destruction of skin lesions","code_information":[{"code":"17280","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":148.84,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":198.45,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":383.01,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":148.84,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":202.42,"additional_payer_notes":"APC"}]}]},{"description":"Destruction of skin lesions","code_information":[{"code":"17264","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":301.57,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":402.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":776.03,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":301.57,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":410.13,"additional_payer_notes":"APC"}]}]},{"description":"Destruction of skin lesions","code_information":[{"code":"17108","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1530.61,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2040.81,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3938.76,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1530.61,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2081.63,"additional_payer_notes":"APC"}]}]},{"description":"Prepare face/oral prosthesis","code_information":[{"code":"21085","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":175.7,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":234.27,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":452.14,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":175.7,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":238.96,"additional_payer_notes":"APC"}]}]},{"description":"Reconstruction of chin","code_information":[{"code":"21120","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":11300.84,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Reduction of forehead","code_information":[{"code":"21139","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Lefort ii w/bone grafts","code_information":[{"code":"21151","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Reconstruct entire forehead","code_information":[{"code":"21180","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Reconst lwr jaw w/o fixation","code_information":[{"code":"21195","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Lower jaw bone graft","code_information":[{"code":"21215","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Reconstruction of jaw","code_information":[{"code":"21246","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Revise eye sockets","code_information":[{"code":"21263","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Revision of jaw muscle/bone","code_information":[{"code":"21296","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2459.51,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3279.35,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6329.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2459.51,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3344.94,"additional_payer_notes":"APC"}]}]},{"description":"Closed tx septal&nose fx","code_information":[{"code":"21337","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2459.51,"maximum":6329.15,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3279.35,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6329.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2459.51,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3344.94,"additional_payer_notes":"APC"}]}]},{"description":"Opn tx nasomax fx multple","code_information":[{"code":"21347","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Opn tx orbit fx periorbital","code_information":[{"code":"21386","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Opn tx orbit fx w/bone grft","code_information":[{"code":"21408","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Treat craniofacial fracture","code_information":[{"code":"21436","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Treat lower jaw fracture","code_information":[{"code":"21461","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Head surgery procedure","code_information":[{"code":"21499","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":175.7,"maximum":13249.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":234.27,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":13249.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":10779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":13249.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":452.14,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":175.7,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":238.96,"additional_payer_notes":"APC"}]}]},{"description":"Exc neck tum deep < 5 cm","code_information":[{"code":"21556","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2154.81,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2873.08,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5545.05,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2154.81,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2930.54,"additional_payer_notes":"APC"}]}]},{"description":"Sternal debridement","code_information":[{"code":"21627","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Repair stern/nuss w/o scope","code_information":[{"code":"21742","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Neck/chest surgery procedure","code_information":[{"code":"21899","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":175.7,"maximum":13249.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":234.27,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":13249.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":10779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":13249.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":452.14,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":175.7,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":238.96,"additional_payer_notes":"APC"}]}]},{"description":"Resect back tum 5 cm/>","code_information":[{"code":"21936","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2154.81,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2873.08,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5545.05,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2154.81,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2930.54,"additional_payer_notes":"APC"}]}]},{"description":"Remove part thorax vertebra","code_information":[{"code":"22112","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Incis 1 vertebral seg lumbar","code_information":[{"code":"22214","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Treat odontoid fx w/o graft","code_information":[{"code":"22318","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":24508.8,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12698.86,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":24508.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9524.15,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12952.84,"additional_payer_notes":"APC"}]}]},{"description":"Perq lumbosacral injection","code_information":[{"code":"22511","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Lat lumbar spine fusion","code_information":[{"code":"22533","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6779.0,"maximum":33471.73,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17342.86,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":33471.73,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13007.15,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":27583.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17689.72,"additional_payer_notes":"APC"}]}]},{"description":"Additional spinal fusion","code_information":[{"code":"22585","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5512.0,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0}]}]},{"description":"Lumbar spine fusion","code_information":[{"code":"22630","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":51798.34,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26838.52,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":51798.34,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20128.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":27583.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27375.29,"additional_payer_notes":"APC"}]}]},{"description":"Ant fusion 4-7 vert seg","code_information":[{"code":"22810","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":33471.73,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17342.86,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":33471.73,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13007.15,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":27583.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17689.72,"additional_payer_notes":"APC"}]}]},{"description":"Insert spine fixation device","code_information":[{"code":"22843","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":4106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Remove spine fixation device","code_information":[{"code":"22852","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3388.0,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Remove Lumb Artif Disc","code_information":[{"code":"22865","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Abdomen surgery procedure","code_information":[{"code":"22999","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":182.99,"maximum":13249.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":243.98,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":13249.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":10779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":13249.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":470.88,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":182.99,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":248.86,"additional_payer_notes":"APC"}]}]},{"description":"Biopsy shoulder tissues","code_information":[{"code":"23065","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1225.21,"maximum":4106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1633.61,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3152.87,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1225.21,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1666.28,"additional_payer_notes":"APC"}]}]},{"description":"Biopsy of shoulder joint","code_information":[{"code":"23100","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Removal of bone lesion","code_information":[{"code":"23140","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Remove humerus lesion","code_information":[{"code":"23174","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":13851.98,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Resect prox humerus tumor","code_information":[{"code":"23220","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Fixation of shoulder blade","code_information":[{"code":"23400","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":13851.98,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Remove/transplant tendon","code_information":[{"code":"23440","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":13851.98,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Reconstruct shoulder joint","code_information":[{"code":"23472","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6779.0,"maximum":33471.73,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17342.86,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":33471.73,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13007.15,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":27583.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17689.72,"additional_payer_notes":"APC"}]}]},{"description":"Treat clavicle fracture","code_information":[{"code":"23505","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1192.86,"maximum":4106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1590.48,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3069.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1192.86,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1622.29,"additional_payer_notes":"APC"}]}]},{"description":"Treat clavicle dislocation","code_information":[{"code":"23550","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Treat humerus fracture","code_information":[{"code":"23616","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8923.0,"maximum":33471.73,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17342.86,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":10765.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":8923.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":10765.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":33471.73,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13007.15,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17689.72,"additional_payer_notes":"APC"}]}]},{"description":"Treat dislocation/fracture","code_information":[{"code":"23670","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Amputation follow-up surgery","code_information":[{"code":"23921","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1530.61,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2040.81,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3938.76,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1530.61,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2081.63,"additional_payer_notes":"APC"}]}]},{"description":"Biopsy arm/elbow soft tissue","code_information":[{"code":"24066","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2154.81,"maximum":5545.05,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2873.08,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5545.05,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2154.81,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2930.54,"additional_payer_notes":"APC"}]}]},{"description":"Explore/treat elbow joint","code_information":[{"code":"24101","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Remove/graft bone lesion","code_information":[{"code":"24126","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":13851.98,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Radical resection of elbow","code_information":[{"code":"24149","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":13851.98,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Injection for elbow x-ray","code_information":[{"code":"24220","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Tenolysis triceps","code_information":[{"code":"24332","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Repair elbow perc","code_information":[{"code":"24357","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Reconstruct head of radius","code_information":[{"code":"24366","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":27583.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12698.86,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":24508.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9524.15,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":27583.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12952.84,"additional_payer_notes":"APC"}]}]},{"description":"Revision of elbow joint","code_information":[{"code":"24470","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Treat humerus fracture","code_information":[{"code":"24535","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1192.86,"maximum":4106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1590.48,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3069.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1192.86,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1622.29,"additional_payer_notes":"APC"}]}]},{"description":"Treat humerus fracture","code_information":[{"code":"24576","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":182.99,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":243.98,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":470.88,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":182.99,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":248.86,"additional_payer_notes":"APC"}]}]},{"description":"Treat elbow dislocation","code_information":[{"code":"24615","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Treat ulnar fracture","code_information":[{"code":"24670","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":182.99,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":243.98,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":470.88,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":182.99,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":248.86,"additional_payer_notes":"APC"}]}]},{"description":"Amputation follow-up surgery","code_information":[{"code":"24930","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Dlyd plmt xtn prosth 1st vsl","code_information":[{"code":"34710","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6019.0,"maximum":7398.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":7398.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6019.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":7398.0}]}]},{"description":"Njx noncmpnd sclrsnt mlt vn","code_information":[{"code":"36466","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1530.61,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2040.81,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3938.76,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1530.61,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2081.63,"additional_payer_notes":"APC"}]}]},{"description":"Tprnl plmt biodegrdabl matrl","code_information":[{"code":"55874","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3977.55,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5303.4,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":10235.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3977.55,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5409.47,"additional_payer_notes":"APC"}]}]},{"description":"Gfrg autol fat lipo ea addl","code_information":[{"code":"15774","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Tcat rmvl perm ldls pm","code_information":[{"code":"33275","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2342.32,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3123.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6027.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2342.32,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3185.56,"additional_payer_notes":"APC"}]}]},{"description":"Rplc gtube no revj trc","code_information":[{"code":"43762","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":185.35,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":247.13,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":476.96,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":185.35,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":252.07,"additional_payer_notes":"APC"}]}]},{"description":"Dilat xst trc ndurlgc px","code_information":[{"code":"50436","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2614.94,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3486.59,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6729.12,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2614.94,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3556.32,"additional_payer_notes":"APC"}]}]},{"description":"Ev cath dir chem abltj w/img","code_information":[{"code":"0524T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2342.32,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3123.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6027.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2342.32,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3185.56,"additional_payer_notes":"APC"}]}]},{"description":"Exc chest wall tumor w/ribs","code_information":[{"code":"21601","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2154.81,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2873.08,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5545.05,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2154.81,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2930.54,"additional_payer_notes":"APC"}]}]},{"description":"Transvrs a-arch grf hypthrm","code_information":[{"code":"33871","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":9356.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0}]}]},{"description":"Njx aa&/strd nrv nrvtg si jt","code_information":[{"code":"64451","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":523.65,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":698.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1347.51,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":523.65,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":712.16,"additional_payer_notes":"APC"}]}]},{"description":"Perq prcrd drg insj cath ct","code_information":[{"code":"33019","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3388.0,"maximum":4106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0}]}]},{"description":"Xcapsl ctrc rmvl cplx w/ecp","code_information":[{"code":"66987","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3066.31,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4088.41,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7890.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3066.31,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4170.17,"additional_payer_notes":"APC"}]}]},{"description":"Osteot hum xtrnl lngth dev","code_information":[{"code":"0594T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Egd flx transnasal dx br/wa","code_information":[{"code":"0652T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1423.51,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1898.01,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3663.16,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1423.51,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1935.97,"additional_payer_notes":"APC"}]}]},{"description":"Xcapsl ctrc rmvl insj 1+","code_information":[{"code":"66991","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3947.51,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5263.35,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":10158.27,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3947.51,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5368.62,"additional_payer_notes":"APC"}]}]},{"description":"Trml dstrj ios bvn 1st 2 l/s","code_information":[{"code":"64628","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":24508.8,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12698.86,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":24508.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9524.15,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12952.84,"additional_payer_notes":"APC"}]}]},{"description":"Litt icr mlt trj mlt/cplx ls","code_information":[{"code":"61737","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"R hrt cath chd abnl nt cnj","code_information":[{"code":"93594","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2404.97,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3206.62,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6188.79,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2404.97,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3270.76,"additional_payer_notes":"APC"}]}]},{"description":"Insj ant sgm aq drg dev 1+","code_information":[{"code":"0671T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3388.0,"maximum":10158.27,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5263.35,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":10158.27,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3947.51,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5368.62,"additional_payer_notes":"APC"}]}]},{"description":"Rplc oi implt sk tc esp>=100","code_information":[{"code":"69730","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":24508.8,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12698.86,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":24508.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9524.15,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12952.84,"additional_payer_notes":"APC"}]}]},{"description":"Rpr aa hrn 1st > 10 rdc","code_information":[{"code":"49595","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":12358.4,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6403.32,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":12358.4,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4802.49,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6531.38,"additional_payer_notes":"APC"}]}]},{"description":"Rpr aa hrn rcr < 3 rdc","code_information":[{"code":"49613","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2656.06,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3541.41,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6834.92,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2656.06,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3612.24,"additional_payer_notes":"APC"}]}]},{"description":"Rpr aa hrn rcr 3-10 rdc","code_information":[{"code":"49615","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":12358.4,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6403.32,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":12358.4,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4802.49,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6531.38,"additional_payer_notes":"APC"}]}]},{"description":"Endo sleeve gastro w/tube","code_information":[{"code":"C9784","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":17314.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0}]}]},{"description":"Insj/rplcmt prq ra sac nstim","code_information":[{"code":"0786T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":27583.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11021.34,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":21271.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8266.01,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":27583.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11241.77,"additional_payer_notes":"APC"}]}]},{"description":"Rmv&rplcmt phrnc nrv stim ld","code_information":[{"code":"33288","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":27583.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11021.34,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":21271.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8266.01,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":27583.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11241.77,"additional_payer_notes":"APC"}]}]},{"description":"Revj/rmvl nea sac w/nstim","code_information":[{"code":"0787T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2593.52,"maximum":8657.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3458.03,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6674.0,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2593.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3527.19,"additional_payer_notes":"APC"}]}]},{"description":"Revj rplcmt/rmvl vrt tethrg","code_information":[{"code":"0790T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6779.0,"maximum":33471.73,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17342.86,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":33471.73,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13007.15,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17689.72,"additional_payer_notes":"APC"}]}]},{"description":"Revj/rmvl ins ptn subf","code_information":[{"code":"0819T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2593.52,"maximum":8657.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3458.03,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6674.0,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2593.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3527.19,"additional_payer_notes":"APC"}]}]},{"description":"Intraop ther estim pn ue 1st","code_information":[{"code":"0882T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5512.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0}]}]},{"description":"Cysto flx ins&xpns urtl scaf","code_information":[{"code":"0941T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":18071.3,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9363.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":18071.3,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7022.52,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9550.63,"additional_payer_notes":"APC"}]}]},{"description":"Prq tcat ther rx ntrac balo1","code_information":[{"code":"0913T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5512.0,"maximum":22037.64,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11418.47,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":22037.64,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8563.85,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11646.84,"additional_payer_notes":"APC"}]}]},{"description":"App skn cl ssp agrf t/a/l ea","code_information":[{"code":"15016","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5512.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0}]}]},{"description":"Opn exc/dstr ntra-abd >30 cm","code_information":[{"code":"49190","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Ablt trurl prst8 tis thrm us","code_information":[{"code":"55881","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Rmvl perm ccm-d sys dual ld","code_information":[{"code":"0922T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2772.2,"maximum":7133.79,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3696.26,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7133.79,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2772.2,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3770.19,"additional_payer_notes":"APC"}]}]},{"description":"I&cst prp jw xpn dl arch non","code_information":[{"code":"0965T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2459.51,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3279.35,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6329.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2459.51,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3344.94,"additional_payer_notes":"APC"}]}]},{"description":"Abltj b9 prst8 tissue hifu","code_information":[{"code":"0950T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5512.0,"maximum":18071.3,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9363.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":18071.3,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7022.52,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9550.63,"additional_payer_notes":"APC"}]}]},{"description":"Decompress forearm 1 space","code_information":[{"code":"25023","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Biopsy forearm soft tissues","code_information":[{"code":"25066","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2154.81,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2873.08,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5545.05,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2154.81,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2930.54,"additional_payer_notes":"APC"}]}]},{"description":"Biopsy of wrist joint","code_information":[{"code":"25100","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Remove wrist/forearm lesion","code_information":[{"code":"25115","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1192.86,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1590.48,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3069.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1192.86,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1622.29,"additional_payer_notes":"APC"}]}]},{"description":"Remove & graft wrist lesion","code_information":[{"code":"25135","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":13851.98,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Partial removal of radius","code_information":[{"code":"25230","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Repair forearm tendon/muscle","code_information":[{"code":"25263","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":13851.98,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Release wrist/forearm tendon","code_information":[{"code":"25295","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Revise wrist joint","code_information":[{"code":"25332","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Revise radius & ulna","code_information":[{"code":"25375","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Repair radius & ulna","code_information":[{"code":"25415","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Reconstruct wrist joint","code_information":[{"code":"25442","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8923.0,"maximum":33471.73,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17342.86,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":10765.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":8923.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":10765.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":33471.73,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13007.15,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":27583.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17689.72,"additional_payer_notes":"APC"}]}]},{"description":"Revision of wrist joint","code_information":[{"code":"25455","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Treat fracture of radius","code_information":[{"code":"25525","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Treat fracture radius/ulna","code_information":[{"code":"25575","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Treat wrist bone fracture","code_information":[{"code":"25624","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1192.86,"maximum":4106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1590.48,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3069.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1192.86,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1622.29,"additional_payer_notes":"APC"}]}]},{"description":"Treat wrist dislocation","code_information":[{"code":"25660","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":182.99,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":243.98,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":470.88,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":182.99,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":248.86,"additional_payer_notes":"APC"}]}]},{"description":"Treat wrist dislocation","code_information":[{"code":"25695","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":13851.98,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Amputation of forearm","code_information":[{"code":"25905","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Amputation follow-up surgery","code_information":[{"code":"25929","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1530.61,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2040.81,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3938.76,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1530.61,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2081.63,"additional_payer_notes":"APC"}]}]},{"description":"Treat hand bone lesion","code_information":[{"code":"26034","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1192.86,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1590.48,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3069.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1192.86,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1622.29,"additional_payer_notes":"APC"}]}]},{"description":"Explore/treat finger joint","code_information":[{"code":"26075","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":6246.19,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Exc hand tum deep < 1.5 cm","code_information":[{"code":"26116","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1225.21,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1633.61,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3152.87,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1225.21,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1666.28,"additional_payer_notes":"APC"}]}]},{"description":"Revise finger joint each","code_information":[{"code":"26140","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1192.86,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1590.48,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3069.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1192.86,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1622.29,"additional_payer_notes":"APC"}]}]},{"description":"Removal of finger lesion","code_information":[{"code":"26210","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1192.86,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1590.48,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3069.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1192.86,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1622.29,"additional_payer_notes":"APC"}]}]},{"description":"Removal of implant from hand","code_information":[{"code":"26320","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1225.21,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1633.61,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3152.87,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1225.21,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1666.28,"additional_payer_notes":"APC"}]}]},{"description":"Repair finger/hand tendon","code_information":[{"code":"26370","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Graft hand or finger tendon","code_information":[{"code":"26416","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Realignment of tendons","code_information":[{"code":"26437","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":6246.19,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Fusion of finger tendons","code_information":[{"code":"26471","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":6246.19,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Transplant palm tendon","code_information":[{"code":"26485","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Revision of finger","code_information":[{"code":"26499","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Release knuckle contracture","code_information":[{"code":"26520","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":6246.19,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Repair hand joint with graft","code_information":[{"code":"26542","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":6246.19,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Positional change of finger","code_information":[{"code":"26555","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":13851.98,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Repair hand deformity","code_information":[{"code":"26580","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":6246.19,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Radiation treatment delivery","code_information":[{"code":"G6012","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":878.79,"maximum":910.21,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":910.21},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":878.79},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":910.21}]}]},{"description":"Radiation treatment delivery","code_information":[{"code":"G6004","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":481.92,"maximum":499.15,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":499.15},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":481.92},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":499.15}]}]},{"description":"Single energy x-ray study","code_information":[{"code":"G0130","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":75.56,"maximum":199.58,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":103.41,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":78.26},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":75.56},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":78.26},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":199.58,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":77.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":105.48,"additional_payer_notes":"APC"}]}]},{"description":"Smallpox&monkeypox vac 0.5ml","code_information":[{"code":"90611","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":0.0075,"maximum":0.03,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":0.01,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":0.01},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":0.01},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":0.01},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":0.02,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":0.0075,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.03},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":0.01,"additional_payer_notes":"APC"}]}]},{"description":"Rp quan meas single area","code_information":[{"code":"78835","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":268.64,"maximum":278.24,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":278.24},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":268.64},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":278.24}]}]},{"description":"Pet image skull-thigh","code_information":[{"code":"78812","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1060.78,"maximum":2729.74,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1414.38,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":2314.6},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2279.56},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":2314.6},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2729.74,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1060.78,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1442.66,"additional_payer_notes":"APC"}]}]},{"description":"Testicular imaging w/flow","code_information":[{"code":"78761","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":296.56,"maximum":763.16,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":395.42,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":619.98},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":598.58},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":619.98},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":763.16,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":296.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":403.33,"additional_payer_notes":"APC"}]}]},{"description":"Kidney imaging morphol","code_information":[{"code":"78700","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":296.56,"maximum":763.16,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":395.42,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":536.3},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":517.78},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":536.3},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":763.16,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":296.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":403.33,"additional_payer_notes":"APC"}]}]},{"description":"Brain imaging (PET)","code_information":[{"code":"78608","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1060.78,"maximum":2729.74,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1414.38,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":1770.79},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1743.99},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":1770.79},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2729.74,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1060.78,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1442.66,"additional_payer_notes":"APC"}]}]},{"description":"Lung perfusion imaging","code_information":[{"code":"78580","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":296.56,"maximum":763.16,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":395.42,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":727.05},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":701.95},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":727.05},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":763.16,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":296.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":403.33,"additional_payer_notes":"APC"}]}]},{"description":"Gated heart multiple","code_information":[{"code":"78473","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":296.56,"maximum":781.95,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":395.42,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":781.95},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":754.94},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":781.95},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":763.16,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":296.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":403.33,"additional_payer_notes":"APC"}]}]},{"description":"Acute venous thrombus image","code_information":[{"code":"78456","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":924.84,"maximum":2471.46,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1280.55,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":957.92},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":924.84},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":957.92},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2471.46,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":960.41,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1306.16,"additional_payer_notes":"APC"}]}]},{"description":"Myocrd img pet 2rtracer","code_information":[{"code":"78432","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1125.83,"maximum":2897.13,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1501.1,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":2054.62},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2023.53},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":2054.62},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2897.13,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1125.83,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1531.12,"additional_payer_notes":"APC"}]}]},{"description":"Bone imaging 3 phase","code_information":[{"code":"78315","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":296.56,"maximum":1063.75,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":395.42,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":1063.75},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1027.03},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":1063.75},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":763.16,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":296.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":403.33,"additional_payer_notes":"APC"}]}]},{"description":"Gastric emptying imag study","code_information":[{"code":"78266","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":402.79,"maximum":1503.85,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":537.06,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":1503.85},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1451.91},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":1503.85},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1036.52,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":402.79,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":547.8,"additional_payer_notes":"APC"}]}]},{"description":"Salivary gland imaging","code_information":[{"code":"78230","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":296.56,"maximum":763.16,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":395.42,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":435.39},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":420.35},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":435.39},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":763.16,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":296.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":403.33,"additional_payer_notes":"APC"}]}]},{"description":"Platelet survival","code_information":[{"code":"78191","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":296.56,"maximum":763.16,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":395.42,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":493.95},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":476.9},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":493.95},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":763.16,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":296.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":403.33,"additional_payer_notes":"APC"}]}]},{"description":"Plasma volume single","code_information":[{"code":"78110","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":289.65,"maximum":2471.46,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1280.55,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":300.01},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":289.65},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":300.01},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2471.46,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":960.41,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1306.16,"additional_payer_notes":"APC"}]}]},{"description":"Thyroid met uptake","code_information":[{"code":"78020","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":192.71,"maximum":199.58,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":199.58},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":192.71},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":199.58}]}]},{"description":"Apply surf ldr radionuclide","code_information":[{"code":"77789","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":75.69,"maximum":209.96,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":100.92,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":209.96},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":202.71},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":209.96},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":194.77,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":75.69,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":102.94,"additional_payer_notes":"APC"}]}]},{"description":"Apply intrcav radiat interm","code_information":[{"code":"77762","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":409.89,"maximum":1054.79,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":546.52,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":763.7},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":737.34},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":763.7},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1054.79,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":409.89,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":557.46,"additional_payer_notes":"APC"}]}]},{"description":"Proton treatment complex","code_information":[{"code":"77525","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":927.1,"maximum":4107.22,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1236.13,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4107.22},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4045.05},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4107.22},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2385.73,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":927.1,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1260.85,"additional_payer_notes":"APC"}]}]},{"description":"Radiation therapy management","code_information":[{"code":"77431","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":346.03,"maximum":358.41,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":358.41},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":346.03},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":358.41}]}]},{"description":"Guidance for radiaj tx dlvr","code_information":[{"code":"77387","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":215.16,"maximum":222.86,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":222.86},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":215.16},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":222.86}]}]},{"description":"Radiation physics consult","code_information":[{"code":"77336","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":99.71,"maximum":272.16,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":132.94,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":272.16},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":262.77},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":272.16},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":256.58,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":99.71,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":135.6,"additional_payer_notes":"APC"}]}]},{"description":"Brachytx isodose plan simple","code_information":[{"code":"77316","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":277.76,"maximum":714.78,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":370.35,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":400.92},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":387.09},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":400.92},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":714.78,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":277.76,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":377.76,"additional_payer_notes":"APC"}]}]},{"description":"Set radiation therapy field","code_information":[{"code":"77285","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":277.76,"maximum":1306.48,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":370.35,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":1306.48},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1261.35},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":1306.48},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":714.78,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":277.76,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":377.76,"additional_payer_notes":"APC"}]}]},{"description":"Tbs dxa cal w/i&r fx risk","code_information":[{"code":"77089","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":145.31,"maximum":147.55,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":147.55},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":145.31},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":147.55}]}]},{"description":"X-rays bone survey infant","code_information":[{"code":"77076","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":77.56,"maximum":208.71,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":103.41,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":208.71},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":201.51},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":208.71},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":199.58,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":77.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":105.48,"additional_payer_notes":"APC"}]}]},{"description":"Breast tomosynthesis uni","code_information":[{"code":"77061","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":318.64,"maximum":323.53,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":323.53},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":318.64},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":323.53}]}]},{"description":"MR Guidance for Needle Place","code_information":[{"code":"77021","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1091.46,"maximum":1130.49,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":1130.49},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1091.46},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":1130.49}]}]},{"description":"Us guide intraop","code_information":[{"code":"76998","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":211.13,"maximum":218.68,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":218.68},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":211.13},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":218.68}]}]},{"description":"Us trgt dyn mbubb ea addl","code_information":[{"code":"76979","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":603.69,"maximum":619.08,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":619.08},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":603.69},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":619.08}]}]},{"description":"Echo guide for biopsy","code_information":[{"code":"76942","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":92.2,"maximum":95.5,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":95.5},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":92.2},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":95.5}]}]},{"description":"Us nrv&acc strux 1xtr compre","code_information":[{"code":"76883","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":52.32,"maximum":199.58,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":103.41,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":54.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":52.32},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":54.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":199.58,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":77.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":105.48,"additional_payer_notes":"APC"}]}]},{"description":"Echo exam uterus","code_information":[{"code":"76831","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":177.0,"maximum":455.49,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":236.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":285.01},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":275.17},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":285.01},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":455.49,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":177.0,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":240.72,"additional_payer_notes":"APC"}]}]},{"description":"Fetal biophys profil w/o nst","code_information":[{"code":"76819","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":77.56,"maximum":199.58,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":103.41,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":171.8},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":165.86},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":171.8},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":199.58,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":77.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":105.48,"additional_payer_notes":"APC"}]}]},{"description":"Ob us detailed sngl fetus","code_information":[{"code":"76811","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":177.0,"maximum":455.49,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":236.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":291.89},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":281.81},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":291.89},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":455.49,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":177.0,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":240.72,"additional_payer_notes":"APC"}]}]},{"description":"Us exam abdo back wall comp","code_information":[{"code":"76770","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":77.56,"maximum":264.08,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":103.41,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":264.08},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":254.99},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":264.08},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":199.58,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":77.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":105.48,"additional_payer_notes":"APC"}]}]},{"description":"Echo exam of eye","code_information":[{"code":"76519","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":77.56,"maximum":199.58,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":103.41,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":184.1},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":177.75},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":184.1},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":199.58,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":77.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":105.48,"additional_payer_notes":"APC"}]}]},{"description":"Mri procedure","code_information":[{"code":"76498","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":64.56,"maximum":240.55,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":86.08,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":240.55},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":236.9},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":240.55},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":166.13,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":64.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":87.8,"additional_payer_notes":"APC"}]}]},{"description":"Med physic dos eval rad exps","code_information":[{"code":"76145","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":276.82,"maximum":2964.04,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":369.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":2964.04},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2890.42},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":2964.04},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":712.35,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":276.82,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":376.48,"additional_payer_notes":"APC"}]}]},{"description":"Mr sfty med physics xm cstmz","code_information":[{"code":"76017","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":177.0,"maximum":694.54,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":236.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":694.54},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":636.66},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":694.54},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":455.49,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":177.0,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":240.72,"additional_payer_notes":"APC"}]}]},{"description":"Vascular biopsy","code_information":[{"code":"75970","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1341.89,"maximum":1389.89,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":1389.89},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1341.89},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":1389.89}]}]},{"description":"X-rays transcath therapy","code_information":[{"code":"75894","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2922.55,"maximum":3027.07,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3027.07},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2922.55},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3027.07}]}]},{"description":"Vein x-ray skull","code_information":[{"code":"75870","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":301.32,"maximum":6027.57,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3123.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":312.09},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":301.32},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":312.09},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6027.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2342.32,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3185.56,"additional_payer_notes":"APC"}]}]},{"description":"Vein x-ray arms/legs","code_information":[{"code":"75822","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":283.5,"maximum":3005.03,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1557.01,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":293.62},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":283.5},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":293.62},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3005.03,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1167.76,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1588.15,"additional_payer_notes":"APC"}]}]},{"description":"Artery x-ray each vessel","code_information":[{"code":"75774","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":233.59,"maximum":241.94,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":241.94},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":233.59},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":241.94}]}]},{"description":"Artery x-rays abdomen","code_information":[{"code":"75726","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":312.01,"maximum":10622.5,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5503.89,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":323.17},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":312.01},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":323.17},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":10622.5,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4127.91,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5613.96,"additional_payer_notes":"APC"}]}]},{"description":"Contrast exam thoracic aorta","code_information":[{"code":"75600","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":578.16,"maximum":6027.57,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3123.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":598.82},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":578.16},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":598.82},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6027.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2342.32,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3185.56,"additional_payer_notes":"APC"}]}]},{"description":"Cardiac mri for morph w/dye","code_information":[{"code":"75561","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":258.81,"maximum":1011.84,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":345.07,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":1011.84},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":976.91},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":1011.84},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":665.99,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":258.81,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":351.98,"additional_payer_notes":"APC"}]}]},{"description":"X-ray guide gu dilation","code_information":[{"code":"74485","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":219.33,"maximum":3990.5,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2067.62,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":227.17},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":219.33},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":227.17},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3990.5,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1550.71,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2108.97,"additional_payer_notes":"APC"}]}]},{"description":"Contrst x-ray urinary tract","code_information":[{"code":"74420","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":258.81,"maximum":1204.35,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":345.07,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":1204.35},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1162.75},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":1204.35},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":665.99,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":258.81,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":351.98,"additional_payer_notes":"APC"}]}]},{"description":"X-ray bile/panc endoscopy","code_information":[{"code":"74330","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":406.44,"maximum":420.99,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":420.99},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":406.44},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":420.99}]}]},{"description":"Contrast x-ray exam of colon","code_information":[{"code":"74270","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":130.12,"maximum":395.78,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":173.49,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":395.78},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":382.13},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":395.78},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":334.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":130.12,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":176.96,"additional_payer_notes":"APC"}]}]},{"description":"X-ray upper gi delay w/o kub","code_information":[{"code":"74240","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":130.12,"maximum":334.84,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":173.49,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":269.03},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":259.73},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":269.03},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":334.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":130.12,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":176.96,"additional_payer_notes":"APC"}]}]},{"description":"Mri abdomen w/o & w/dye","code_information":[{"code":"74183","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":258.81,"maximum":1351.52,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":345.07,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":1351.52},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1304.85},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":1351.52},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":665.99,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":258.81,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":351.98,"additional_payer_notes":"APC"}]}]},{"description":"Ct abdomen w/o & w/dye","code_information":[{"code":"74170","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":130.12,"maximum":659.14,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":173.49,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":659.14},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":636.39},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":659.14},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":334.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":130.12,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":176.96,"additional_payer_notes":"APC"}]}]},{"description":"Mri joint lwr extr w/o&w/dye","code_information":[{"code":"73723","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":258.81,"maximum":1246.9,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":345.07,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":1246.9},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1203.85},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":1246.9},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":665.99,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":258.81,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":351.98,"additional_payer_notes":"APC"}]}]},{"description":"Ct lower extremity w/dye","code_information":[{"code":"73701","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":130.12,"maximum":576.7,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":173.49,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":576.7},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":556.76},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":576.7},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":334.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":130.12,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":176.96,"additional_payer_notes":"APC"}]}]},{"description":"X-ray exam of ankle","code_information":[{"code":"73600","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":64.56,"maximum":166.13,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":86.08,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":73.35},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":70.8},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":73.35},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":166.13,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":64.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":87.8,"additional_payer_notes":"APC"}]}]},{"description":"X-ray exam of femur 2/>","code_information":[{"code":"73552","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":64.56,"maximum":166.13,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":86.08,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":78.26},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":75.56},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":78.26},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":166.13,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":64.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":87.8,"additional_payer_notes":"APC"}]}]},{"description":"X-ray exam hip uni 1 view","code_information":[{"code":"73501","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":64.56,"maximum":166.13,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":86.08,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":69.65},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":67.24},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":69.65},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":166.13,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":64.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":87.8,"additional_payer_notes":"APC"}]}]},{"description":"Ct angio upr extrm w/o&w/dye","code_information":[{"code":"73206","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":130.12,"maximum":814.95,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":173.49,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":814.95},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":786.79},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":814.95},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":334.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":130.12,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":176.96,"additional_payer_notes":"APC"}]}]},{"description":"X-ray exam of wrist","code_information":[{"code":"73110","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":64.56,"maximum":166.13,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":86.08,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":90.57},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":87.44},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":90.57},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":166.13,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":64.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":87.8,"additional_payer_notes":"APC"}]}]},{"description":"X-ray exam of shoulders","code_information":[{"code":"73050","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":64.56,"maximum":166.13,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":86.08,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":85.63},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":82.68},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":85.63},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":166.13,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":64.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":87.8,"additional_payer_notes":"APC"}]}]},{"description":"Myelogphy 2/> spine regions","code_information":[{"code":"72270","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":197.94,"maximum":1496.49,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":775.38,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":205.03},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":197.94},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":205.03},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1496.49,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":581.54,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":790.89,"additional_payer_notes":"APC"}]}]},{"description":"Mri pelvis w/o & w/dye","code_information":[{"code":"72197","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":258.81,"maximum":1347.81,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":345.07,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":1347.81},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1301.27},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":1347.81},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":665.99,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":258.81,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":351.98,"additional_payer_notes":"APC"}]}]},{"description":"X-ray exam of pelvis","code_information":[{"code":"72170","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":75.56,"maximum":199.58,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":103.41,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":78.26},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":75.56},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":78.26},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":199.58,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":77.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":105.48,"additional_payer_notes":"APC"}]}]},{"description":"Mri chest spine w/o dye","code_information":[{"code":"72146","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":177.0,"maximum":512.69,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":236.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":512.69},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":494.98},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":512.69},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":455.49,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":177.0,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":240.72,"additional_payer_notes":"APC"}]}]},{"description":"Ct chest spine w/o dye","code_information":[{"code":"72128","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":77.56,"maximum":446.24,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":103.41,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":446.24},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":430.83},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":446.24},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":199.58,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":77.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":105.48,"additional_payer_notes":"APC"}]}]},{"description":"X-ray exam entire spi 6/> vw","code_information":[{"code":"72084","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":77.56,"maximum":206.26,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":103.41,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":206.26},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":199.13},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":206.26},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":199.58,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":77.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":105.48,"additional_payer_notes":"APC"}]}]},{"description":"Treat metacarpal fracture","code_information":[{"code":"26607","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":6246.19,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Treat hand dislocation","code_information":[{"code":"26675","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1192.86,"maximum":4106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1590.48,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3069.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1192.86,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1622.29,"additional_payer_notes":"APC"}]}]},{"description":"Treat finger fracture each","code_information":[{"code":"26720","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":182.99,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":243.98,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":470.88,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":182.99,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":248.86,"additional_payer_notes":"APC"}]}]},{"description":"Treat finger fracture each","code_information":[{"code":"26755","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":182.99,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":243.98,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":470.88,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":182.99,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":248.86,"additional_payer_notes":"APC"}]}]},{"description":"Fusion of thumb","code_information":[{"code":"26841","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":13851.98,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Fusion/graft of finger joint","code_information":[{"code":"26862","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Drainage of bone lesion","code_information":[{"code":"26992","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Drainage of hip joint","code_information":[{"code":"27030","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Exc hip/pelvis les sc < 3 cm","code_information":[{"code":"27047","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2154.81,"maximum":5545.05,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2873.08,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5545.05,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2154.81,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2930.54,"additional_payer_notes":"APC"}]}]},{"description":"Removal of ischial bursa","code_information":[{"code":"27060","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":13851.98,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Resect hip tum incl acetabul","code_information":[{"code":"27076","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Injection for hip x-ray","code_information":[{"code":"27093","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Transfer of iliopsoas muscle","code_information":[{"code":"27111","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Revise hip joint replacement","code_information":[{"code":"27138","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6779.0,"maximum":27583.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12698.86,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":24508.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9524.15,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":27583.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12952.84,"additional_payer_notes":"APC"}]}]},{"description":"Incision/fixation of femur","code_information":[{"code":"27165","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Revision of femur epiphysis","code_information":[{"code":"27185","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Treat hip socket fracture","code_information":[{"code":"27220","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":182.99,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":243.98,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":470.88,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":182.99,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":248.86,"additional_payer_notes":"APC"}]}]},{"description":"Treat thigh fracture","code_information":[{"code":"27236","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Treat hip dislocation","code_information":[{"code":"27252","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1192.86,"maximum":4106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1590.48,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3069.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1192.86,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1622.29,"additional_payer_notes":"APC"}]}]},{"description":"Treat hip dislocation","code_information":[{"code":"27266","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1192.86,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1590.48,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3069.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1192.86,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1622.29,"additional_payer_notes":"APC"}]}]},{"description":"Fusion of hip joint","code_information":[{"code":"27284","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":27583.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12698.86,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":24508.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9524.15,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":27583.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12952.84,"additional_payer_notes":"APC"}]}]},{"description":"Incision of thigh tendon","code_information":[{"code":"27306","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Exc thigh/knee tum deep <5cm","code_information":[{"code":"27328","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2154.81,"maximum":5545.05,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2873.08,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5545.05,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2154.81,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2930.54,"additional_payer_notes":"APC"}]}]},{"description":"Exc thigh/knee les sc 3 cm/>","code_information":[{"code":"27337","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2154.81,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2873.08,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5545.05,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2154.81,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2930.54,"additional_payer_notes":"APC"}]}]},{"description":"Remove femur lesion/graft","code_information":[{"code":"27357","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":13851.98,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Repair of thigh muscle","code_information":[{"code":"27385","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":13851.98,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Transplant of thigh tendon","code_information":[{"code":"27396","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":13851.98,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Osteochondral knee allograft","code_information":[{"code":"27415","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":24508.8,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12698.86,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":24508.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9524.15,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12952.84,"additional_payer_notes":"APC"}]}]},{"description":"Reconstruction knee","code_information":[{"code":"27428","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":24508.8,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12698.86,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":24508.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9524.15,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12952.84,"additional_payer_notes":"APC"}]}]},{"description":"Revision of knee joint","code_information":[{"code":"27442","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":24508.8,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12698.86,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":24508.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9524.15,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12952.84,"additional_payer_notes":"APC"}]}]},{"description":"Realignment of knee","code_information":[{"code":"27455","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Surgery to stop leg growth","code_information":[{"code":"27477","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":13851.98,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Decompression of thigh/knee","code_information":[{"code":"27497","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Treatment of thigh fracture","code_information":[{"code":"27507","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Treat thigh fx growth plate","code_information":[{"code":"27517","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1192.86,"maximum":4106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1590.48,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3069.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1192.86,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1622.29,"additional_payer_notes":"APC"}]}]},{"description":"Treat knee fracture(s)","code_information":[{"code":"27538","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":182.99,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":243.98,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":470.88,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":182.99,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":248.86,"additional_payer_notes":"APC"}]}]},{"description":"X-ray exam neck spine 6/>vws","code_information":[{"code":"72052","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":77.56,"maximum":199.58,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":103.41,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":129.93},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":125.46},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":129.93},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":199.58,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":77.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":105.48,"additional_payer_notes":"APC"}]}]},{"description":"Ct angiography chest","code_information":[{"code":"71275","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":130.12,"maximum":715.26,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":173.49,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":715.26},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":690.54},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":715.26},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":334.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":130.12,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":176.96,"additional_payer_notes":"APC"}]}]},{"description":"X-ray exam ribs bil 3 views","code_information":[{"code":"71110","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":77.56,"maximum":199.58,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":103.41,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":80.72},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":77.94},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":80.72},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":199.58,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":77.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":105.48,"additional_payer_notes":"APC"}]}]},{"description":"Mri brain w/dye","code_information":[{"code":"70558","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":130.12,"maximum":4788.76,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":173.49,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4788.76},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4716.28},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4788.76},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":334.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":130.12,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":176.96,"additional_payer_notes":"APC"}]}]},{"description":"Mr Angiography Neck W/Dye","code_information":[{"code":"70548","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":258.81,"maximum":1213.68,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":345.07,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":1213.68},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1171.76},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":1213.68},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":665.99,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":258.81,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":351.98,"additional_payer_notes":"APC"}]}]},{"description":"Ct angiography neck","code_information":[{"code":"70498","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":130.12,"maximum":705.41,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":173.49,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":705.41},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":681.05},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":705.41},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":334.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":130.12,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":176.96,"additional_payer_notes":"APC"}]}]},{"description":"Ct orbit/ear/fossa w/o&w/dye","code_information":[{"code":"70482","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":130.12,"maximum":786.62,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":173.49,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":786.62},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":759.45},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":786.62},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":334.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":130.12,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":176.96,"additional_payer_notes":"APC"}]}]},{"description":"Speech evaluation complex","code_information":[{"code":"70371","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":159.92,"maximum":455.49,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":236.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":165.65},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":159.92},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":165.65},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":455.49,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":177.0,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":240.72,"additional_payer_notes":"APC"}]}]},{"description":"X-ray exam of jaw joint","code_information":[{"code":"70328","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":64.56,"maximum":166.13,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":86.08,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":73.35},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":70.8},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":73.35},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":166.13,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":64.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":87.8,"additional_payer_notes":"APC"}]}]},{"description":"X-ray exam of sinuses","code_information":[{"code":"70210","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":64.56,"maximum":166.13,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":86.08,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":70.88},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":68.42},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":70.88},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":166.13,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":64.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":87.8,"additional_payer_notes":"APC"}]}]},{"description":"X-ray exam of mastoids","code_information":[{"code":"70130","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":77.56,"maximum":199.58,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":103.41,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":127.47},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":123.08},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":127.47},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":199.58,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":77.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":105.48,"additional_payer_notes":"APC"}]}]},{"description":"Ncntc ifr spctrsc o/t pad ea","code_information":[{"code":"0859T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":60.52,"maximum":66.02,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":66.02},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":60.52},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":66.02}]}]},{"description":"Quan mr tiss w/mri mlt orgn","code_information":[{"code":"0698T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":262.2,"maximum":1776.02,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":920.22,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":283.29},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":262.2},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":283.29},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1776.02,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":690.16,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":938.62,"additional_payer_notes":"APC"}]}]},{"description":"Ct breast w/3d bi c+","code_information":[{"code":"0637T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":258.81,"maximum":665.99,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":345.07,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":502.24},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":486.53},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":502.24},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":665.99,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":258.81,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":351.98,"additional_payer_notes":"APC"}]}]},{"description":"Mrs disc pain acquisj data","code_information":[{"code":"0609T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":177.0,"maximum":1143.67,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":236.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":1143.67},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1126.35},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":1143.67},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":455.49,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":177.0,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":240.72,"additional_payer_notes":"APC"}]}]},{"description":"Antmc mdl 3d print ea addl","code_information":[{"code":"0560T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":98.13,"maximum":99.64,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":99.64},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":98.13},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":99.64}]}]},{"description":"Ev fempop artl revsc","code_information":[{"code":"0505T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8563.85,"maximum":27583.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11418.47,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":20119.27},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":19814.71},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":20119.27},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":22037.64,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8563.85,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":27583.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11646.84,"additional_payer_notes":"APC"}]}]},{"description":"Oct brst/node i&r per spec","code_information":[{"code":"0352T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3401.23,"maximum":3453.5,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3453.5},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3401.23},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3453.5}]}]},{"description":"Ct perfusion w/contrast cbf","code_information":[{"code":"0042T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":509.24,"maximum":525.67,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":525.67},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":509.24},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":525.67}]}]},{"description":"Drainage of pilonidal cyst","code_information":[{"code":"10081","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":525.32,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":700.42,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1351.81,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":525.32,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":714.43,"additional_payer_notes":"APC"}]}]},{"description":"Debride genitalia & perineum","code_information":[{"code":"11004","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2654.0,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0}]}]},{"description":"Deb musc/fascia 20 sq cm/<","code_information":[{"code":"11043","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":548.27,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":731.02,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1410.87,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":548.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":745.64,"additional_payer_notes":"APC"}]}]},{"description":"Removal of skin tags <w/15","code_information":[{"code":"11200","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":148.84,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":198.45,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":383.01,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":148.84,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":202.42,"additional_payer_notes":"APC"}]}]},{"description":"Shave skin lesion 1.1-2.0 cm","code_information":[{"code":"11307","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":148.84,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":198.45,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":383.01,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":148.84,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":202.42,"additional_payer_notes":"APC"}]}]},{"description":"Exc tr-ext b9+marg 1.1-2 cm","code_information":[{"code":"11402","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":525.32,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":700.42,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1351.81,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":525.32,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":714.43,"additional_payer_notes":"APC"}]}]},{"description":"Exc h-f-nk-sp b9+marg 3.1-4","code_information":[{"code":"11424","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1225.21,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1633.61,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3152.87,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1225.21,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1666.28,"additional_payer_notes":"APC"}]}]},{"description":"Removal sweat gland lesion","code_information":[{"code":"11450","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2154.81,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2873.08,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5545.05,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2154.81,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2930.54,"additional_payer_notes":"APC"}]}]},{"description":"Exc tr-ext mal+marg 1.1-2 cm","code_information":[{"code":"11602","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":301.57,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":402.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":776.03,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":301.57,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":410.13,"additional_payer_notes":"APC"}]}]},{"description":"Exc s/n/h/f/g mal+mrg 3.1-4","code_information":[{"code":"11624","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1225.21,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1633.61,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3152.87,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1225.21,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1666.28,"additional_payer_notes":"APC"}]}]},{"description":"Trim nail(s) any number","code_information":[{"code":"11719","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":43.76,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":58.35,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":112.62,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":43.76,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":59.52,"additional_payer_notes":"APC"}]}]},{"description":"Repair of nail bed","code_information":[{"code":"11760","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":548.27,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":731.02,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1410.87,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":548.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":745.64,"additional_payer_notes":"APC"}]}]},{"description":"Correct skin color 6.0 cm/<","code_information":[{"code":"11920","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":548.27,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":731.02,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1410.87,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":548.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":745.64,"additional_payer_notes":"APC"}]}]},{"description":"Replace tissue expander","code_information":[{"code":"11970","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Rpr s/n/ax/gen/trnk2.6-7.5cm","code_information":[{"code":"12002","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":148.84,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":198.45,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":383.01,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":148.84,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":202.42,"additional_payer_notes":"APC"}]}]},{"description":"Rpr f/e/e/n/l/m 7.6-12.5 cm","code_information":[{"code":"12015","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":148.84,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":198.45,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":383.01,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":148.84,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":202.42,"additional_payer_notes":"APC"}]}]},{"description":"Intmd rpr s/tr/ext 7.6-12.5","code_information":[{"code":"12034","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":301.57,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":402.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":776.03,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":301.57,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":410.13,"additional_payer_notes":"APC"}]}]},{"description":"Treat kneecap dislocation","code_information":[{"code":"27562","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":182.99,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":243.98,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":470.88,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":182.99,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":248.86,"additional_payer_notes":"APC"}]}]},{"description":"Amputation follow-up surgery","code_information":[{"code":"27596","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Incision of achilles tendon","code_information":[{"code":"27605","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1192.86,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1590.48,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3069.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1192.86,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1622.29,"additional_payer_notes":"APC"}]}]},{"description":"Resect leg/ankle tum 5 cm/>","code_information":[{"code":"27616","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2154.81,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2873.08,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5545.05,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2154.81,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2930.54,"additional_payer_notes":"APC"}]}]},{"description":"Exc leg/ankle tum dep 5 cm/>","code_information":[{"code":"27634","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2154.81,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2873.08,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5545.05,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2154.81,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2930.54,"additional_payer_notes":"APC"}]}]},{"description":"Resect talus/calcaneus tum","code_information":[{"code":"27647","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Repair of leg tendon each","code_information":[{"code":"27664","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":13851.98,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Revision of calf tendon","code_information":[{"code":"27687","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Reconstruct ankle joint","code_information":[{"code":"27702","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":51798.34,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26838.52,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":51798.34,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20128.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27375.29,"additional_payer_notes":"APC"}]}]},{"description":"Repair of tibia","code_information":[{"code":"27720","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Repair lower leg epiphyses","code_information":[{"code":"27734","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Treatment of tibia fracture","code_information":[{"code":"27759","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":24508.8,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12698.86,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":24508.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9524.15,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12952.84,"additional_payer_notes":"APC"}]}]},{"description":"Treatment of fibula fracture","code_information":[{"code":"27781","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1192.86,"maximum":4106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1590.48,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3069.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1192.86,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1622.29,"additional_payer_notes":"APC"}]}]},{"description":"Treatment of ankle fracture","code_information":[{"code":"27816","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":182.99,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":243.98,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":470.88,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":182.99,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":248.86,"additional_payer_notes":"APC"}]}]},{"description":"Treat lower leg fracture","code_information":[{"code":"27828","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":24508.8,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12698.86,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":24508.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9524.15,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12952.84,"additional_payer_notes":"APC"}]}]},{"description":"Treat ankle dislocation","code_information":[{"code":"27848","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Amputation follow-up surgery","code_information":[{"code":"27886","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Treatment of foot infection","code_information":[{"code":"28002","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1192.86,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1590.48,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3069.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1192.86,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1622.29,"additional_payer_notes":"APC"}]}]},{"description":"Exploration of toe joint","code_information":[{"code":"28024","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1192.86,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1590.48,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3069.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1192.86,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1622.29,"additional_payer_notes":"APC"}]}]},{"description":"Biopsy of foot joint lining","code_information":[{"code":"28050","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Removal of foot lesion","code_information":[{"code":"28080","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1192.86,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1590.48,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3069.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1192.86,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1622.29,"additional_payer_notes":"APC"}]}]},{"description":"Shoulder arthroscopy/surgery","code_information":[{"code":"29823","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Jaw arthroscopy/surgery","code_information":[{"code":"29804","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Removal/revision of cast","code_information":[{"code":"29705","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":207.48,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":276.65,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":533.93,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":207.48,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":282.18,"additional_payer_notes":"APC"}]}]},{"description":"Strapping of hip","code_information":[{"code":"29520","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":98.7,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":131.6,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":253.99,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":98.7,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":134.23,"additional_payer_notes":"APC"}]}]},{"description":"Apply short leg cast","code_information":[{"code":"29405","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":207.48,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":276.65,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":533.93,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":207.48,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":282.18,"additional_payer_notes":"APC"}]}]},{"description":"Strapping of elbow or wrist","code_information":[{"code":"29260","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":43.76,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":58.35,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":112.62,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":43.76,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":59.52,"additional_payer_notes":"APC"}]}]},{"description":"Apply finger cast","code_information":[{"code":"29086","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":120.55,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":160.73,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":310.21,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":120.55,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":163.95,"additional_payer_notes":"APC"}]}]},{"description":"Application of body cast","code_information":[{"code":"29044","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":120.55,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":160.73,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":310.21,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":120.55,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":163.95,"additional_payer_notes":"APC"}]}]},{"description":"Partial amputation of toe","code_information":[{"code":"28825","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Fusion of foot bones","code_information":[{"code":"28740","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Treat toe dislocation","code_information":[{"code":"28666","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Treat foot dislocation","code_information":[{"code":"28606","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Treat foot dislocation","code_information":[{"code":"28546","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1192.86,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1590.48,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3069.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1192.86,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1622.29,"additional_payer_notes":"APC"}]}]},{"description":"Treat big toe fracture","code_information":[{"code":"28505","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Treat midfoot fracture each","code_information":[{"code":"28465","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Treatment of ankle fracture","code_information":[{"code":"28430","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":182.99,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":243.98,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":470.88,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":182.99,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":248.86,"additional_payer_notes":"APC"}]}]},{"description":"Repair extra toe(s)","code_information":[{"code":"28344","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Revision of big toe","code_information":[{"code":"28310","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":13851.98,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Incision of heel bone","code_information":[{"code":"28300","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Repair of hammertoe","code_information":[{"code":"28286","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Release of midfoot joint","code_information":[{"code":"28260","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Release of foot tendon","code_information":[{"code":"28225","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Removal of foot foreign body","code_information":[{"code":"28192","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1225.21,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1633.61,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3152.87,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1225.21,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1666.28,"additional_payer_notes":"APC"}]}]},{"description":"Removal of metatarsal","code_information":[{"code":"28140","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Revision of foot","code_information":[{"code":"28116","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Remove/graft foot lesion","code_information":[{"code":"28106","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Excise foot tendon sheath","code_information":[{"code":"28086","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Treat pleurodesis w/agent","code_information":[{"code":"32560","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":465.35,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":620.47,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1197.51,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":465.35,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":632.88,"additional_payer_notes":"APC"}]}]},{"description":"Thoracoscopy w/bx pleura","code_information":[{"code":"32609","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4484.77,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5979.69,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5257.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11540.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4484.77,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6099.28,"additional_payer_notes":"APC"}]}]},{"description":"Thoracoscopy w/sac fb remove","code_information":[{"code":"32658","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5257.0,"maximum":6462.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5257.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6462.0}]}]},{"description":"Thoracoscopy w/w resect addl","code_information":[{"code":"32667","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5257.0,"maximum":6462.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5257.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6462.0}]}]},{"description":"Remove nasal foreign body","code_information":[{"code":"30300","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":98.7,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":131.6,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":253.99,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":98.7,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":134.23,"additional_payer_notes":"APC"}]}]},{"description":"Removal of nose lesion","code_information":[{"code":"30125","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Drainage of nose lesion","code_information":[{"code":"30020","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":400.09,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":533.45,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1029.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":400.09,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":544.12,"additional_payer_notes":"APC"}]}]},{"description":"Subtalar arthro w/exc","code_information":[{"code":"29905","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":13851.98,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Ankle arthroscopy/surgery","code_information":[{"code":"29895","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Knee arthroscopy/surgery","code_information":[{"code":"29886","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Knee arthroscopy/surgery","code_information":[{"code":"29877","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5067.0},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Allgrft implnt knee w/scope","code_information":[{"code":"29867","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":24508.8,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12698.86,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":24508.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9524.15,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12952.84,"additional_payer_notes":"APC"}]}]},{"description":"Knee arthroscopy/surgery","code_information":[{"code":"29851","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1192.86,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1590.48,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3069.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1192.86,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1622.29,"additional_payer_notes":"APC"}]}]},{"description":"Wrist arthroscopy","code_information":[{"code":"29840","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Repair Nasal Stenosis","code_information":[{"code":"30465","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Repair nasal septum defect","code_information":[{"code":"30630","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2459.51,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3279.35,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6329.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2459.51,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3344.94,"additional_payer_notes":"APC"}]}]},{"description":"Ligation upper jaw artery","code_information":[{"code":"30920","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2342.32,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3123.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6027.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2342.32,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3185.56,"additional_payer_notes":"APC"}]}]},{"description":"Exploration behind upper jaw","code_information":[{"code":"31040","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":11300.84,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Removal of frontal sinus","code_information":[{"code":"31085","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Removal of upper jaw","code_information":[{"code":"31230","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Revision of ethmoid sinus","code_information":[{"code":"31254","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4956.0,"maximum":13472.56,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6980.6,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":7398.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6019.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":7398.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13472.56,"additional_payer_notes":"APC"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":4956.0},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5235.45,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7120.21,"additional_payer_notes":"APC"}]}]},{"description":"Nasal/sinus endoscopy surg","code_information":[{"code":"31291","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6019.0,"maximum":7398.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":7398.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6019.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":7398.0}]}]},{"description":"Removal of larynx lesion","code_information":[{"code":"31300","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2459.51,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3279.35,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6329.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2459.51,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3344.94,"additional_payer_notes":"APC"}]}]},{"description":"Partial removal of larynx","code_information":[{"code":"31382","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Intmd rpr n-hf/genit20.1-30","code_information":[{"code":"12046","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":548.27,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":731.02,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1410.87,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":548.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":745.64,"additional_payer_notes":"APC"}]}]},{"description":"Intmd rpr face/mm >30.0 cm","code_information":[{"code":"12057","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":301.57,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":402.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":776.03,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":301.57,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":410.13,"additional_payer_notes":"APC"}]}]},{"description":"Cmplx rpr f/c/c/m/n/ax/g/h/f","code_information":[{"code":"13132","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":301.57,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":402.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":776.03,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":301.57,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":410.13,"additional_payer_notes":"APC"}]}]},{"description":"Tis trnfr s/a/l 10 sq cm/<","code_information":[{"code":"14020","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1530.61,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2040.81,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3938.76,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1530.61,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2081.63,"additional_payer_notes":"APC"}]}]},{"description":"Filleted finger/toe flap","code_information":[{"code":"14350","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1530.61,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2040.81,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3938.76,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1530.61,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2081.63,"additional_payer_notes":"APC"}]}]},{"description":"Skin splt grft t/a/l add-on","code_information":[{"code":"15101","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Derm autograft t/a/l add-on","code_information":[{"code":"15131","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Cult epiderm grft f/n/hfg +%","code_information":[{"code":"15157","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Skin full graft add-on","code_information":[{"code":"15261","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Skn sub grft f/n/hf/g ch add","code_information":[{"code":"15278","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Delay flap eye/nos/ear/lip","code_information":[{"code":"15630","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1530.61,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2040.81,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3938.76,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1530.61,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2081.63,"additional_payer_notes":"APC"}]}]},{"description":"Free myo/skin flap microvasc","code_information":[{"code":"15756","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0}]}]},{"description":"Dermabrasion total face","code_information":[{"code":"15780","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2154.81,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2873.08,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5545.05,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2154.81,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2930.54,"additional_payer_notes":"APC"}]}]},{"description":"Chemical peel nonfacial","code_information":[{"code":"15792","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":548.27,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":731.02,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1410.87,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":548.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":745.64,"additional_payer_notes":"APC"}]}]},{"description":"Removal of brow wrinkles","code_information":[{"code":"15826","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2628.85,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3505.13,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6764.9,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2628.85,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3575.23,"additional_payer_notes":"APC"}]}]},{"description":"Excise excessive skin arm","code_information":[{"code":"15836","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2154.81,"maximum":5545.05,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2873.08,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5545.05,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2154.81,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2930.54,"additional_payer_notes":"APC"}]}]},{"description":"Exc Skin Abd Add-on","code_information":[{"code":"15847","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Removal of tail bone ulcer","code_information":[{"code":"15920","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2154.81,"maximum":5545.05,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2873.08,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5545.05,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2154.81,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2930.54,"additional_payer_notes":"APC"}]}]},{"description":"Remove hip pressure sore","code_information":[{"code":"15940","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2154.81,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2873.08,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5545.05,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2154.81,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2930.54,"additional_payer_notes":"APC"}]}]},{"description":"Remove thigh pressure sore","code_information":[{"code":"15953","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2628.85,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3505.13,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6764.9,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2628.85,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3575.23,"additional_payer_notes":"APC"}]}]},{"description":"Incision of burn scab initi","code_information":[{"code":"16035","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":301.57,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":402.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":776.03,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":301.57,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":410.13,"additional_payer_notes":"APC"}]}]},{"description":"Ablate bone tumor(s) perq","code_information":[{"code":"20983","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Resect face/scalp tum < 2 cm","code_information":[{"code":"21015","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2154.81,"maximum":5545.05,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2873.08,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5545.05,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2154.81,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2930.54,"additional_payer_notes":"APC"}]}]},{"description":"Excise max/zygoma mal tumor","code_information":[{"code":"21034","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Removal of jaw joint","code_information":[{"code":"21050","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Bone/skin graft great toe","code_information":[{"code":"20973","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Fluid pressure muscle","code_information":[{"code":"20950","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":525.32,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":700.42,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1351.81,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":525.32,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":714.43,"additional_payer_notes":"APC"}]}]},{"description":"Removal of fascia for graft","code_information":[{"code":"20920","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1530.61,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2040.81,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3938.76,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1530.61,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2081.63,"additional_payer_notes":"APC"}]}]},{"description":"Replantation digit complete","code_information":[{"code":"20822","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1192.86,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1590.48,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3069.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1192.86,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1622.29,"additional_payer_notes":"APC"}]}]},{"description":"Adjust bone fixation device","code_information":[{"code":"20693","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":13851.98,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Application of pelvis brace","code_information":[{"code":"20662","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1192.86,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1590.48,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3069.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1192.86,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1622.29,"additional_payer_notes":"APC"}]}]},{"description":"Drain/inj joint/bursa w/us","code_information":[{"code":"20606","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":523.65,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":698.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1347.51,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":523.65,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":712.16,"additional_payer_notes":"APC"}]}]},{"description":"Inj tendon sheath/ligament","code_information":[{"code":"20550","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":227.71,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":303.61,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":585.96,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":227.71,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":309.68,"additional_payer_notes":"APC"}]}]},{"description":"Open bone biopsy","code_information":[{"code":"20250","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Excise epiphyseal bar","code_information":[{"code":"20150","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Removal of breast capsule","code_information":[{"code":"19371","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2904.59,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3872.79,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7474.49,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2904.59,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3950.25,"additional_payer_notes":"APC"}]}]},{"description":"Laryngoscopy with biopsy","code_information":[{"code":"31510","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2765.81,"maximum":7117.34,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3687.74,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7117.34,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2765.81,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3761.5,"additional_payer_notes":"APC"}]}]},{"description":"Laryngoscopy for treatment","code_information":[{"code":"31527","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2765.81,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3687.74,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7117.34,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2765.81,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3761.5,"additional_payer_notes":"APC"}]}]},{"description":"Larynscop w/tumr exc + scope","code_information":[{"code":"31541","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2765.81,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3687.74,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7117.34,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2765.81,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3761.5,"additional_payer_notes":"APC"}]}]},{"description":"Laryngoscopy with biopsy","code_information":[{"code":"31576","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1320.39,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1760.51,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3397.79,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1320.39,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1795.72,"additional_payer_notes":"APC"}]}]},{"description":"Larynx surgery procedure","code_information":[{"code":"31599","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":175.7,"maximum":13249.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":234.27,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":13249.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":10779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":13249.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":452.14,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":175.7,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":238.96,"additional_payer_notes":"APC"}]}]},{"description":"Repair windpipe opening","code_information":[{"code":"31613","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2459.51,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3279.35,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6329.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2459.51,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3344.94,"additional_payer_notes":"APC"}]}]},{"description":"Navigational bronchoscopy","code_information":[{"code":"31627","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Bronchoscopy w/fb removal","code_information":[{"code":"31635","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1320.39,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1760.51,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3397.79,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1320.39,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1795.72,"additional_payer_notes":"APC"}]}]},{"description":"Bronchoscopy reclear airway","code_information":[{"code":"31646","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":290.14,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":386.86,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":746.64,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":290.14,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":394.6,"additional_payer_notes":"APC"}]}]},{"description":"Bronch thermoplsty 1 lobe","code_information":[{"code":"31660","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5235.45,"maximum":13472.56,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6980.6,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":7398.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6019.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":7398.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13472.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5235.45,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7120.21,"additional_payer_notes":"APC"}]}]},{"description":"Repair of windpipe","code_information":[{"code":"31760","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Repair of windpipe injury","code_information":[{"code":"31800","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3579.0,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0}]}]},{"description":"Open wedge/bx lung infiltr","code_information":[{"code":"32096","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5257.0,"maximum":6462.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5257.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6462.0}]}]},{"description":"Remove/treat lung lesions","code_information":[{"code":"32141","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6019.0,"maximum":7398.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":7398.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6019.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":7398.0}]}]},{"description":"Removal of chest lining","code_information":[{"code":"32310","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5257.0,"maximum":6462.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5257.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6462.0}]}]},{"description":"Segmentectomy","code_information":[{"code":"32484","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":9356.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0}]}]},{"description":"Wedge resect of lung add-on","code_information":[{"code":"32506","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":9356.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0}]}]},{"description":"Thoracoscopy for lvrs","code_information":[{"code":"32672","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5257.0,"maximum":6462.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5257.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6462.0}]}]},{"description":"Donor pneumonectomy","code_information":[{"code":"32850","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5257.0,"maximum":6462.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5257.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6462.0}]}]},{"description":"Revise & repair chest wall","code_information":[{"code":"32905","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":9356.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0}]}]},{"description":"Incision of heart sac","code_information":[{"code":"33025","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6019.0,"maximum":7398.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":7398.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6019.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":7398.0}]}]},{"description":"Insert epicard eltrd open","code_information":[{"code":"33202","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":9356.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0}]}]},{"description":"Insert pulse gen dual leads","code_information":[{"code":"33213","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":27583.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10338.17,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":19952.66,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7753.63,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":27583.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10544.93,"additional_payer_notes":"APC"}]}]},{"description":"Relocation pocket pacemaker","code_information":[{"code":"33222","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1530.61,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2040.81,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3938.76,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1530.61,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2081.63,"additional_payer_notes":"APC"}]}]},{"description":"Insrt pulse gen w/dual leads","code_information":[{"code":"33230","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8923.0,"maximum":54996.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22001.33,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":10765.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":8923.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":10765.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":54996.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":54996.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":54996.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":42462.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16501.0,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":51942.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22441.36,"additional_payer_notes":"APC"}]}]},{"description":"Insrt pulse gen w/singl lead","code_information":[{"code":"33240","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8923.0,"maximum":54996.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22001.33,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":10765.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":8923.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":10765.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":54996.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":54996.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":54996.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":42462.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16501.0,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":51942.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22441.36,"additional_payer_notes":"APC"}]}]},{"description":"Ablate atria w/o bypass ext","code_information":[{"code":"33255","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6019.0,"maximum":7398.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":7398.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6019.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":7398.0}]}]},{"description":"Rmvl & rplcmt dfb gen mlt ld","code_information":[{"code":"33264","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8923.0,"maximum":59920.75,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":31047.02,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":10765.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":8923.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":10765.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":54996.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":54996.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":54996.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":59920.75,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23285.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":51942.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":31667.96,"additional_payer_notes":"APC"}]}]},{"description":"Repair of heart wound","code_information":[{"code":"33305","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":9356.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0}]}]},{"description":"Replace aortic valve perq","code_information":[{"code":"33361","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":9356.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0}]}]},{"description":"Replace aortic valve w/byp","code_information":[{"code":"33369","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":9356.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0}]}]},{"description":"Repair of aortic valve","code_information":[{"code":"33414","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":9356.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0}]}]},{"description":"Repair of mitral valve","code_information":[{"code":"33425","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":9356.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0}]}]},{"description":"Revision of tricuspid valve","code_information":[{"code":"33468","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":9356.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0}]}]},{"description":"Repair heart vessel fistula","code_information":[{"code":"33501","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":9356.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0}]}]},{"description":"Cabg vein single","code_information":[{"code":"33510","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":9356.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0}]}]},{"description":"Correct inverted nipple(s)","code_information":[{"code":"19355","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2904.59,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3872.79,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7474.49,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2904.59,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3950.25,"additional_payer_notes":"APC"}]}]},{"description":"Suspension of breast","code_information":[{"code":"19316","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4925.89,"maximum":12675.95,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6567.85,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":7398.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6019.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":7398.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":12675.95,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4925.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6699.21,"additional_payer_notes":"APC"}]}]},{"description":"Place breast rad tube/caths","code_information":[{"code":"19298","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6019.0,"maximum":26307.58,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13630.87,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":7398.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6019.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":7398.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":26307.58,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10223.15,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13903.49,"additional_payer_notes":"APC"}]}]},{"description":"Perq dev breast 1st strtctc","code_information":[{"code":"19283","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":525.32,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":700.42,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1351.81,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":525.32,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":714.43,"additional_payer_notes":"APC"}]}]},{"description":"Cryosurg ablate fa each","code_information":[{"code":"19105","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2904.59,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3872.79,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7474.49,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2904.59,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3950.25,"additional_payer_notes":"APC"}]}]},{"description":"Bx breast 1st lesion strtctc","code_information":[{"code":"19081","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1225.21,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1633.61,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3152.87,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1225.21,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1666.28,"additional_payer_notes":"APC"}]}]},{"description":"Cryotherapy of skin","code_information":[{"code":"17340","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":43.76,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":58.35,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":112.62,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":43.76,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":59.52,"additional_payer_notes":"APC"}]}]},{"description":"Destruction of skin lesions","code_information":[{"code":"17283","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":301.57,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":402.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":776.03,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":301.57,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":410.13,"additional_payer_notes":"APC"}]}]},{"description":"Destruction of skin lesions","code_information":[{"code":"17271","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":148.84,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":198.45,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":383.01,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":148.84,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":202.42,"additional_payer_notes":"APC"}]}]},{"description":"Chemical cautery tissue","code_information":[{"code":"17250","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":148.84,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":198.45,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":383.01,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":148.84,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":202.42,"additional_payer_notes":"APC"}]}]},{"description":"Prepare face/oral prosthesis","code_information":[{"code":"21082","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2459.51,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3279.35,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6329.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2459.51,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3344.94,"additional_payer_notes":"APC"}]}]},{"description":"Maxillofacial fixation","code_information":[{"code":"21100","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Augmentation lower jaw bone","code_information":[{"code":"21127","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Lefort i-2 piece w/ graft","code_information":[{"code":"21146","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Reconstruct orbit/forehead","code_information":[{"code":"21172","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Reconstruction of midface","code_information":[{"code":"21188","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Augmentation of facial bones","code_information":[{"code":"21208","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Reconstruction of jaw joint","code_information":[{"code":"21243","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8923.0,"maximum":51798.34,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26838.52,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":10765.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":8923.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":10765.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":51798.34,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20128.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27375.29,"additional_payer_notes":"APC"}]}]},{"description":"Reconstruction of orbit","code_information":[{"code":"21256","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Revision of eyelid","code_information":[{"code":"21280","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2459.51,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3279.35,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6329.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2459.51,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3344.94,"additional_payer_notes":"APC"}]}]},{"description":"Open tx nose fx w/skele fixj","code_information":[{"code":"21330","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":11300.84,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Open tx compl front sinus fx","code_information":[{"code":"21344","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Opn tx complx malar fx","code_information":[{"code":"21365","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Closed tx orbit w/manipulj","code_information":[{"code":"21401","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1151.01,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1534.69,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2961.94,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1151.01,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1565.38,"additional_payer_notes":"APC"}]}]},{"description":"Treat craniofacial fracture","code_information":[{"code":"21432","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Treat lower jaw fracture","code_information":[{"code":"21452","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3579.0,"maximum":11300.84,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Reset dislocated jaw","code_information":[{"code":"21485","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1151.01,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1534.69,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2961.94,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1151.01,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1565.38,"additional_payer_notes":"APC"}]}]},{"description":"Exc neck les sc 3 cm/>","code_information":[{"code":"21552","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2154.81,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2873.08,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5545.05,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2154.81,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2930.54,"additional_payer_notes":"APC"}]}]},{"description":"Removal of rib","code_information":[{"code":"21615","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Revision of neck muscle","code_information":[{"code":"21720","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Treatment of rib fracture","code_information":[{"code":"21813","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1192.86,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1590.48,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3069.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1192.86,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1622.29,"additional_payer_notes":"APC"}]}]},{"description":"Exc back tum deep < 5 cm","code_information":[{"code":"21932","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2154.81,"maximum":5545.05,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2873.08,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5545.05,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2154.81,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2930.54,"additional_payer_notes":"APC"}]}]},{"description":"Remove part lumbar vertebra","code_information":[{"code":"22102","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Incis spine 3 column adl seg","code_information":[{"code":"22208","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":8333.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Revise extra spine segment","code_information":[{"code":"22226","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":9356.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Treat each add spine fx","code_information":[{"code":"22328","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Cabg artery-vein three","code_information":[{"code":"33519","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":9356.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0}]}]},{"description":"Cabg arterial four or more","code_information":[{"code":"33536","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":9356.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0}]}]},{"description":"Repair anomaly w/conduit","code_information":[{"code":"33608","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":9356.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0}]}]},{"description":"Transthor cath for stent","code_information":[{"code":"33621","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Close Mult Vsd","code_information":[{"code":"33675","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":9356.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0}]}]},{"description":"Repair of heart defects","code_information":[{"code":"33694","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":9356.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0}]}]},{"description":"Repair heart-vein defect","code_information":[{"code":"33732","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6019.0,"maximum":7398.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":7398.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6019.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":7398.0}]}]},{"description":"Major vessel shunt","code_information":[{"code":"33767","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6019.0,"maximum":7398.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":7398.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6019.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":7398.0}]}]},{"description":"Repair great vessels defect","code_information":[{"code":"33778","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6019.0,"maximum":7398.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":7398.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6019.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":7398.0}]}]},{"description":"Aortic suspension","code_information":[{"code":"33800","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6019.0,"maximum":7398.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":7398.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6019.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":7398.0}]}]},{"description":"Remove aorta constriction","code_information":[{"code":"33845","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":9356.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0}]}]},{"description":"Endovasc taa repr incl subcl","code_information":[{"code":"33880","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":9356.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0}]}]},{"description":"Remove lung artery emboli","code_information":[{"code":"33915","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":9356.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0}]}]},{"description":"Removal of donor heart/lung","code_information":[{"code":"33930","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5257.0,"maximum":6462.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5257.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6462.0}]}]},{"description":"Ecmo/ecls daily mgmt-venous","code_information":[{"code":"33948","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3388.0,"maximum":4106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0}]}]},{"description":"Ecmo/ecls repos perph cnula","code_information":[{"code":"33957","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3388.0,"maximum":4106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0}]}]},{"description":"Insert i-aort percut device","code_information":[{"code":"33967","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":44873.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":44873.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":44873.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":44873.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":43285.0}]}]},{"description":"Implant ventricular device","code_information":[{"code":"33976","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":9356.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0}]}]},{"description":"Ecmo/ecls rmvl prph cannula","code_information":[{"code":"33984","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3388.0,"maximum":4106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0}]}]},{"description":"Remove vad different session","code_information":[{"code":"33992","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":9356.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0}]}]},{"description":"Removal of artery clot","code_information":[{"code":"34201","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4127.91,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5503.89,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":10622.5,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4127.91,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5613.96,"additional_payer_notes":"APC"}]}]},{"description":"Reconstruct vena cava","code_information":[{"code":"34502","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":9356.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0}]}]},{"description":"Open Aortic Tube Prosth Repr","code_information":[{"code":"34830","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":9356.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0}]}]},{"description":"Endovasc visc aorta 3 graft","code_information":[{"code":"34843","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6019.0,"maximum":7398.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":7398.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6019.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":7398.0}]}]},{"description":"Repair defect of artery","code_information":[{"code":"35005","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6019.0,"maximum":7398.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":7398.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6019.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":7398.0}]}]},{"description":"Repair defect of artery","code_information":[{"code":"35091","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Repair defect of artery","code_information":[{"code":"35131","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Repair blood vessel lesion","code_information":[{"code":"35184","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2342.32,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3123.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6027.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2342.32,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3185.56,"additional_payer_notes":"APC"}]}]},{"description":"Repair blood vessel lesion","code_information":[{"code":"35216","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Repair blood vessel lesion","code_information":[{"code":"35256","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4127.91,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5503.89,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":10622.5,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4127.91,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5613.96,"additional_payer_notes":"APC"}]}]},{"description":"Rechanneling of Artery","code_information":[{"code":"35302","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Rechanneling of artery","code_information":[{"code":"35341","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Angioscopy","code_information":[{"code":"35400","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3388.0,"maximum":4106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0}]}]},{"description":"Art byp grft subclav-brchial","code_information":[{"code":"35512","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Art byp grft aor/carot/innom","code_information":[{"code":"35526","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Art byp grft aortbifemoral","code_information":[{"code":"35540","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Idet single level","code_information":[{"code":"22526","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0}]}]},{"description":"Neck spine fusion","code_information":[{"code":"22554","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":24508.8,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12698.86,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":24508.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9524.15,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12952.84,"additional_payer_notes":"APC"}]}]},{"description":"Thorax spine fusion","code_information":[{"code":"22610","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":33471.73,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17342.86,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":33471.73,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13007.15,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":27583.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17689.72,"additional_payer_notes":"APC"}]}]},{"description":"Post fusion 7-12 vert seg","code_information":[{"code":"22802","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6779.0,"maximum":33471.73,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17342.86,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":33471.73,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13007.15,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":27583.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17689.72,"additional_payer_notes":"APC"}]}]},{"description":"Insert spine fixation device","code_information":[{"code":"22840","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Insert pelv fixation device","code_information":[{"code":"22848","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":4106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Revise cerv artific disc","code_information":[{"code":"22861","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6779.0,"maximum":33471.73,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17342.86,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":33471.73,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13007.15,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":27583.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17689.72,"additional_payer_notes":"APC"}]}]},{"description":"Exc abd les sc 3 cm/>","code_information":[{"code":"22903","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2154.81,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2873.08,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5545.05,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2154.81,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2930.54,"additional_payer_notes":"APC"}]}]},{"description":"Drain shoulder bone lesion","code_information":[{"code":"23035","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1192.86,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1590.48,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3069.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1192.86,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1622.29,"additional_payer_notes":"APC"}]}]},{"description":"Exc shoulder tum deep < 5 cm","code_information":[{"code":"23076","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2154.81,"maximum":5545.05,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2873.08,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5545.05,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2154.81,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2930.54,"additional_payer_notes":"APC"}]}]},{"description":"Partial removal collar bone","code_information":[{"code":"23120","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Removal of humerus lesion","code_information":[{"code":"23156","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":13851.98,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Removal of head of humerus","code_information":[{"code":"23195","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":13851.98,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Injection for shoulder x-ray","code_information":[{"code":"23350","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Release of shoulder ligament","code_information":[{"code":"23415","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Repair shoulder capsule","code_information":[{"code":"23465","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Reinforce clavicle","code_information":[{"code":"23490","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Treat clavicle dislocation","code_information":[{"code":"23532","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":13851.98,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Treat humerus fracture","code_information":[{"code":"23600","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":182.99,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":243.98,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":470.88,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":182.99,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":248.86,"additional_payer_notes":"APC"}]}]},{"description":"Treat shoulder dislocation","code_information":[{"code":"23655","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1192.86,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1590.48,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3069.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1192.86,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1622.29,"additional_payer_notes":"APC"}]}]},{"description":"Fusion of shoulder joint","code_information":[{"code":"23802","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":24508.8,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12698.86,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":24508.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9524.15,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12952.84,"additional_payer_notes":"APC"}]}]},{"description":"Exploratory elbow surgery","code_information":[{"code":"24000","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Resect arm/elbow tum < 5 cm","code_information":[{"code":"24077","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2154.81,"maximum":5545.05,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2873.08,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5545.05,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2154.81,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2930.54,"additional_payer_notes":"APC"}]}]},{"description":"Remove/graft bone lesion","code_information":[{"code":"24116","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":13851.98,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Partial removal of arm bone","code_information":[{"code":"24140","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Remove radius head implant","code_information":[{"code":"24164","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Repair of arm tendon","code_information":[{"code":"24320","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":13851.98,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Reconstruct elbow lat ligmnt","code_information":[{"code":"24344","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Reconstruct elbow joint","code_information":[{"code":"24362","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":24508.8,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12698.86,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":24508.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9524.15,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12952.84,"additional_payer_notes":"APC"}]}]},{"description":"Revision of humerus","code_information":[{"code":"24420","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Treat humerus fracture","code_information":[{"code":"24515","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":24508.8,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12698.86,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":24508.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9524.15,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12952.84,"additional_payer_notes":"APC"}]}]},{"description":"Treat humerus fracture","code_information":[{"code":"24565","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1192.86,"maximum":4106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1590.48,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3069.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1192.86,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1622.29,"additional_payer_notes":"APC"}]}]},{"description":"Treat elbow fracture","code_information":[{"code":"24587","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":24508.8,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12698.86,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":24508.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9524.15,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12952.84,"additional_payer_notes":"APC"}]}]},{"description":"Treat radius fracture","code_information":[{"code":"24655","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1192.86,"maximum":4106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1590.48,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3069.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1192.86,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1622.29,"additional_payer_notes":"APC"}]}]},{"description":"Amputation of upper arm","code_information":[{"code":"24900","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":24508.8,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12698.86,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":24508.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9524.15,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12952.84,"additional_payer_notes":"APC"}]}]},{"description":"Incision of tendon sheath","code_information":[{"code":"25000","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1192.86,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1590.48,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3069.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1192.86,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1622.29,"additional_payer_notes":"APC"}]}]},{"description":"Art byp pop-tibl-prl-other","code_information":[{"code":"35571","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Art byp subclav-subclavian","code_information":[{"code":"35612","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Art byp iliorenal","code_information":[{"code":"35634","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Art byp axillary-axillary","code_information":[{"code":"35650","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Composite byp grft pros&vein","code_information":[{"code":"35681","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Art trnsposj carotid subclav","code_information":[{"code":"35695","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Repair vessel graft defect","code_information":[{"code":"35870","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Excision graft extremity","code_information":[{"code":"35903","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2342.32,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3123.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6027.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2342.32,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3185.56,"additional_payer_notes":"APC"}]}]},{"description":"Place catheter in vein","code_information":[{"code":"36012","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Place catheter in artery","code_information":[{"code":"36215","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Place cath subclavian art","code_information":[{"code":"36225","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2342.32,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3123.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6027.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2342.32,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3185.56,"additional_payer_notes":"APC"}]}]},{"description":"Ins cath ren art 1st unilat","code_information":[{"code":"36251","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2342.32,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3123.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6027.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2342.32,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3185.56,"additional_payer_notes":"APC"}]}]},{"description":"Blood transfusion service","code_information":[{"code":"36430","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":327.28,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":436.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":842.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":327.28,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":445.1,"additional_payer_notes":"APC"}]}]},{"description":"Endovenous rf 1st vein","code_information":[{"code":"36475","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2342.32,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3123.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6027.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2342.32,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3185.56,"additional_payer_notes":"APC"}]}]},{"description":"Apheresis rbc","code_information":[{"code":"36512","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1155.35,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1540.47,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2973.1,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1155.35,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1571.27,"additional_payer_notes":"APC"}]}]},{"description":"Insert tunneled cv cath","code_information":[{"code":"36558","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2342.32,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3123.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6027.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2342.32,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3185.56,"additional_payer_notes":"APC"}]}]},{"description":"Insert picvad cath","code_information":[{"code":"36570","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2342.32,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3123.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6027.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2342.32,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3185.56,"additional_payer_notes":"APC"}]}]},{"description":"Replace tunneled cv cath","code_information":[{"code":"36583","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4127.91,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5503.89,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":10622.5,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4127.91,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5613.96,"additional_payer_notes":"APC"}]}]},{"description":"Inj w/fluor eval cv device","code_information":[{"code":"36598","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":157.79,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":210.39,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":406.05,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":157.79,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":214.59,"additional_payer_notes":"APC"}]}]},{"description":"Insertion of cannula","code_information":[{"code":"36815","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4127.91,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5503.89,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":10622.5,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4127.91,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5613.96,"additional_payer_notes":"APC"}]}]},{"description":"Open thrombect av fistula","code_information":[{"code":"36831","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4127.91,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5503.89,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":10622.5,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4127.91,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5613.96,"additional_payer_notes":"APC"}]}]},{"description":"Revision of circulation","code_information":[{"code":"37145","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Sec art thrombectomy add-on","code_information":[{"code":"37186","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Transcatheter biopsy","code_information":[{"code":"37200","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4127.91,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5503.89,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":10622.5,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4127.91,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5613.96,"additional_payer_notes":"APC"}]}]},{"description":"Stent placemt ante carotid","code_information":[{"code":"37218","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Fem/popl revasc stnt & ather","code_information":[{"code":"37227","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8923.0,"maximum":44873.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":10765.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":8923.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":10765.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":44873.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":44873.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":44873.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":43285.0}]}]},{"description":"Tib/per revasc stnt & ather","code_information":[{"code":"37235","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5512.0,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0}]}]},{"description":"Vasc embolize/occlude bleed","code_information":[{"code":"37244","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":27583.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11418.47,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":22037.64,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8563.85,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":27583.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11646.84,"additional_payer_notes":"APC"}]}]},{"description":"Ligation of neck artery","code_information":[{"code":"37606","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2342.32,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3123.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6027.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2342.32,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3185.56,"additional_payer_notes":"APC"}]}]},{"description":"Revision of major vein","code_information":[{"code":"37650","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2342.32,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3123.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6027.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2342.32,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3185.56,"additional_payer_notes":"APC"}]}]},{"description":"Stab phleb veins xtr 10-20","code_information":[{"code":"37765","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2342.32,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3123.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6027.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2342.32,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3185.56,"additional_payer_notes":"APC"}]}]},{"description":"Removal of spleen partial","code_information":[{"code":"38101","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Harvest auto stem cells","code_information":[{"code":"38206","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1155.35,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1540.47,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2973.1,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1155.35,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1571.27,"additional_payer_notes":"APC"}]}]},{"description":"Volume deplete of harvest","code_information":[{"code":"38214","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":327.28,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":436.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":842.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":327.28,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":445.1,"additional_payer_notes":"APC"}]}]},{"description":"Transplt allo lymphocytes","code_information":[{"code":"38242","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1155.35,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1540.47,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2973.1,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1155.35,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1571.27,"additional_payer_notes":"APC"}]}]},{"description":"Biopsy/removal lymph nodes","code_information":[{"code":"38500","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2904.59,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3872.79,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7474.49,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2904.59,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3950.25,"additional_payer_notes":"APC"}]}]},{"description":"Intmd rpr s/a/t/ext 20.1-30","code_information":[{"code":"12036","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":548.27,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":731.02,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1410.87,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":548.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":745.64,"additional_payer_notes":"APC"}]}]},{"description":"Intmd rpr face/mm 2.5 cm/<","code_information":[{"code":"12051","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":301.57,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":402.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":776.03,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":301.57,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":410.13,"additional_payer_notes":"APC"}]}]},{"description":"Cmplx rpr trunk 2.6-7.5 cm","code_information":[{"code":"13101","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":548.27,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":731.02,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1410.87,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":548.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":745.64,"additional_payer_notes":"APC"}]}]},{"description":"Cmplx rpr e/n/e/l 1.1-2.5 cm","code_information":[{"code":"13151","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":548.27,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":731.02,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1410.87,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":548.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":745.64,"additional_payer_notes":"APC"}]}]},{"description":"Tis trnfr f/c/c/m/n/a/g/h/f","code_information":[{"code":"14040","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1530.61,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2040.81,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3938.76,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1530.61,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2081.63,"additional_payer_notes":"APC"}]}]},{"description":"Wound prep addl 100 cm","code_information":[{"code":"15003","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Epidrm autogrft t/a/l add-on","code_information":[{"code":"15111","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Derm autograft f/n/hf/g add","code_information":[{"code":"15136","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Skin full graft trunk add-on","code_information":[{"code":"15201","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Skin sub graft t/a/l add-on","code_information":[{"code":"15272","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Skin pedicle flap arms/legs","code_information":[{"code":"15572","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2628.85,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3505.13,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6764.9,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2628.85,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3575.23,"additional_payer_notes":"APC"}]}]},{"description":"Forehead Flap w/Vasc Pedicle","code_information":[{"code":"15731","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2628.85,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3505.13,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6764.9,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2628.85,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3575.23,"additional_payer_notes":"APC"}]}]},{"description":"Free fascial flap microvasc","code_information":[{"code":"15758","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0}]}]},{"description":"Dermabrasion other than face","code_information":[{"code":"15782","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2154.81,"maximum":5545.05,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2873.08,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5545.05,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2154.81,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2930.54,"additional_payer_notes":"APC"}]}]},{"description":"Revision of lower eyelid","code_information":[{"code":"15820","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1530.61,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2040.81,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3938.76,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1530.61,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2081.63,"additional_payer_notes":"APC"}]}]},{"description":"Removal of skin wrinkles","code_information":[{"code":"15829","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2628.85,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3505.13,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6764.9,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2628.85,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3575.23,"additional_payer_notes":"APC"}]}]},{"description":"Excise excess skin fat pad","code_information":[{"code":"15838","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2154.81,"maximum":5545.05,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2873.08,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5545.05,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2154.81,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2930.54,"additional_payer_notes":"APC"}]}]},{"description":"Dressing change not for burn","code_information":[{"code":"15852","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":548.27,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":731.02,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1410.87,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":548.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":745.64,"additional_payer_notes":"APC"}]}]},{"description":"Remove sacrum pressure sore","code_information":[{"code":"15931","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2154.81,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2873.08,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5545.05,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2154.81,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2930.54,"additional_payer_notes":"APC"}]}]},{"description":"Remove hip pressure sore","code_information":[{"code":"15944","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2628.85,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3505.13,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6764.9,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2628.85,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3575.23,"additional_payer_notes":"APC"}]}]},{"description":"Remove thigh pressure sore","code_information":[{"code":"15958","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2628.85,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3505.13,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6764.9,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2628.85,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3575.23,"additional_payer_notes":"APC"}]}]},{"description":"Destruct premalg lesion","code_information":[{"code":"17000","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":148.84,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":198.45,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":383.01,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":148.84,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":202.42,"additional_payer_notes":"APC"}]}]},{"description":"Musculoskeletal surgery","code_information":[{"code":"20999","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":182.99,"maximum":13249.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":243.98,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":13249.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":10779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":13249.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":470.88,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":182.99,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":248.86,"additional_payer_notes":"APC"}]}]},{"description":"Excision of bone lower jaw","code_information":[{"code":"21025","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Removal of jaw bone lesion","code_information":[{"code":"21044","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Remove coronoid process","code_information":[{"code":"21070","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Bone/skin graft iliac crest","code_information":[{"code":"20970","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Sp bone agrft morsel add-on","code_information":[{"code":"20937","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5512.0,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0}]}]},{"description":"Remove cartilage for graft","code_information":[{"code":"20910","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":548.27,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":731.02,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1410.87,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":548.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":745.64,"additional_payer_notes":"APC"}]}]},{"description":"Replantation hand complete","code_information":[{"code":"20808","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6779.0,"maximum":33471.73,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17342.86,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":33471.73,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13007.15,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":27583.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17689.72,"additional_payer_notes":"APC"}]}]},{"description":"Apply bone fixation device","code_information":[{"code":"20690","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":13851.98,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Apply rem fixation device","code_information":[{"code":"20660","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1192.86,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1590.48,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3069.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1192.86,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1622.29,"additional_payer_notes":"APC"}]}]},{"description":"Drain/inj joint/bursa w/us","code_information":[{"code":"20604","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":227.71,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":303.61,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":585.96,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":227.71,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":309.68,"additional_payer_notes":"APC"}]}]},{"description":"Ther injection carp tunnel","code_information":[{"code":"20526","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":227.71,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":303.61,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":585.96,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":227.71,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":309.68,"additional_payer_notes":"APC"}]}]},{"description":"Bone biopsy open superficial","code_information":[{"code":"20240","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2154.81,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2873.08,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5545.05,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2154.81,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2930.54,"additional_payer_notes":"APC"}]}]},{"description":"Explore wound abdomen","code_information":[{"code":"20102","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1530.61,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2040.81,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3938.76,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1530.61,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2081.63,"additional_payer_notes":"APC"}]}]},{"description":"Breast reconstruction","code_information":[{"code":"19369","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6019.0,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":7398.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6019.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":7398.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0}]}]},{"description":"Delayed breast prosthesis","code_information":[{"code":"19342","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6063.28,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8084.38,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":15602.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6063.28,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8246.06,"additional_payer_notes":"APC"}]}]},{"description":"Mast rad urban type","code_information":[{"code":"19306","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6019.0,"maximum":7398.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":7398.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6019.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":7398.0}]}]},{"description":"Place po breast cath for rad","code_information":[{"code":"19296","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6063.28,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8084.38,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":15602.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6063.28,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8246.06,"additional_payer_notes":"APC"}]}]},{"description":"Perq device breast 1st imag","code_information":[{"code":"19281","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1225.21,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1633.61,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3152.87,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1225.21,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1666.28,"additional_payer_notes":"APC"}]}]},{"description":"Bx breast percut w/o image","code_information":[{"code":"19100","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1225.21,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1633.61,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3152.87,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1225.21,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1666.28,"additional_payer_notes":"APC"}]}]},{"description":"Incision of breast lesion","code_information":[{"code":"19020","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1225.21,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1633.61,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3152.87,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1225.21,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1666.28,"additional_payer_notes":"APC"}]}]},{"description":"Mohs addl stage t/a/l","code_information":[{"code":"17314","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Destruction of skin lesions","code_information":[{"code":"17281","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":148.84,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":198.45,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":383.01,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":148.84,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":202.42,"additional_payer_notes":"APC"}]}]},{"description":"Destruction of skin lesions","code_information":[{"code":"17266","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":301.57,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":402.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":776.03,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":301.57,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":410.13,"additional_payer_notes":"APC"}]}]},{"description":"Destruct b9 lesion 1-14","code_information":[{"code":"17110","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":148.84,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":198.45,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":383.01,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":148.84,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":202.42,"additional_payer_notes":"APC"}]}]},{"description":"Prepare face/oral prosthesis","code_information":[{"code":"21084","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2459.51,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3279.35,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6329.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2459.51,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3344.94,"additional_payer_notes":"APC"}]}]},{"description":"Injection jaw joint x-ray","code_information":[{"code":"21116","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Reduction of forehead","code_information":[{"code":"21138","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Lefort ii anterior intrusion","code_information":[{"code":"21150","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Reconstruct entire forehead","code_information":[{"code":"21179","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Reconst lwr jaw w/graft","code_information":[{"code":"21194","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Face bone graft","code_information":[{"code":"21210","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Reconstruction of jaw","code_information":[{"code":"21245","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Revise eye sockets","code_information":[{"code":"21261","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Revision of jaw muscle/bone","code_information":[{"code":"21295","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1151.01,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1534.69,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2961.94,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1151.01,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1565.38,"additional_payer_notes":"APC"}]}]},{"description":"Open tx septal fx w/wo stabj","code_information":[{"code":"21336","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Opn tx nasomax fx w/fixj","code_information":[{"code":"21346","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":11300.84,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Opn tx orbit fx transantral","code_information":[{"code":"21385","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Opn tx orbit fx w/implant","code_information":[{"code":"21407","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Treat craniofacial fracture","code_information":[{"code":"21435","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Treat lower jaw fracture","code_information":[{"code":"21454","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":11300.84,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Interdental wiring","code_information":[{"code":"21497","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1151.01,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1534.69,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2961.94,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1151.01,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1565.38,"additional_payer_notes":"APC"}]}]},{"description":"Exc neck les sc < 3 cm","code_information":[{"code":"21555","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1225.21,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1633.61,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3152.87,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1225.21,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1666.28,"additional_payer_notes":"APC"}]}]},{"description":"Partial removal of sternum","code_information":[{"code":"21620","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Reconstruction of sternum","code_information":[{"code":"21740","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Treat sternum fracture","code_information":[{"code":"21825","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Resect back tum < 5 cm","code_information":[{"code":"21935","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2154.81,"maximum":5545.05,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2873.08,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5545.05,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2154.81,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2930.54,"additional_payer_notes":"APC"}]}]},{"description":"Remove part of neck vertebra","code_information":[{"code":"22110","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Incis 1 vertebral seg thorac","code_information":[{"code":"22212","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Closed tx vert fx w/manj","code_information":[{"code":"22315","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":6246.19,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Perq cervicothoracic inject","code_information":[{"code":"22510","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Lat thorax spine fusion","code_information":[{"code":"22532","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6779.0,"maximum":27583.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12698.86,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":24508.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9524.15,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":27583.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12952.84,"additional_payer_notes":"APC"}]}]},{"description":"Lumbar spine fusion","code_information":[{"code":"22558","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":51798.34,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26838.52,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":51798.34,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20128.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":27583.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27375.29,"additional_payer_notes":"APC"}]}]},{"description":"Spine fusion extra segment","code_information":[{"code":"22614","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Ant fusion 2-3 vert seg","code_information":[{"code":"22808","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":33471.73,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17342.86,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":33471.73,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13007.15,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":27583.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17689.72,"additional_payer_notes":"APC"}]}]},{"description":"Insert spine fixation device","code_information":[{"code":"22842","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Remove spine fixation device","code_information":[{"code":"22850","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3388.0,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Remove cerv artif disc","code_information":[{"code":"22864","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Rad resect abd tumor 5 cm/>","code_information":[{"code":"22905","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2154.81,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2873.08,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5545.05,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2154.81,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2930.54,"additional_payer_notes":"APC"}]}]},{"description":"Exploratory shoulder surgery","code_information":[{"code":"23044","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Resect shoulder tumor 5 cm/>","code_information":[{"code":"23078","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2154.81,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2873.08,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5545.05,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2154.81,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2930.54,"additional_payer_notes":"APC"}]}]},{"description":"Remove shoulder bone part","code_information":[{"code":"23130","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Remove shoulder blade lesion","code_information":[{"code":"23172","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Resect scapula tumor","code_information":[{"code":"23210","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Muscle transfers","code_information":[{"code":"23397","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Repair biceps tendon","code_information":[{"code":"23430","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Reconstruct shoulder joint","code_information":[{"code":"23470","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":27583.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12698.86,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":24508.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9524.15,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":27583.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12952.84,"additional_payer_notes":"APC"}]}]},{"description":"Treat clavicle fracture","code_information":[{"code":"23500","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":182.99,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":243.98,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":470.88,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":182.99,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":248.86,"additional_payer_notes":"APC"}]}]},{"description":"Treat clavicle dislocation","code_information":[{"code":"23545","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":182.99,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":243.98,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":470.88,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":182.99,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":248.86,"additional_payer_notes":"APC"}]}]},{"description":"Treat humerus fracture","code_information":[{"code":"23615","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":24508.8,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12698.86,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":24508.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9524.15,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12952.84,"additional_payer_notes":"APC"}]}]},{"description":"Treat dislocation/fracture","code_information":[{"code":"23665","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1192.86,"maximum":4106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1590.48,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3069.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1192.86,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1622.29,"additional_payer_notes":"APC"}]}]},{"description":"Amputation at shoulder joint","code_information":[{"code":"23920","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":24508.8,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12698.86,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":24508.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9524.15,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12952.84,"additional_payer_notes":"APC"}]}]},{"description":"Biopsy arm/elbow soft tissue","code_information":[{"code":"24065","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1225.21,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1633.61,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3152.87,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1225.21,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1666.28,"additional_payer_notes":"APC"}]}]},{"description":"Biopsy elbow joint lining","code_information":[{"code":"24100","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Remove/graft bone lesion","code_information":[{"code":"24125","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Partial removal of elbow","code_information":[{"code":"24147","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Removal of arm foreign body","code_information":[{"code":"24201","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2154.81,"maximum":5545.05,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2873.08,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5545.05,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2154.81,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2930.54,"additional_payer_notes":"APC"}]}]},{"description":"Revision of arm muscles","code_information":[{"code":"24331","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Reconstruct elbow med ligmnt","code_information":[{"code":"24346","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":24508.8,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12698.86,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":24508.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9524.15,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12952.84,"additional_payer_notes":"APC"}]}]},{"description":"Reconstruct head of radius","code_information":[{"code":"24365","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":24508.8,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12698.86,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":24508.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9524.15,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12952.84,"additional_payer_notes":"APC"}]}]},{"description":"Repair humerus with graft","code_information":[{"code":"24435","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":24508.8,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12698.86,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":24508.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9524.15,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12952.84,"additional_payer_notes":"APC"}]}]},{"description":"Treat humerus fracture","code_information":[{"code":"24530","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":182.99,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":243.98,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":470.88,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":182.99,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":248.86,"additional_payer_notes":"APC"}]}]},{"description":"Treat humerus fracture","code_information":[{"code":"24575","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":24508.8,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12698.86,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":24508.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9524.15,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12952.84,"additional_payer_notes":"APC"}]}]},{"description":"Treat elbow dislocation","code_information":[{"code":"24605","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1192.86,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1590.48,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3069.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1192.86,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1622.29,"additional_payer_notes":"APC"}]}]},{"description":"Treat radius fracture","code_information":[{"code":"24666","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":24508.8,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12698.86,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":24508.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9524.15,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12952.84,"additional_payer_notes":"APC"}]}]},{"description":"Amputation follow-up surgery","code_information":[{"code":"24925","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Decompress forearm 1 space","code_information":[{"code":"25020","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1192.86,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1590.48,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3069.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1192.86,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1622.29,"additional_payer_notes":"APC"}]}]},{"description":"Biopsy forearm soft tissues","code_information":[{"code":"25065","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1225.21,"maximum":4106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1633.61,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3152.87,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1225.21,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1666.28,"additional_payer_notes":"APC"}]}]},{"description":"Incision of wrist capsule","code_information":[{"code":"25085","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Reremove wrist tendon lesion","code_information":[{"code":"25112","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1192.86,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1590.48,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3069.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1192.86,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1622.29,"additional_payer_notes":"APC"}]}]},{"description":"Removal of wrist lesion","code_information":[{"code":"25130","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Removal of wrist bones","code_information":[{"code":"25215","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Repair forearm tendon/muscle","code_information":[{"code":"25260","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Incise wrist/forearm tendon","code_information":[{"code":"25290","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Repair/revise wrist joint","code_information":[{"code":"25320","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Revise radius or ulna","code_information":[{"code":"25370","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Repair/graft radius or ulna","code_information":[{"code":"25405","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Reconstruct wrist joint","code_information":[{"code":"25441","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":27583.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12698.86,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":24508.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9524.15,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":27583.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12952.84,"additional_payer_notes":"APC"}]}]},{"description":"Revision of wrist joint","code_information":[{"code":"25450","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Treat fracture of radius","code_information":[{"code":"25520","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1192.86,"maximum":4106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1590.48,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3069.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1192.86,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1622.29,"additional_payer_notes":"APC"}]}]},{"description":"Treat fracture radius & ulna","code_information":[{"code":"25574","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Treat wrist bone fracture","code_information":[{"code":"25622","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":182.99,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":243.98,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":470.88,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":182.99,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":248.86,"additional_payer_notes":"APC"}]}]},{"description":"Treat fracture ulnar styloid","code_information":[{"code":"25652","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Treat wrist dislocation","code_information":[{"code":"25690","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1192.86,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1590.48,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3069.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1192.86,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1622.29,"additional_payer_notes":"APC"}]}]},{"description":"Amputation of forearm","code_information":[{"code":"25900","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Amputation of hand","code_information":[{"code":"25927","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Drainage of palm bursas","code_information":[{"code":"26030","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":6246.19,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Explore/treat hand joint","code_information":[{"code":"26070","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1192.86,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1590.48,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3069.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1192.86,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1622.29,"additional_payer_notes":"APC"}]}]},{"description":"Exc hand les sc < 1.5 cm","code_information":[{"code":"26115","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1225.21,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1633.61,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3152.87,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1225.21,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1666.28,"additional_payer_notes":"APC"}]}]},{"description":"Revise finger joint each","code_information":[{"code":"26135","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Remove/graft bone lesion","code_information":[{"code":"26205","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":13851.98,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Resect distal finger tumor","code_information":[{"code":"26262","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1192.86,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1590.48,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3069.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1192.86,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1622.29,"additional_payer_notes":"APC"}]}]},{"description":"Repair/graft hand tendon","code_information":[{"code":"26358","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":13851.98,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Excision hand/finger tendon","code_information":[{"code":"26415","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Repair/graft finger tendon","code_information":[{"code":"26434","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Incise hand/finger tendon","code_information":[{"code":"26460","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1192.86,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1590.48,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3069.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1192.86,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1622.29,"additional_payer_notes":"APC"}]}]},{"description":"Transplant/graft hand tendon","code_information":[{"code":"26483","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Finger tendon transfer","code_information":[{"code":"26498","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Fusion of knuckle joints","code_information":[{"code":"26518","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":13851.98,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Repair hand joint with graft","code_information":[{"code":"26541","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Double transfer toe-hand","code_information":[{"code":"26554","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Lengthen metacarpal/finger","code_information":[{"code":"26568","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":13851.98,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Treat metacarpal fracture","code_information":[{"code":"26605","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":182.99,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":243.98,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":470.88,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":182.99,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":248.86,"additional_payer_notes":"APC"}]}]},{"description":"Treat hand dislocation","code_information":[{"code":"26670","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":182.99,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":243.98,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":470.88,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":182.99,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":248.86,"additional_payer_notes":"APC"}]}]},{"description":"Treat knuckle dislocation","code_information":[{"code":"26715","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Treat finger fracture each","code_information":[{"code":"26750","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":182.99,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":243.98,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":470.88,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":182.99,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":248.86,"additional_payer_notes":"APC"}]}]},{"description":"Thumb fusion with graft","code_information":[{"code":"26820","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":13851.98,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Fusion of finger jnt add-on","code_information":[{"code":"26861","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Drainage of pelvis bursa","code_information":[{"code":"26991","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1192.86,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1590.48,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3069.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1192.86,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1622.29,"additional_payer_notes":"APC"}]}]},{"description":"Buttock fasciotomy","code_information":[{"code":"27027","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":13851.98,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Exc hip/pelv tum deep 5 cm/>","code_information":[{"code":"27045","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2154.81,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2873.08,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5545.05,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2154.81,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2930.54,"additional_payer_notes":"APC"}]}]},{"description":"Resect hip/pelv tum 5 cm/>","code_information":[{"code":"27059","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2154.81,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2873.08,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5545.05,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2154.81,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2930.54,"additional_payer_notes":"APC"}]}]},{"description":"Resect hip tumor","code_information":[{"code":"27075","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Removal of hip prosthesis","code_information":[{"code":"27091","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":24508.8,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12698.86,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":24508.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9524.15,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12952.84,"additional_payer_notes":"APC"}]}]},{"description":"Transfer of iliopsoas muscle","code_information":[{"code":"27110","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Revise hip joint replacement","code_information":[{"code":"27137","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6779.0,"maximum":27583.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12698.86,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":24508.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9524.15,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":27583.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12952.84,"additional_payer_notes":"APC"}]}]},{"description":"Incision of neck of femur","code_information":[{"code":"27161","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Treat slipped epiphysis","code_information":[{"code":"27181","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Treat pelvic ring fracture","code_information":[{"code":"27218","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3579.0,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0}]}]},{"description":"Treat thigh fracture","code_information":[{"code":"27235","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":13851.98,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Treat hip dislocation","code_information":[{"code":"27250","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":182.99,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":243.98,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":470.88,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":182.99,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":248.86,"additional_payer_notes":"APC"}]}]},{"description":"Treat hip dislocation","code_information":[{"code":"27265","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":182.99,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":243.98,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":470.88,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":182.99,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":248.86,"additional_payer_notes":"APC"}]}]},{"description":"Fusion of pubic bones","code_information":[{"code":"27282","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Incise thigh tendon & fascia","code_information":[{"code":"27305","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Exc thigh/knee les sc < 3 cm","code_information":[{"code":"27327","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1225.21,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1633.61,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3152.87,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1225.21,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1666.28,"additional_payer_notes":"APC"}]}]},{"description":"Remove knee joint lining","code_information":[{"code":"27335","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":13851.98,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Remove femur lesion/graft","code_information":[{"code":"27356","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":24508.8,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12698.86,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":24508.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9524.15,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12952.84,"additional_payer_notes":"APC"}]}]},{"description":"Repair/graft kneecap tendon","code_information":[{"code":"27381","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":13851.98,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Lengthening of thigh tendons","code_information":[{"code":"27395","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Autochondrocyte implant knee","code_information":[{"code":"27412","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Reconstruction knee","code_information":[{"code":"27427","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Revision of knee joint","code_information":[{"code":"27441","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":24508.8,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12698.86,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":24508.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9524.15,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12952.84,"additional_payer_notes":"APC"}]}]},{"description":"Realignment of thigh bone","code_information":[{"code":"27454","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Surgery to stop leg growth","code_information":[{"code":"27475","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":13851.98,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Decompression of thigh/knee","code_information":[{"code":"27496","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Treatment of thigh fracture","code_information":[{"code":"27506","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Treat thigh fx growth plate","code_information":[{"code":"27516","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":182.99,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":243.98,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":470.88,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":182.99,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":248.86,"additional_payer_notes":"APC"}]}]},{"description":"Treat knee fracture","code_information":[{"code":"27536","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Treat kneecap dislocation","code_information":[{"code":"27560","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":182.99,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":243.98,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":470.88,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":182.99,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":248.86,"additional_payer_notes":"APC"}]}]},{"description":"Amputation follow-up surgery","code_information":[{"code":"27594","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Drain lower leg bursa","code_information":[{"code":"27604","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Resect leg/ankle tum < 5 cm","code_information":[{"code":"27615","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2154.81,"maximum":5545.05,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2873.08,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5545.05,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2154.81,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2930.54,"additional_payer_notes":"APC"}]}]},{"description":"Exc leg/ankle les sc 3 cm/>","code_information":[{"code":"27632","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2154.81,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2873.08,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5545.05,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2154.81,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2930.54,"additional_payer_notes":"APC"}]}]},{"description":"Resect fibula tumor","code_information":[{"code":"27646","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Repair of leg tendon each","code_information":[{"code":"27659","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":13851.98,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Revise lower leg tendons","code_information":[{"code":"27686","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Revision of ankle joint","code_information":[{"code":"27700","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Revision of lower leg","code_information":[{"code":"27715","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":24508.8,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12698.86,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":24508.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9524.15,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12952.84,"additional_payer_notes":"APC"}]}]},{"description":"Repair of fibula epiphysis","code_information":[{"code":"27732","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Treatment of tibia fracture","code_information":[{"code":"27758","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":24508.8,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12698.86,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":24508.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9524.15,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12952.84,"additional_payer_notes":"APC"}]}]},{"description":"Treatment of fibula fracture","code_information":[{"code":"27780","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":182.99,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":243.98,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":470.88,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":182.99,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":248.86,"additional_payer_notes":"APC"}]}]},{"description":"Treatment of ankle fracture","code_information":[{"code":"27814","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Treat lower leg fracture","code_information":[{"code":"27827","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":24508.8,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12698.86,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":24508.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9524.15,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12952.84,"additional_payer_notes":"APC"}]}]},{"description":"Treat ankle dislocation","code_information":[{"code":"27846","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Amputation follow-up surgery","code_information":[{"code":"27884","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Drainage of bursa of foot","code_information":[{"code":"28001","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1225.21,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1633.61,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3152.87,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1225.21,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1666.28,"additional_payer_notes":"APC"}]}]},{"description":"Exploration of foot joint","code_information":[{"code":"28022","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Resect foot/toe tumor 3 cm/>","code_information":[{"code":"28047","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2154.81,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2873.08,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5545.05,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2154.81,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2930.54,"additional_payer_notes":"APC"}]}]},{"description":"Removal of foot joint lining","code_information":[{"code":"28072","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Shoulder arthroscopy/surgery","code_information":[{"code":"29824","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5067.0},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Shoulder arthroscopy dx","code_information":[{"code":"29805","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Removal/revision of cast","code_information":[{"code":"29710","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":207.48,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":276.65,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":533.93,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":207.48,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":282.18,"additional_payer_notes":"APC"}]}]},{"description":"Strapping of knee","code_information":[{"code":"29530","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":98.7,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":131.6,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":253.99,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":98.7,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":134.23,"additional_payer_notes":"APC"}]}]},{"description":"Apply short leg cast","code_information":[{"code":"29425","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":207.48,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":276.65,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":533.93,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":207.48,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":282.18,"additional_payer_notes":"APC"}]}]},{"description":"Strapping of hand or finger","code_information":[{"code":"29280","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":43.76,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":58.35,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":112.62,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":43.76,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":59.52,"additional_payer_notes":"APC"}]}]},{"description":"Apply long arm splint","code_information":[{"code":"29105","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":120.55,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":160.73,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":310.21,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":120.55,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":163.95,"additional_payer_notes":"APC"}]}]},{"description":"Application of body cast","code_information":[{"code":"29046","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":207.48,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":276.65,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":533.93,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":207.48,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":282.18,"additional_payer_notes":"APC"}]}]},{"description":"Hi enrgy eswt plantar fascia","code_information":[{"code":"28890","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1192.86,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1590.48,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3069.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1192.86,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1622.29,"additional_payer_notes":"APC"}]}]},{"description":"Fusion of big toe joint","code_information":[{"code":"28750","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Repair of toe dislocation","code_information":[{"code":"28675","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Repair foot dislocation","code_information":[{"code":"28615","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Repair foot dislocation","code_information":[{"code":"28555","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Treatment of toe fracture","code_information":[{"code":"28510","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":182.99,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":243.98,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":470.88,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":182.99,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":248.86,"additional_payer_notes":"APC"}]}]},{"description":"Treat metatarsal fracture","code_information":[{"code":"28470","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":182.99,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":243.98,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":470.88,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":182.99,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":248.86,"additional_payer_notes":"APC"}]}]},{"description":"Treatment of ankle fracture","code_information":[{"code":"28435","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1192.86,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1590.48,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3069.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1192.86,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1622.29,"additional_payer_notes":"APC"}]}]},{"description":"Repair webbed toe(s)","code_information":[{"code":"28345","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1192.86,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1590.48,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3069.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1192.86,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1622.29,"additional_payer_notes":"APC"}]}]},{"description":"Revision of toe","code_information":[{"code":"28312","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Incision of ankle bone","code_information":[{"code":"28302","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":13851.98,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Partial removal of foot bone","code_information":[{"code":"28288","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Revision of foot tendon","code_information":[{"code":"28261","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1192.86,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1590.48,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3069.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1192.86,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1622.29,"additional_payer_notes":"APC"}]}]},{"description":"Release of foot tendons","code_information":[{"code":"28226","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Removal of foot foreign body","code_information":[{"code":"28193","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1225.21,"maximum":4106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1633.61,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3152.87,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1225.21,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1666.28,"additional_payer_notes":"APC"}]}]},{"description":"Removal of toe","code_information":[{"code":"28150","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Removal of heel bone","code_information":[{"code":"28118","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Remove/graft foot lesion","code_information":[{"code":"28107","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Excise foot tendon sheath","code_information":[{"code":"28088","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Insert cath pleura w/ image","code_information":[{"code":"32557","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1167.76,"maximum":4106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1557.01,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3005.03,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1167.76,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1588.15,"additional_payer_notes":"APC"}]}]},{"description":"Thoracoscopy w/bx nodule","code_information":[{"code":"32608","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5257.0,"maximum":20292.15,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10514.07,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5257.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":20292.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7885.55,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10724.35,"additional_payer_notes":"APC"}]}]},{"description":"Thoracoscopy w/pleurectomy","code_information":[{"code":"32656","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5257.0,"maximum":27583.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5257.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":27583.0}]}]},{"description":"Thoracoscopy w/wedge resect","code_information":[{"code":"32666","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":9356.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0}]}]},{"description":"Remove nasal foreign body","code_information":[{"code":"30310","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2459.51,"maximum":6329.15,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3279.35,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6329.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2459.51,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3344.94,"additional_payer_notes":"APC"}]}]},{"description":"Excise inferior turbinate","code_information":[{"code":"30130","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2459.51,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3279.35,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6329.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2459.51,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3344.94,"additional_payer_notes":"APC"}]}]},{"description":"Intranasal biopsy","code_information":[{"code":"30100","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1151.01,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1534.69,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2961.94,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1151.01,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1565.38,"additional_payer_notes":"APC"}]}]},{"description":"Subtalar arthro w/deb","code_information":[{"code":"29906","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Ankle arthroscopy/surgery","code_information":[{"code":"29897","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Knee arthroscopy/surgery","code_information":[{"code":"29887","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":13851.98,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Knee arthroscopy/surgery","code_information":[{"code":"29879","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Meniscal trnspl knee w/scpe","code_information":[{"code":"29868","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Tibial arthroscopy/surgery","code_information":[{"code":"29855","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Wrist arthroscopy/surgery","code_information":[{"code":"29843","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Revision of nose","code_information":[{"code":"30462","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Intranasal reconstruction","code_information":[{"code":"30620","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Ligation nasal sinus artery","code_information":[{"code":"30915","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2342.32,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3123.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6027.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2342.32,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3185.56,"additional_payer_notes":"APC"}]}]},{"description":"Explore sinus remove polyps","code_information":[{"code":"31032","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Removal of frontal sinus","code_information":[{"code":"31084","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Removal of upper jaw","code_information":[{"code":"31225","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Nasal/sinus endoscopy surg","code_information":[{"code":"31240","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1320.39,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1760.51,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3397.79,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1320.39,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1795.72,"additional_payer_notes":"APC"}]}]},{"description":"Nasal/sinus endoscopy surg","code_information":[{"code":"31290","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6019.0,"maximum":7398.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":7398.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6019.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":7398.0}]}]},{"description":"Sinus surgery procedure","code_information":[{"code":"31299","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":175.7,"maximum":13249.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":234.27,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":13249.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":10779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":13249.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":452.14,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":175.7,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":238.96,"additional_payer_notes":"APC"}]}]},{"description":"Partial removal of larynx","code_information":[{"code":"31380","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Diagnostic laryngoscopy","code_information":[{"code":"31505","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":148.07,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":197.43,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":381.05,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":148.07,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":201.38,"additional_payer_notes":"APC"}]}]},{"description":"Dx laryngoscopy w/oper scope","code_information":[{"code":"31526","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1320.39,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1760.51,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3397.79,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1320.39,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1795.72,"additional_payer_notes":"APC"}]}]},{"description":"Laryngoscopy w/exc of tumor","code_information":[{"code":"31540","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2765.81,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3687.74,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7117.34,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2765.81,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3761.5,"additional_payer_notes":"APC"}]}]},{"description":"Diagnostic laryngoscopy","code_information":[{"code":"31575","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":148.07,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":197.43,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":381.05,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":148.07,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":201.38,"additional_payer_notes":"APC"}]}]},{"description":"Reinnervate larynx","code_information":[{"code":"31590","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Puncture/clear windpipe","code_information":[{"code":"31612","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2459.51,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3279.35,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6329.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2459.51,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3344.94,"additional_payer_notes":"APC"}]}]},{"description":"Bronchoscopy w/markers","code_information":[{"code":"31626","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5235.45,"maximum":13472.56,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6980.6,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":7398.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6019.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":7398.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13472.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5235.45,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7120.21,"additional_payer_notes":"APC"}]}]},{"description":"Bronch w/balloon occlusion","code_information":[{"code":"31634","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5235.45,"maximum":13472.56,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6980.6,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":7398.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6019.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":7398.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13472.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5235.45,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7120.21,"additional_payer_notes":"APC"}]}]},{"description":"Bronchoscopy clear airways","code_information":[{"code":"31645","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1320.39,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1760.51,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3397.79,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1320.39,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1795.72,"additional_payer_notes":"APC"}]}]},{"description":"Bronch ebus ivntj perph les","code_information":[{"code":"31654","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Repair of windpipe","code_information":[{"code":"31755","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Remove windpipe lesion","code_information":[{"code":"31786","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Thoracostomy w/flap drainage","code_information":[{"code":"32036","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5257.0,"maximum":6462.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5257.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6462.0}]}]},{"description":"Removal of lung lesion(s)","code_information":[{"code":"32140","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6019.0,"maximum":7398.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":7398.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6019.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":7398.0}]}]},{"description":"Partial release of lung","code_information":[{"code":"32225","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5257.0,"maximum":6462.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5257.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6462.0}]}]},{"description":"Bilobectomy","code_information":[{"code":"32482","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":9356.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0}]}]},{"description":"Wedge resect of lung initial","code_information":[{"code":"32505","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":9356.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0}]}]},{"description":"Thoracoscopy pneumonectomy","code_information":[{"code":"32671","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5257.0,"maximum":6462.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5257.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6462.0}]}]},{"description":"Reconstruct injured chest","code_information":[{"code":"32820","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5257.0,"maximum":6462.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5257.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6462.0}]}]},{"description":"Removal of rib(s)","code_information":[{"code":"32900","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Incision of heart sac","code_information":[{"code":"33020","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6019.0,"maximum":7398.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":7398.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6019.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":7398.0}]}]},{"description":"Heart Tmr W/Other Procedure","code_information":[{"code":"33141","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6019.0,"maximum":7398.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":7398.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6019.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":7398.0}]}]},{"description":"Insert pulse gen sngl lead","code_information":[{"code":"33212","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6138.95,"maximum":27583.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8185.27,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":15797.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6138.95,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":27583.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8348.97,"additional_payer_notes":"APC"}]}]},{"description":"Insert pulse gen mult leads","code_information":[{"code":"33221","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8923.0,"maximum":36770.21,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19051.92,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":10765.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":8923.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":10765.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":36770.21,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14288.94,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":27583.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19432.96,"additional_payer_notes":"APC"}]}]},{"description":"Remv&replc pm gen mult leads","code_information":[{"code":"33229","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8923.0,"maximum":36770.21,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19051.92,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":10765.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":8923.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":10765.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":36770.21,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14288.94,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":27583.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19432.96,"additional_payer_notes":"APC"}]}]},{"description":"Remove electrode/thoracotomy","code_information":[{"code":"33238","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Ablate atria lmtd","code_information":[{"code":"33254","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6019.0,"maximum":7398.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":7398.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6019.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":7398.0}]}]},{"description":"Rmvl & rplcmt dfb gen 2 lead","code_information":[{"code":"33263","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8923.0,"maximum":54996.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22001.33,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":10765.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":8923.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":10765.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":54996.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":54996.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":54996.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":42462.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16501.0,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":51942.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22441.36,"additional_payer_notes":"APC"}]}]},{"description":"Repair of heart wound","code_information":[{"code":"33300","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":9356.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0}]}]},{"description":"Insert major vessel graft","code_information":[{"code":"33335","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6019.0,"maximum":7398.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":7398.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6019.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":7398.0}]}]},{"description":"Replace aortic valve w/byp","code_information":[{"code":"33368","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":9356.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0}]}]},{"description":"Replacement of aortic valve","code_information":[{"code":"33413","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":9356.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0}]}]},{"description":"Revision of mitral valve","code_information":[{"code":"33422","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8923.0,"maximum":10765.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":10765.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":8923.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":10765.0}]}]},{"description":"Replace tricuspid valve","code_information":[{"code":"33465","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":9356.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0}]}]},{"description":"Repair heart vessel fistula","code_information":[{"code":"33500","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":9356.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0}]}]},{"description":"Endoscopic vein harvest","code_information":[{"code":"33508","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Cabg artery-vein two","code_information":[{"code":"33518","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":9356.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0}]}]},{"description":"Cabg arterial three","code_information":[{"code":"33535","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":9356.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0}]}]},{"description":"Anastomosis/artery-aorta","code_information":[{"code":"33606","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":9356.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0}]}]},{"description":"Apply r&l pulm art bands","code_information":[{"code":"33620","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6019.0,"maximum":7398.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":7398.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6019.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":7398.0}]}]},{"description":"Repair of heart chambers","code_information":[{"code":"33670","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":9356.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0}]}]},{"description":"Repair of heart defects","code_information":[{"code":"33692","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":9356.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0}]}]},{"description":"Repair heart-vein defect(s)","code_information":[{"code":"33730","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6019.0,"maximum":7398.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":7398.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6019.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":7398.0}]}]},{"description":"Major vessel shunt","code_information":[{"code":"33766","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6019.0,"maximum":7398.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":7398.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6019.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":7398.0}]}]},{"description":"Repair great vessels defect","code_information":[{"code":"33777","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6019.0,"maximum":7398.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":7398.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6019.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":7398.0}]}]},{"description":"Revision of pulmonary artery","code_information":[{"code":"33788","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6019.0,"maximum":7398.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":7398.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6019.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":7398.0}]}]},{"description":"Remove aorta constriction","code_information":[{"code":"33840","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":9356.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0}]}]},{"description":"Thoracoabdominal graft","code_information":[{"code":"33877","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":9356.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0}]}]},{"description":"Remove lung artery emboli","code_information":[{"code":"33910","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":9356.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0}]}]},{"description":"Repr pul art unifocal w/cpb","code_information":[{"code":"33926","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6019.0,"maximum":7398.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":7398.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6019.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":7398.0}]}]},{"description":"Ecmo/ecls initiation artery","code_information":[{"code":"33947","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3388.0,"maximum":4106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0}]}]},{"description":"Ecmo/ecls insj ctr cannula","code_information":[{"code":"33956","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3388.0,"maximum":4106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0}]}]},{"description":"Ecmo/ecls rmvl prph cannula","code_information":[{"code":"33966","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3388.0,"maximum":4106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0}]}]},{"description":"Implant ventricular device","code_information":[{"code":"33975","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":9356.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0}]}]},{"description":"Replace vad intra w/bp","code_information":[{"code":"33983","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":9356.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0}]}]},{"description":"Insert vad art&vein access","code_information":[{"code":"33991","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":9356.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0}]}]},{"description":"Removal of artery clot","code_information":[{"code":"34151","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Repair valve femoral vein","code_information":[{"code":"34501","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4127.91,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5503.89,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":10622.5,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4127.91,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5613.96,"additional_payer_notes":"APC"}]}]},{"description":"Xpose for endoprosth iliac","code_information":[{"code":"34820","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Endovasc visc aorta 2 graft","code_information":[{"code":"34842","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6019.0,"maximum":7398.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":7398.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6019.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":7398.0}]}]},{"description":"Repair artery rupture neck","code_information":[{"code":"35002","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6019.0,"maximum":7398.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":7398.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6019.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":7398.0}]}]},{"description":"Repair artery rupture aorta","code_information":[{"code":"35082","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Repair artery rupture belly","code_information":[{"code":"35122","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Repair blood vessel lesion","code_information":[{"code":"35182","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Repair blood vessel lesion","code_information":[{"code":"35211","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Repair blood vessel lesion","code_information":[{"code":"35251","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Rechanneling of artery","code_information":[{"code":"35301","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Rechanneling of artery","code_information":[{"code":"35331","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Reoperation carotid add-on","code_information":[{"code":"35390","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Art byp grft subclav-subclav","code_information":[{"code":"35511","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Art byp grft brachial-brchl","code_information":[{"code":"35525","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Art byp grft aortofemoral","code_information":[{"code":"35539","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Art byp tibial-tib/peroneal","code_information":[{"code":"35570","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Art byp carotid-subclavian","code_information":[{"code":"35606","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Art byp ilio-mesenteric","code_information":[{"code":"35633","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Art byp aortofemoral","code_information":[{"code":"35647","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Art byp pop-tibl-prl-other","code_information":[{"code":"35671","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Art trnsposj subclav carotid","code_information":[{"code":"35694","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Explore limb vessels","code_information":[{"code":"35860","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2342.32,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3123.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6027.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2342.32,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3185.56,"additional_payer_notes":"APC"}]}]},{"description":"Excision graft neck","code_information":[{"code":"35901","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Place catheter in vein","code_information":[{"code":"36011","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Place catheter in aorta","code_information":[{"code":"36200","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Place cath carotd art","code_information":[{"code":"36224","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4127.91,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5503.89,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":10622.5,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4127.91,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5613.96,"additional_payer_notes":"APC"}]}]},{"description":"Ins cath abd/l-ext art addl","code_information":[{"code":"36248","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Vessel injection procedure","code_information":[{"code":"36299","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Injection therapy of veins","code_information":[{"code":"36471","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":301.57,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":402.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":776.03,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":301.57,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":410.13,"additional_payer_notes":"APC"}]}]},{"description":"Apheresis wbc","code_information":[{"code":"36511","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1155.35,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1540.47,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2973.1,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1155.35,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1571.27,"additional_payer_notes":"APC"}]}]},{"description":"Insert tunneled cv cath","code_information":[{"code":"36557","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4127.91,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5503.89,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":10622.5,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4127.91,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5613.96,"additional_payer_notes":"APC"}]}]},{"description":"Insert picc cath","code_information":[{"code":"36569","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1167.76,"maximum":4106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1557.01,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3005.03,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1167.76,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1588.15,"additional_payer_notes":"APC"}]}]},{"description":"Replace tunneled cv cath","code_information":[{"code":"36582","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2342.32,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3123.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6027.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2342.32,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3185.56,"additional_payer_notes":"APC"}]}]},{"description":"Reposition venous catheter","code_information":[{"code":"36597","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1167.76,"maximum":4106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1557.01,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3005.03,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1167.76,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1588.15,"additional_payer_notes":"APC"}]}]},{"description":"Insertion of cannula","code_information":[{"code":"36810","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2342.32,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3123.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6027.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2342.32,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3185.56,"additional_payer_notes":"APC"}]}]},{"description":"Artery-vein nonautograft","code_information":[{"code":"36830","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4127.91,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5503.89,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":10622.5,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4127.91,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5613.96,"additional_payer_notes":"APC"}]}]},{"description":"Revision of circulation","code_information":[{"code":"37140","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Prim art m-thrmbc sbsq vsl","code_information":[{"code":"37185","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Remove intrvas foreign body","code_information":[{"code":"37197","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2342.32,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3123.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6027.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2342.32,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3185.56,"additional_payer_notes":"APC"}]}]},{"description":"Stent placemt retro carotid","code_information":[{"code":"37217","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6019.0,"maximum":7398.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":7398.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6019.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":7398.0}]}]},{"description":"Fem/popl revasc w/stent","code_information":[{"code":"37226","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":27583.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":27583.0}]}]},{"description":"Revsc opn/prq tib/pero stent","code_information":[{"code":"37234","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5512.0,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0}]}]},{"description":"Vasc embolize/occlude organ","code_information":[{"code":"37243","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":27583.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11418.47,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":22037.64,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8563.85,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":27583.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11646.84,"additional_payer_notes":"APC"}]}]},{"description":"Ligation of neck artery","code_information":[{"code":"37605","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2342.32,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3123.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6027.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2342.32,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3185.56,"additional_payer_notes":"APC"}]}]},{"description":"Ligation of inf vena cava","code_information":[{"code":"37619","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4127.91,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5503.89,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":10622.5,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4127.91,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5613.96,"additional_payer_notes":"APC"}]}]},{"description":"Ligate leg veins open","code_information":[{"code":"37761","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2342.32,"maximum":6027.57,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3123.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6027.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2342.32,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3185.56,"additional_payer_notes":"APC"}]}]},{"description":"Removal of spleen total","code_information":[{"code":"38100","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Harvest allogeneic stem cell","code_information":[{"code":"38205","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Platelet deplete of harvest","code_information":[{"code":"38213","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":327.28,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":436.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":842.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":327.28,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":445.1,"additional_payer_notes":"APC"}]}]},{"description":"Transplt autol hct/donor","code_information":[{"code":"38241","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1155.35,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1540.47,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2973.1,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1155.35,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1571.27,"additional_payer_notes":"APC"}]}]},{"description":"Thoracic duct procedure","code_information":[{"code":"38382","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Removal neck/armpit lesion","code_information":[{"code":"38550","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2904.59,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3872.79,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7474.49,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2904.59,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3950.25,"additional_payer_notes":"APC"}]}]},{"description":"Removal of lymph nodes neck","code_information":[{"code":"38700","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4925.89,"maximum":12675.95,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6567.85,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":7398.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6019.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":7398.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":12675.95,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4925.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6699.21,"additional_payer_notes":"APC"}]}]},{"description":"Remove groin lymph nodes","code_information":[{"code":"38765","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5257.0,"maximum":6462.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5257.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6462.0}]}]},{"description":"Exploration of chest","code_information":[{"code":"39000","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5257.0,"maximum":6462.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5257.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6462.0}]}]},{"description":"Repair of diaphragm hernia","code_information":[{"code":"39503","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5257.0,"maximum":6462.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5257.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6462.0}]}]},{"description":"Partial excision of lip","code_information":[{"code":"40500","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2459.51,"maximum":6329.15,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3279.35,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6329.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2459.51,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3344.94,"additional_payer_notes":"APC"}]}]},{"description":"Repair lip","code_information":[{"code":"40654","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1151.01,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1534.69,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2961.94,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1151.01,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1565.38,"additional_payer_notes":"APC"}]}]},{"description":"Drainage of mouth lesion","code_information":[{"code":"40801","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":400.09,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":533.45,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1029.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":400.09,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":544.12,"additional_payer_notes":"APC"}]}]},{"description":"Excision of mouth lesion","code_information":[{"code":"40816","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2459.51,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3279.35,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6329.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2459.51,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3344.94,"additional_payer_notes":"APC"}]}]},{"description":"Reconstruction of mouth","code_information":[{"code":"40843","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":11300.84,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Drainage of mouth lesion","code_information":[{"code":"41008","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2459.51,"maximum":6329.15,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3279.35,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6329.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2459.51,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3344.94,"additional_payer_notes":"APC"}]}]},{"description":"Biopsy of tongue","code_information":[{"code":"41100","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":400.09,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":533.45,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1029.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":400.09,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":544.12,"additional_payer_notes":"APC"}]}]},{"description":"Excision of mouth lesion","code_information":[{"code":"41116","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2459.51,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3279.35,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6329.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2459.51,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3344.94,"additional_payer_notes":"APC"}]}]},{"description":"Tongue jaw & neck surgery","code_information":[{"code":"41155","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Tongue and mouth surgery","code_information":[{"code":"41599","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":175.7,"maximum":13249.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":234.27,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":13249.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":10779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":13249.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":452.14,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":175.7,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":238.96,"additional_payer_notes":"APC"}]}]},{"description":"Excision of gum lesion","code_information":[{"code":"41825","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2459.51,"maximum":6329.15,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3279.35,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6329.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2459.51,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3344.94,"additional_payer_notes":"APC"}]}]},{"description":"Repair tooth socket","code_information":[{"code":"41874","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2459.51,"maximum":6329.15,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3279.35,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6329.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2459.51,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3344.94,"additional_payer_notes":"APC"}]}]},{"description":"Excision of uvula","code_information":[{"code":"42140","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2459.51,"maximum":6329.15,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3279.35,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6329.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2459.51,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3344.94,"additional_payer_notes":"APC"}]}]},{"description":"Reconstruct cleft palate","code_information":[{"code":"42215","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Insertion palate prosthesis","code_information":[{"code":"42281","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3579.0,"maximum":11300.84,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Removal of salivary stone","code_information":[{"code":"42340","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2459.51,"maximum":6329.15,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3279.35,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6329.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2459.51,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3344.94,"additional_payer_notes":"APC"}]}]},{"description":"Excise parotid gland/lesion","code_information":[{"code":"42425","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Parotid duct diversion","code_information":[{"code":"42510","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2459.51,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3279.35,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6329.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2459.51,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3344.94,"additional_payer_notes":"APC"}]}]},{"description":"Drainage of throat abscess","code_information":[{"code":"42720","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2459.51,"maximum":6329.15,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3279.35,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6329.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2459.51,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3344.94,"additional_payer_notes":"APC"}]}]},{"description":"Excision of neck cyst","code_information":[{"code":"42815","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Removal of adenoids","code_information":[{"code":"42836","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2459.51,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3279.35,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6329.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2459.51,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3344.94,"additional_payer_notes":"APC"}]}]},{"description":"Revision of pharyngeal walls","code_information":[{"code":"42894","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Control nose/throat bleeding","code_information":[{"code":"42970","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":175.7,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":234.27,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":452.14,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":175.7,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":238.96,"additional_payer_notes":"APC"}]}]},{"description":"Excision of esophagus lesion","code_information":[{"code":"43101","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Partial removal of esophagus","code_information":[{"code":"43121","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Esophagoscp rig trnso inject","code_information":[{"code":"43192","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1423.51,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1898.01,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3663.16,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1423.51,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1935.97,"additional_payer_notes":"APC"}]}]},{"description":"Esoph scope w/submucous inj","code_information":[{"code":"43201","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1423.51,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1898.01,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3663.16,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1423.51,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1935.97,"additional_payer_notes":"APC"}]}]},{"description":"Esophagoscopy retro balloon","code_information":[{"code":"43213","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1423.51,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1898.01,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3663.16,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1423.51,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1935.97,"additional_payer_notes":"APC"}]}]},{"description":"Esophagoscopy lesion ablate","code_information":[{"code":"43229","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2860.11,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3813.48,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7360.02,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2860.11,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3889.75,"additional_payer_notes":"APC"}]}]},{"description":"Egd biopsy single/multiple","code_information":[{"code":"43239","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":672.83,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":897.11,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1731.42,"additional_payer_notes":"APC"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1484.0},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":672.83,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":915.05,"additional_payer_notes":"APC"}]}]},{"description":"Egd remove foreign body","code_information":[{"code":"43247","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":672.83,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":897.11,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1731.42,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":672.83,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":915.05,"additional_payer_notes":"APC"}]}]},{"description":"Egd control bleeding any","code_information":[{"code":"43255","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1423.51,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1898.01,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3663.16,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1423.51,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1935.97,"additional_payer_notes":"APC"}]}]},{"description":"Ercp lithotripsy calculi","code_information":[{"code":"43265","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":11589.23,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6004.78,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11589.23,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4503.59,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6124.88,"additional_payer_notes":"APC"}]}]},{"description":"Ercp lesion ablate w/dilate","code_information":[{"code":"43278","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2860.11,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3813.48,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7360.02,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2860.11,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3889.75,"additional_payer_notes":"APC"}]}]},{"description":"Repair esophagus and fistula","code_information":[{"code":"43305","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Esoph fundoplasty thor","code_information":[{"code":"43328","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5257.0,"maximum":6462.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5257.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6462.0}]}]},{"description":"Thorabd diaphr hern repair","code_information":[{"code":"43337","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5257.0,"maximum":6462.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5257.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6462.0}]}]},{"description":"Ligate esophagus veins","code_information":[{"code":"43400","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0}]}]},{"description":"Pressure treatment esophagus","code_information":[{"code":"43460","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3388.0,"maximum":4106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0}]}]},{"description":"Biopsy of stomach","code_information":[{"code":"43605","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0}]}]},{"description":"Removal of stomach partial","code_information":[{"code":"43633","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Lap revise/remv eltrd antrum","code_information":[{"code":"43648","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5257.0,"maximum":20292.15,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10514.07,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5257.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":20292.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7885.55,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10724.35,"additional_payer_notes":"APC"}]}]},{"description":"Dx gastr intub w/asp specs","code_information":[{"code":"43755","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":95.45,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":127.27,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":245.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":95.45,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":129.82,"additional_payer_notes":"APC"}]}]},{"description":"Lap rmvl gastr adj all parts","code_information":[{"code":"43774","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2860.11,"maximum":27583.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3813.48,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7360.02,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2860.11,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":27583.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3889.75,"additional_payer_notes":"APC"}]}]},{"description":"Place gastrostomy tube","code_information":[{"code":"43832","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Revise stomach-bowel fusion","code_information":[{"code":"43860","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Change gastric port open","code_information":[{"code":"43888","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2628.85,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3505.13,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6764.9,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2628.85,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3575.23,"additional_payer_notes":"APC"}]}]},{"description":"Reduce bowel obstruction","code_information":[{"code":"44050","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Enterectomy w/o taper cong","code_information":[{"code":"44126","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Remove intestinal allograft","code_information":[{"code":"44137","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Partial removal of colon","code_information":[{"code":"44147","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Lap enterolysis","code_information":[{"code":"44180","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4484.77,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5979.69,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5257.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11540.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4484.77,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6099.28,"additional_payer_notes":"APC"}]}]},{"description":"Lap part colectomy w/stoma","code_information":[{"code":"44206","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5257.0,"maximum":6462.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5257.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6462.0}]}]},{"description":"Laparoscope proc intestine","code_information":[{"code":"44238","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4484.77,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5979.69,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5257.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11540.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4484.77,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6099.28,"additional_payer_notes":"APC"}]}]},{"description":"Revision of colostomy","code_information":[{"code":"44340","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2628.85,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3505.13,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6764.9,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2628.85,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3575.23,"additional_payer_notes":"APC"}]}]},{"description":"Small bowel endoscopy","code_information":[{"code":"44366","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1423.51,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1898.01,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3663.16,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1423.51,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1935.97,"additional_payer_notes":"APC"}]}]},{"description":"S Bowel Endoscope W/Stent","code_information":[{"code":"44379","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":11589.23,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6004.78,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11589.23,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4503.59,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6124.88,"additional_payer_notes":"APC"}]}]},{"description":"Colonoscopy with biopsy","code_information":[{"code":"44389","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":887.71,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1183.61,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2284.37,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":887.71,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1207.28,"additional_payer_notes":"APC"}]}]},{"description":"Colonoscopy w/injection","code_information":[{"code":"44404","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":887.71,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1183.61,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2284.37,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":887.71,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1207.28,"additional_payer_notes":"APC"}]}]},{"description":"Suture large intestine","code_information":[{"code":"44604","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Repair bowel-bladder fistula","code_information":[{"code":"44660","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Prep donor intestine/artery","code_information":[{"code":"44721","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Appendectomy add-on","code_information":[{"code":"44955","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Removal of anorectal lesion","code_information":[{"code":"45108","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2059.07,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2745.43,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5298.68,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2059.07,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2800.34,"additional_payer_notes":"APC"}]}]},{"description":"Removal of rectum","code_information":[{"code":"45120","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Excision of rectal lesion","code_information":[{"code":"45160","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2059.07,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2745.43,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5298.68,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2059.07,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2800.34,"additional_payer_notes":"APC"}]}]},{"description":"Proctosigmoidoscopy removal","code_information":[{"code":"45308","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2059.07,"maximum":5298.68,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2745.43,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5298.68,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2059.07,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2800.34,"additional_payer_notes":"APC"}]}]},{"description":"Sigmoidoscopy and biopsy","code_information":[{"code":"45331","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":689.87,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":919.83,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1775.27,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":689.87,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":938.23,"additional_payer_notes":"APC"}]}]},{"description":"Sigmoidoscopy W/Ultrasound","code_information":[{"code":"45341","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":689.87,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":919.83,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1775.27,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":689.87,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":938.23,"additional_payer_notes":"APC"}]}]},{"description":"Colonoscopy and biopsy","code_information":[{"code":"45380","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":887.71,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1183.61,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2284.37,"additional_payer_notes":"APC"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1543.0},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":887.71,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1207.28,"additional_payer_notes":"APC"}]}]},{"description":"Colonoscopy w/resection","code_information":[{"code":"45390","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2059.07,"maximum":5298.68,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2745.43,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5298.68,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2059.07,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2800.34,"additional_payer_notes":"APC"}]}]},{"description":"Laparoscopic proc","code_information":[{"code":"45400","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Repair rectum/remove sigmoid","code_information":[{"code":"45550","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Reduction of rectal prolapse","code_information":[{"code":"45900","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":689.87,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":919.83,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1775.27,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":689.87,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":938.23,"additional_payer_notes":"APC"}]}]},{"description":"Incision of rectal abscess","code_information":[{"code":"46040","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":887.71,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1183.61,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2284.37,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":887.71,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1207.28,"additional_payer_notes":"APC"}]}]},{"description":"Excise anal ext tag/papilla","code_information":[{"code":"46220","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":887.71,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1183.61,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2284.37,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":887.71,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1207.28,"additional_payer_notes":"APC"}]}]},{"description":"Remove in/ex hem grps & fiss","code_information":[{"code":"46261","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2059.07,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2745.43,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5298.68,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2059.07,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2800.34,"additional_payer_notes":"APC"}]}]},{"description":"Injection into hemorrhoid(s)","code_information":[{"code":"46500","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":689.87,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":919.83,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1775.27,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":689.87,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":938.23,"additional_payer_notes":"APC"}]}]},{"description":"Anoscopy remove lesion","code_information":[{"code":"46610","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2059.07,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2745.43,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5298.68,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2059.07,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2800.34,"additional_payer_notes":"APC"}]}]},{"description":"Repair anorectal fist w/plug","code_information":[{"code":"46707","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2059.07,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2745.43,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5298.68,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2059.07,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2800.34,"additional_payer_notes":"APC"}]}]},{"description":"Repair of imperforated anus","code_information":[{"code":"46742","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Repair of anal sphincter","code_information":[{"code":"46760","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2059.07,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2745.43,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5298.68,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2059.07,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2800.34,"additional_payer_notes":"APC"}]}]},{"description":"Destroy internal hemorrhoids","code_information":[{"code":"46930","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":887.71,"maximum":4106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1183.61,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2284.37,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":887.71,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1207.28,"additional_payer_notes":"APC"}]}]},{"description":"Needle biopsy liver add-on","code_information":[{"code":"47001","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Removal of donor liver","code_information":[{"code":"47133","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Prep donor liver/venous","code_information":[{"code":"47146","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Laparo ablate liver cryosurg","code_information":[{"code":"47371","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":27583.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10514.07,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":20292.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7885.55,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":27583.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10724.35,"additional_payer_notes":"APC"}]}]},{"description":"Incision of bile duct","code_information":[{"code":"47420","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Plmt biliary drainage cath","code_information":[{"code":"47534","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2656.06,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3541.41,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6834.92,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2656.06,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3612.24,"additional_payer_notes":"APC"}]}]},{"description":"Dilate biliary duct/ampulla","code_information":[{"code":"47542","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Biliary endoscopy thru skin","code_information":[{"code":"47556","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5257.0,"maximum":20292.15,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10514.07,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5257.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":20292.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7885.55,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10724.35,"additional_payer_notes":"APC"}]}]},{"description":"Removal of gallbladder","code_information":[{"code":"47610","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Fuse gallbladder & bowel","code_information":[{"code":"47720","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Reconstruction of bile ducts","code_information":[{"code":"47800","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Needle biopsy pancreas","code_information":[{"code":"48102","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1225.21,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1633.61,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3152.87,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1225.21,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1666.28,"additional_payer_notes":"APC"}]}]},{"description":"Pancreatectomy","code_information":[{"code":"48152","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Fuse pancreas cyst and bowel","code_information":[{"code":"48520","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Transpl allograft pancreas","code_information":[{"code":"48554","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8923.0,"maximum":10765.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":10765.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":8923.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":10765.0}]}]},{"description":"Drain open retroperi abscess","code_information":[{"code":"49060","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Excision of umbilicus","code_information":[{"code":"49250","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2656.06,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3541.41,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6834.92,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2656.06,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3612.24,"additional_payer_notes":"APC"}]}]},{"description":"Lap w/Omentopexy Add-on","code_information":[{"code":"49326","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Ins mark abd/pel for rt perq","code_information":[{"code":"49411","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1026.79,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1369.06,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2642.28,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1026.79,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1396.44,"additional_payer_notes":"APC"}]}]},{"description":"Insert abdomen-venous drain","code_information":[{"code":"49425","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3579.0,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0}]}]},{"description":"Radiation treatment delivery","code_information":[{"code":"G6011","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1076.02,"maximum":1114.5,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":1114.5},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1076.02},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":1114.5}]}]},{"description":"Radiation treatment delivery","code_information":[{"code":"G6003","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":625.68,"maximum":648.08,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":648.08},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":625.68},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":648.08}]}]},{"description":"Colon ca scrn; barium enema","code_information":[{"code":"G0122","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":730.96,"maximum":757.1,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":757.1},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":730.96},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":757.1}]}]},{"description":"Nuclear rx intra-arterial","code_information":[{"code":"79445","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":173.1,"maximum":445.43,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":230.79,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":323.3},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":312.15},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":323.3},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":445.43,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":173.1,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":235.41,"additional_payer_notes":"APC"}]}]},{"description":"Rp loclzj tum spect w/ct 2","code_information":[{"code":"78832","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1060.78,"maximum":2841.29,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1414.38,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":2841.29},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2743.17},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":2841.29},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2729.74,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1060.78,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1442.66,"additional_payer_notes":"APC"}]}]},{"description":"Pet image ltd area","code_information":[{"code":"78811","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":960.41,"maximum":2471.46,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1280.55,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":1832.62},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1804.88},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":1832.62},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2471.46,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":960.41,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1306.16,"additional_payer_notes":"APC"}]}]},{"description":"Ureteral reflux study","code_information":[{"code":"78740","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":296.56,"maximum":763.16,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":395.42,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":681.52},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":657.99},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":681.52},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":763.16,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":296.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":403.33,"additional_payer_notes":"APC"}]}]},{"description":"Nuclear exam of tear flow","code_information":[{"code":"78660","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":296.56,"maximum":763.16,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":395.42,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":549.83},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":530.86},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":549.83},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":763.16,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":296.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":403.33,"additional_payer_notes":"APC"}]}]},{"description":"Brain image w/flow 4 + views","code_information":[{"code":"78606","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":402.79,"maximum":1072.37,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":537.06,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":1072.37},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1035.36},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":1072.37},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1036.52,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":402.79,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":547.8,"additional_payer_notes":"APC"}]}]},{"description":"Lung ventilation imaging","code_information":[{"code":"78579","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":296.56,"maximum":763.16,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":395.42,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":583.06},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":562.93},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":583.06},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":763.16,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":296.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":403.33,"additional_payer_notes":"APC"}]}]},{"description":"Gated heart planar single","code_information":[{"code":"78472","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":296.56,"maximum":763.16,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":395.42,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":651.99},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":629.45},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":651.99},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":763.16,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":296.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":403.33,"additional_payer_notes":"APC"}]}]},{"description":"Ht musc image planar mult","code_information":[{"code":"78454","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":960.41,"maximum":2471.46,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1280.55,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":1327.86},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1282.01},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":1327.86},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2471.46,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":960.41,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1306.16,"additional_payer_notes":"APC"}]}]},{"description":"Myocrd img pet rst&strs ct","code_information":[{"code":"78431","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1634.1,"maximum":4205.08,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2178.8,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":1940.73},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1911.35},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":1940.73},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4205.08,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1634.1,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2222.38,"additional_payer_notes":"APC"}]}]},{"description":"Bone imaging whole body","code_information":[{"code":"78306","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":296.56,"maximum":763.16,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":395.42,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":752.89},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":726.9},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":752.89},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":763.16,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":296.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":403.33,"additional_payer_notes":"APC"}]}]},{"description":"Gastric emptying imag study","code_information":[{"code":"78265","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":296.56,"maximum":1256.48,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":395.42,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":1256.48},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1213.11},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":1256.48},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":763.16,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":296.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":403.33,"additional_payer_notes":"APC"}]}]},{"description":"Hepatobil syst image w/drug","code_information":[{"code":"78227","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":402.79,"maximum":1453.37,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":537.06,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":1453.37},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1403.19},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":1453.37},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1036.52,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":402.79,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":547.8,"additional_payer_notes":"APC"}]}]},{"description":"Spleen imaging","code_information":[{"code":"78185","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":296.56,"maximum":763.16,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":395.42,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":685.23},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":661.55},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":685.23},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":763.16,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":296.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":403.33,"additional_payer_notes":"APC"}]}]},{"description":"Bone marrow imaging body","code_information":[{"code":"78104","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":296.56,"maximum":763.16,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":395.42,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":740.61},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":715.01},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":740.61},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":763.16,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":296.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":403.33,"additional_payer_notes":"APC"}]}]},{"description":"Thyroid met imaging body","code_information":[{"code":"78018","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":402.79,"maximum":1036.52,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":537.06,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":970.23},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":936.73},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":970.23},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1036.52,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":402.79,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":547.8,"additional_payer_notes":"APC"}]}]},{"description":"Apply interstit radiat compl","code_information":[{"code":"77778","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":516.67,"maximum":1329.56,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":688.89,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":1271.43},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1227.54},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":1271.43},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1329.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":516.67,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":702.67,"additional_payer_notes":"APC"}]}]},{"description":"Apply intrcav radiat simple","code_information":[{"code":"77761","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":409.89,"maximum":1054.79,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":546.52,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":665.75},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":642.76},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":665.75},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1054.79,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":409.89,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":557.46,"additional_payer_notes":"APC"}]}]},{"description":"Proton trmt intermediate","code_information":[{"code":"77523","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":927.1,"maximum":3712.33,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1236.13,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3712.33},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3656.14},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3712.33},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2385.73,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":927.1,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1260.85,"additional_payer_notes":"APC"}]}]},{"description":"Radiation tx management x5","code_information":[{"code":"77427","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":629.87,"maximum":652.39,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":652.39},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":629.87},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":652.39}]}]},{"description":"Ntsty modul rad tx dlvr cplx","code_information":[{"code":"77386","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1150.59,"maximum":1191.75,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":1191.75},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1150.59},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":1191.75}]}]},{"description":"Radiation treatment aid(s)","code_information":[{"code":"77334","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":277.76,"maximum":714.78,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":370.35,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":305.93},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":295.36},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":305.93},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":714.78,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":277.76,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":377.76,"additional_payer_notes":"APC"}]}]},{"description":"Telethx isodose plan cplx","code_information":[{"code":"77307","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":277.76,"maximum":714.78,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":370.35,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":479.7},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":463.12},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":479.7},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":714.78,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":277.76,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":377.76,"additional_payer_notes":"APC"}]}]},{"description":"Set radiation therapy field","code_information":[{"code":"77280","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":99.71,"maximum":822.81,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":132.94,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":822.81},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":794.4},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":822.81},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":256.58,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":99.71,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":135.6,"additional_payer_notes":"APC"}]}]},{"description":"Fracture assessment via dxa","code_information":[{"code":"77086","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":64.56,"maximum":166.13,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":86.08,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":91.8},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":88.63},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":91.8},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":166.13,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":64.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":87.8,"additional_payer_notes":"APC"}]}]},{"description":"X-rays bone survey complete","code_information":[{"code":"77075","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":77.56,"maximum":207.49,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":103.41,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":207.49},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":200.31},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":207.49},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":199.58,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":77.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":105.48,"additional_payer_notes":"APC"}]}]},{"description":"X-ray of mammary ducts","code_information":[{"code":"77054","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":177.0,"maximum":455.49,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":236.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":185.34},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":178.93},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":185.34},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":455.49,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":177.0,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":240.72,"additional_payer_notes":"APC"}]}]},{"description":"CT Scan for Therapy Guide","code_information":[{"code":"77014","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":246.65,"maximum":255.47,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":255.47},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":246.65},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":255.47}]}]},{"description":"Dx intraop epcar us chd i&r","code_information":[{"code":"76989","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":99.0,"maximum":106.96,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":106.96},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":99.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":106.96}]}]},{"description":"Us trgt dyn mbubb 1st les","code_information":[{"code":"76978","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":258.81,"maximum":847.66,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":345.07,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":847.66},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":826.59},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":847.66},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":665.99,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":258.81,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":351.98,"additional_payer_notes":"APC"}]}]},{"description":"Echo guide for transfusion","code_information":[{"code":"76941","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":193.37,"maximum":200.29,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":200.29},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":193.37},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":200.29}]}]},{"description":"Us xtr non-vasc lmtd","code_information":[{"code":"76882","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":37.54,"maximum":199.58,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":103.41,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":38.87},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":37.54},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":38.87},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":199.58,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":77.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":105.48,"additional_payer_notes":"APC"}]}]},{"description":"Transvaginal us non-ob","code_information":[{"code":"76830","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":77.56,"maximum":302.25,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":103.41,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":302.25},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":291.8},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":302.25},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":199.58,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":77.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":105.48,"additional_payer_notes":"APC"}]}]},{"description":"Treat forearm bone lesion","code_information":[{"code":"25035","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":13851.98,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Resect forearm/wrist tum<3cm","code_information":[{"code":"25077","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2154.81,"maximum":5545.05,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2873.08,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5545.05,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2154.81,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2930.54,"additional_payer_notes":"APC"}]}]},{"description":"Remove wrist tendon lesion","code_information":[{"code":"25110","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1192.86,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1590.48,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3069.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1192.86,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1622.29,"additional_payer_notes":"APC"}]}]},{"description":"Remove/graft forearm lesion","code_information":[{"code":"25125","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1192.86,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1590.48,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3069.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1192.86,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1622.29,"additional_payer_notes":"APC"}]}]},{"description":"Resect radius/ulnar tumor","code_information":[{"code":"25170","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":13851.98,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Removal of wrist prosthesis","code_information":[{"code":"25251","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Repair forearm tendon sheath","code_information":[{"code":"25275","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Revise palsy hand tendon(s)","code_information":[{"code":"25315","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":13851.98,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Revision of ulna","code_information":[{"code":"25360","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Repair carpal bone shorten","code_information":[{"code":"25394","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Repair nonunion carpal bone","code_information":[{"code":"25431","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Repair wrist joints","code_information":[{"code":"25447","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Treat fracture of radius","code_information":[{"code":"25505","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1192.86,"maximum":4106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1590.48,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3069.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1192.86,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1622.29,"additional_payer_notes":"APC"}]}]},{"description":"Treat fracture radius & ulna","code_information":[{"code":"25560","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":182.99,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":243.98,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":470.88,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":182.99,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":248.86,"additional_payer_notes":"APC"}]}]},{"description":"Treat Fx Rad Intra-Articul","code_information":[{"code":"25608","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Treat wrist bone fracture","code_information":[{"code":"25650","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":182.99,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":243.98,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":470.88,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":182.99,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":248.86,"additional_payer_notes":"APC"}]}]},{"description":"Treat wrist fracture","code_information":[{"code":"25680","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":182.99,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":243.98,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":470.88,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":182.99,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":248.86,"additional_payer_notes":"APC"}]}]},{"description":"Fuse hand bones with graft","code_information":[{"code":"25825","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Amputate hand at wrist","code_information":[{"code":"25922","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1192.86,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1590.48,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3069.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1192.86,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1622.29,"additional_payer_notes":"APC"}]}]},{"description":"Drain hand tendon sheath","code_information":[{"code":"26020","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":6246.19,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Incise finger tendon sheath","code_information":[{"code":"26055","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1192.86,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1590.48,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3069.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1192.86,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1622.29,"additional_payer_notes":"APC"}]}]},{"description":"Exc hand les sc 1.5 cm/>","code_information":[{"code":"26111","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1225.21,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1633.61,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3152.87,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1225.21,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1666.28,"additional_payer_notes":"APC"}]}]},{"description":"Release palm contracture","code_information":[{"code":"26125","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Remove finger bone","code_information":[{"code":"26185","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1192.86,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1590.48,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3069.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1192.86,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1622.29,"additional_payer_notes":"APC"}]}]},{"description":"Extensive hand surgery","code_information":[{"code":"26250","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":6246.19,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Repair finger/hand tendon","code_information":[{"code":"26356","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Repair hand tendon","code_information":[{"code":"26410","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1192.86,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1590.48,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3069.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1192.86,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1622.29,"additional_payer_notes":"APC"}]}]},{"description":"Repair finger tendon","code_information":[{"code":"26432","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1192.86,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1590.48,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3069.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1192.86,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1622.29,"additional_payer_notes":"APC"}]}]},{"description":"Incision of palm tendon","code_information":[{"code":"26450","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":6246.19,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Shortening of hand tendon","code_information":[{"code":"26479","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":6246.19,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Revise thumb tendon","code_information":[{"code":"26496","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Fusion of knuckle joint","code_information":[{"code":"26516","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Revise/implant finger joint","code_information":[{"code":"26536","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Great toe-hand transfer","code_information":[{"code":"26551","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Correct metacarpal flaw","code_information":[{"code":"26565","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Excision constricting tissue","code_information":[{"code":"26596","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":6246.19,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Echo exam of fetal heart","code_information":[{"code":"76826","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":177.0,"maximum":455.49,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":236.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":424.08},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":409.44},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":424.08},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":455.49,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":177.0,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":240.72,"additional_payer_notes":"APC"}]}]},{"description":"Ob us limited fetus(s)","code_information":[{"code":"76815","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":77.56,"maximum":199.58,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":103.41,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":179.18},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":172.98},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":179.18},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":199.58,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":77.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":105.48,"additional_payer_notes":"APC"}]}]},{"description":"Ob us < 14 wks single fetus","code_information":[{"code":"76801","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":77.56,"maximum":254.23,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":103.41,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":254.23},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":245.46},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":254.23},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":199.58,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":77.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":105.48,"additional_payer_notes":"APC"}]}]},{"description":"Ultrasound breast complete","code_information":[{"code":"76641","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":77.56,"maximum":245.63,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":103.41,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":245.63},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":237.15},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":245.63},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":199.58,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":77.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":105.48,"additional_payer_notes":"APC"}]}]},{"description":"Ophth us b w/non-quant a","code_information":[{"code":"76512","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":77.56,"maximum":199.58,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":103.41,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":137.34},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":132.59},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":137.34},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":199.58,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":77.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":105.48,"additional_payer_notes":"APC"}]}]},{"description":"Mr spectroscopy","code_information":[{"code":"76390","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":64.56,"maximum":1295.39,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":86.08,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":1295.39},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1250.67},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":1295.39},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":166.13,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":64.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":87.8,"additional_payer_notes":"APC"}]}]},{"description":"X-ray exam breast specimen","code_information":[{"code":"76098","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":28.03,"maximum":1043.1,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":540.46,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":29.03},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":28.03},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":29.03},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1043.1,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":405.35,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":551.27,"additional_payer_notes":"APC"}]}]},{"description":"X-ray nose to rectum","code_information":[{"code":"76010","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":55.37,"maximum":166.13,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":86.08,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":57.34},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":55.37},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":57.34},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":166.13,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":64.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":87.8,"additional_payer_notes":"APC"}]}]},{"description":"Xray endovasc thor ao repr","code_information":[{"code":"75956","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1167.09,"maximum":1208.83,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":1208.83},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1167.09},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":1208.83}]}]},{"description":"Vein x-ray liver w/o hemodyn","code_information":[{"code":"75887","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":296.56,"maximum":6027.57,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3123.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":307.17},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":296.56},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":307.17},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6027.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2342.32,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3185.56,"additional_payer_notes":"APC"}]}]},{"description":"Vein x-ray kidneys","code_information":[{"code":"75833","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":305.56,"maximum":6027.57,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3123.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":316.51},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":305.56},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":316.51},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6027.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2342.32,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3185.56,"additional_payer_notes":"APC"}]}]},{"description":"Lymph vessel x-ray trunk","code_information":[{"code":"75807","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":734.95,"maximum":6027.57,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3123.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":746.26},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":734.95},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":746.26},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6027.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2342.32,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3185.56,"additional_payer_notes":"APC"}]}]},{"description":"Artery x-rays lung","code_information":[{"code":"75741","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":290.61,"maximum":6027.57,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3123.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":301.02},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":290.61},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":301.02},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6027.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2342.32,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3185.56,"additional_payer_notes":"APC"}]}]},{"description":"Ct Angio Abdominal Arteries","code_information":[{"code":"75635","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":130.12,"maximum":894.43,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":173.49,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":894.43},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":863.55},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":894.43},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":334.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":130.12,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":176.96,"additional_payer_notes":"APC"}]}]},{"description":"Ct hrt w/3d image","code_information":[{"code":"75572","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":258.81,"maximum":675.87,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":345.07,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":675.87},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":652.55},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":675.87},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":665.99,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":258.81,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":351.98,"additional_payer_notes":"APC"}]}]},{"description":"X-ray fallopian tube","code_information":[{"code":"74742","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":181.48,"maximum":187.98,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":187.98},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":181.48},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":187.98}]}]},{"description":"X-ray exam of penis","code_information":[{"code":"74445","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":77.56,"maximum":199.58,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":103.41,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":141.01},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":138.87},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":141.01},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":199.58,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":77.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":105.48,"additional_payer_notes":"APC"}]}]},{"description":"X-ray bile duct dilation","code_information":[{"code":"74363","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":264.39,"maximum":273.86,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":273.86},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":264.39},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":273.86}]}]},{"description":"X-ray bile ducts/pancreas","code_information":[{"code":"74300","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":112.83,"maximum":116.86,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":116.86},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":112.83},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":116.86}]}]},{"description":"X-ray exam of small bowel","code_information":[{"code":"74251","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":130.12,"maximum":1322.48,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":173.49,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":1322.48},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1276.81},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":1322.48},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":334.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":130.12,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":176.96,"additional_payer_notes":"APC"}]}]},{"description":"Contrast x-ray esophagus","code_information":[{"code":"74220","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":130.12,"maximum":334.84,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":173.49,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":224.72},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":216.96},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":224.72},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":334.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":130.12,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":176.96,"additional_payer_notes":"APC"}]}]},{"description":"Ct abd & pelv w/contrast","code_information":[{"code":"74177","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":258.81,"maximum":755.13,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":345.07,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":755.13},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":729.06},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":755.13},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":665.99,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":258.81,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":351.98,"additional_payer_notes":"APC"}]}]},{"description":"X-ray exam abdomen 3+ views","code_information":[{"code":"74021","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":77.56,"maximum":199.58,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":103.41,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":86.76},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":83.79},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":86.76},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":199.58,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":77.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":105.48,"additional_payer_notes":"APC"}]}]},{"description":"Mri Lower Extremity W/Dye","code_information":[{"code":"73719","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":258.81,"maximum":1110.31,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":345.07,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":1110.31},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1071.95},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":1110.31},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":665.99,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":258.81,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":351.98,"additional_payer_notes":"APC"}]}]},{"description":"X-ray exam of foot","code_information":[{"code":"73630","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":64.56,"maximum":166.13,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":86.08,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":70.88},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":68.42},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":70.88},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":166.13,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":64.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":87.8,"additional_payer_notes":"APC"}]}]},{"description":"X-ray exam of knees","code_information":[{"code":"73565","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":64.56,"maximum":166.13,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":86.08,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":93.03},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":89.81},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":93.03},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":166.13,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":64.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":87.8,"additional_payer_notes":"APC"}]}]},{"description":"X-ray exam hips bi 3-4 views","code_information":[{"code":"73522","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":77.56,"maximum":199.58,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":103.41,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":115.18},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":111.2},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":115.18},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":199.58,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":77.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":105.48,"additional_payer_notes":"APC"}]}]},{"description":"Mri joint upr extrem w/o dye","code_information":[{"code":"73221","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":177.0,"maximum":576.19,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":236.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":576.19},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":556.3},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":576.19},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":455.49,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":177.0,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":240.72,"additional_payer_notes":"APC"}]}]},{"description":"X-ray exam of finger(s)","code_information":[{"code":"73140","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":64.56,"maximum":166.13,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":86.08,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":83.18},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":80.32},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":83.18},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":166.13,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":64.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":87.8,"additional_payer_notes":"APC"}]}]},{"description":"Contrast x-ray of elbow","code_information":[{"code":"73085","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":227.65,"maximum":665.99,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":345.07,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":235.79},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":227.65},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":235.79},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":665.99,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":258.81,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":351.98,"additional_payer_notes":"APC"}]}]},{"description":"X-ray exam of shoulder blade","code_information":[{"code":"73010","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":68.42,"maximum":199.58,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":103.41,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":70.88},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":68.42},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":70.88},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":199.58,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":77.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":105.48,"additional_payer_notes":"APC"}]}]},{"description":"X-ray exam sacrum tailbone","code_information":[{"code":"72220","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":63.69,"maximum":166.13,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":86.08,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":65.95},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":63.69},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":65.95},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":166.13,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":64.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":87.8,"additional_payer_notes":"APC"}]}]},{"description":"Ct pelvis w/dye","code_information":[{"code":"72193","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":130.12,"maximum":575.46,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":173.49,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":575.46},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":555.58},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":575.46},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":334.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":130.12,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":176.96,"additional_payer_notes":"APC"}]}]},{"description":"Mri neck spine w/o & w/dye","code_information":[{"code":"72156","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":258.81,"maximum":907.24,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":345.07,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":907.24},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":875.92},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":907.24},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":665.99,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":258.81,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":351.98,"additional_payer_notes":"APC"}]}]},{"description":"Ct lumbar spine w/dye","code_information":[{"code":"72132","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":258.81,"maximum":665.99,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":345.07,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":574.23},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":554.38},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":574.23},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":665.99,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":258.81,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":351.98,"additional_payer_notes":"APC"}]}]},{"description":"X-ray bend only l-s spine","code_information":[{"code":"72120","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":77.56,"maximum":199.58,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":103.41,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":99.2},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":95.75},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":99.2},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":199.58,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":77.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":105.48,"additional_payer_notes":"APC"}]}]},{"description":"Place duod/jej tube perc","code_information":[{"code":"49441","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1423.51,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1898.01,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3663.16,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1423.51,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1935.97,"additional_payer_notes":"APC"}]}]},{"description":"Rpr hern preemie reduc","code_information":[{"code":"49491","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4484.77,"maximum":11540.8,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5979.69,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5257.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11540.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4484.77,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6099.28,"additional_payer_notes":"APC"}]}]},{"description":"Rerepair ing hernia reduce","code_information":[{"code":"49520","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2656.06,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3541.41,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6834.92,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2656.06,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3612.24,"additional_payer_notes":"APC"}]}]},{"description":"Repair umbilical lesion","code_information":[{"code":"49600","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2656.06,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3541.41,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6834.92,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2656.06,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3612.24,"additional_payer_notes":"APC"}]}]},{"description":"Repair of abdominal wall","code_information":[{"code":"49900","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Exploration of kidney","code_information":[{"code":"50045","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Exploration of kidney","code_information":[{"code":"50120","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Removal of kidney & ureter","code_information":[{"code":"50234","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Prep cadaver renal allograft","code_information":[{"code":"50323","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Remove transplanted kidney","code_information":[{"code":"50370","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Drainage of kidney lesion","code_information":[{"code":"50390","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":525.32,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":700.42,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1351.81,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":525.32,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":714.43,"additional_payer_notes":"APC"}]}]},{"description":"Plmt nephroureteral catheter","code_information":[{"code":"50433","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2614.94,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3486.59,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6729.12,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2614.94,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3556.32,"additional_payer_notes":"APC"}]}]},{"description":"Laparo ablate renal cyst","code_information":[{"code":"50541","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5257.0,"maximum":20292.15,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10514.07,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5257.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":20292.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7885.55,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10724.35,"additional_payer_notes":"APC"}]}]},{"description":"Laparoscope proc renal","code_information":[{"code":"50549","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4484.77,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5979.69,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5257.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11540.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4484.77,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6099.28,"additional_payer_notes":"APC"}]}]},{"description":"Kidney endoscopy","code_information":[{"code":"50572","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":517.28,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":689.7,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1331.13,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":517.28,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":703.5,"additional_payer_notes":"APC"}]}]},{"description":"Exploration of ureter","code_information":[{"code":"50600","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Injection for ureter x-ray","code_information":[{"code":"50684","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Ureteral embolization/occl","code_information":[{"code":"50705","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Fusion of ureter & kidney","code_information":[{"code":"50750","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Fusion of ureter & bowel","code_information":[{"code":"50810","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Repair of ureter","code_information":[{"code":"50900","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Endoscopy of ureter","code_information":[{"code":"50951","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2614.94,"maximum":6729.12,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3486.59,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6729.12,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2614.94,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3556.32,"additional_payer_notes":"APC"}]}]},{"description":"Ureter endoscopy & treatment","code_information":[{"code":"50976","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3579.0,"maximum":10235.57,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5303.4,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":10235.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3977.55,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5409.47,"additional_payer_notes":"APC"}]}]},{"description":"Drainage of bladder abscess","code_information":[{"code":"51080","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2154.81,"maximum":5545.05,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2873.08,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5545.05,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2154.81,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2930.54,"additional_payer_notes":"APC"}]}]},{"description":"Repair of ureter lesion","code_information":[{"code":"51535","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2614.94,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3486.59,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6729.12,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2614.94,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3556.32,"additional_payer_notes":"APC"}]}]},{"description":"Remove bladder/revise tract","code_information":[{"code":"51590","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Insert bladder catheter","code_information":[{"code":"51701","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":98.7,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":131.6,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":253.99,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":98.7,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":134.23,"additional_payer_notes":"APC"}]}]},{"description":"Complex cystometrogram","code_information":[{"code":"51726","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":185.35,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":247.13,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":476.96,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":185.35,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":252.07,"additional_payer_notes":"APC"}]}]},{"description":"Urinary reflex study","code_information":[{"code":"51792","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":43.76,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":58.35,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":112.62,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":43.76,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":59.52,"additional_payer_notes":"APC"}]}]},{"description":"Repair of bladder wound","code_information":[{"code":"51860","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":18071.3,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9363.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":18071.3,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7022.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9550.63,"additional_payer_notes":"APC"}]}]},{"description":"Construct bladder opening","code_information":[{"code":"51980","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0}]}]},{"description":"Cystoscopy & duct catheter","code_information":[{"code":"52010","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":517.28,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":689.7,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1331.13,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":517.28,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":703.5,"additional_payer_notes":"APC"}]}]},{"description":"Cystoscopy and treatment","code_information":[{"code":"52260","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1550.71,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2067.62,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3990.5,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1550.71,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2108.97,"additional_payer_notes":"APC"}]}]},{"description":"Cystoscopy and treatment","code_information":[{"code":"52283","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1550.71,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2067.62,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3990.5,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1550.71,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2108.97,"additional_payer_notes":"APC"}]}]},{"description":"Cystoscopy and treatment","code_information":[{"code":"52315","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1550.71,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2067.62,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3990.5,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1550.71,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2108.97,"additional_payer_notes":"APC"}]}]},{"description":"Create passage to kidney","code_information":[{"code":"52334","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2614.94,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3486.59,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6729.12,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2614.94,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3556.32,"additional_payer_notes":"APC"}]}]},{"description":"Fetal biophys profile w/nst","code_information":[{"code":"76818","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":77.56,"maximum":234.06,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":103.41,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":234.06},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":225.98},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":234.06},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":199.58,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":77.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":105.48,"additional_payer_notes":"APC"}]}]},{"description":"Ob us >/= 14 wks addl fetus","code_information":[{"code":"76810","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":146.14,"maximum":151.38,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":151.38},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":146.14},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":151.38}]}]},{"description":"Echo exam of abdomen","code_information":[{"code":"76705","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":77.56,"maximum":213.64,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":103.41,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":213.64},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":206.25},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":213.64},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":199.58,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":77.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":105.48,"additional_payer_notes":"APC"}]}]},{"description":"Echo exam of eye","code_information":[{"code":"76516","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":77.56,"maximum":199.58,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":103.41,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":165.65},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":159.92},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":165.65},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":199.58,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":77.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":105.48,"additional_payer_notes":"APC"}]}]},{"description":"Ct procedure","code_information":[{"code":"76497","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":64.56,"maximum":276.98,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":86.08,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":276.98},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":272.79},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":276.98},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":166.13,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":64.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":87.8,"additional_payer_notes":"APC"}]}]},{"description":"Cine/video x-rays add-on","code_information":[{"code":"76125","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":105.72,"maximum":109.49,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":109.49},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":105.72},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":109.49}]}]},{"description":"Mr safety deter phys/qhp","code_information":[{"code":"76016","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":64.56,"maximum":225.71,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":86.08,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":225.71},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":206.9},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":225.71},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":166.13,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":64.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":87.8,"additional_payer_notes":"APC"}]}]},{"description":"Xray place dist ext thor ao","code_information":[{"code":"75959","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":579.14,"maximum":599.84,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":599.84},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":579.14},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":599.84}]}]},{"description":"Venous sampling by catheter","code_information":[{"code":"75893","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":303.67,"maximum":10622.5,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5503.89,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":314.56},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":303.67},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":314.56},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":10622.5,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4127.91,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5613.96,"additional_payer_notes":"APC"}]}]},{"description":"Vein x-ray neck","code_information":[{"code":"75860","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":290.61,"maximum":6027.57,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3123.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":301.02},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":290.61},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":301.02},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6027.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2342.32,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3185.56,"additional_payer_notes":"APC"}]}]},{"description":"Vein x-ray arm/leg","code_information":[{"code":"75820","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":269.24,"maximum":3005.03,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1557.01,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":278.86},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":269.24},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":278.86},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3005.03,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1167.76,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1588.15,"additional_payer_notes":"APC"}]}]},{"description":"Artery x-rays chest","code_information":[{"code":"75756","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":366.18,"maximum":6027.57,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3123.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":379.28},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":366.18},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":379.28},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6027.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2342.32,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3185.56,"additional_payer_notes":"APC"}]}]},{"description":"Artery x-rays arms/legs","code_information":[{"code":"75716","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":408.47,"maximum":6027.57,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3123.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":423.08},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":408.47},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":423.08},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6027.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2342.32,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3185.56,"additional_payer_notes":"APC"}]}]},{"description":"N-invas est c ffr sw aly cta","code_information":[{"code":"75580","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":637.04,"maximum":2758.96,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":849.39,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":2758.96},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2553.6},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":2758.96},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1639.32,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":637.04,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":866.38,"additional_payer_notes":"APC"}]}]},{"description":"Cardiac mri w/stress img","code_information":[{"code":"75559","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":405.35,"maximum":1043.1,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":540.46,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":1003.74},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":969.06},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":1003.74},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1043.1,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":405.35,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":551.27,"additional_payer_notes":"APC"}]}]},{"description":"X-ray exam of kidney lesion","code_information":[{"code":"74470","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":155.11,"maximum":1043.1,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":540.46,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":157.48},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":155.11},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":157.48},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1043.1,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":405.35,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":551.27,"additional_payer_notes":"APC"}]}]},{"description":"Contrst x-ray urinary tract","code_information":[{"code":"74415","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":130.12,"maximum":384.71,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":173.49,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":384.71},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":371.42},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":384.71},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":334.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":130.12,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":176.96,"additional_payer_notes":"APC"}]}]},{"description":"X-ray for pancreas endoscopy","code_information":[{"code":"74329","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":220.21,"maximum":228.08,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":228.08},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":220.21},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":228.08}]}]},{"description":"Ct colonography screening","code_information":[{"code":"74263","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":177.0,"maximum":2214.22,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":236.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":2214.22},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2137.76},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":2214.22},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":455.49,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":177.0,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":240.72,"additional_payer_notes":"APC"}]}]},{"description":"Remove esophagus obstruction","code_information":[{"code":"74235","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":385.06,"maximum":398.83,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":398.83},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":385.06},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":398.83}]}]},{"description":"Mri Abdomen W/Dye","code_information":[{"code":"74182","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":258.81,"maximum":1262.9,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":345.07,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":1262.9},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1219.3},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":1262.9},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":665.99,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":258.81,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":351.98,"additional_payer_notes":"APC"}]}]},{"description":"Ct abdomen w/dye","code_information":[{"code":"74160","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":130.12,"maximum":573.01,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":173.49,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":573.01},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":553.21},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":573.01},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":334.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":130.12,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":176.96,"additional_payer_notes":"APC"}]}]},{"description":"Mri Joint Of Lwr Extr W/Dye","code_information":[{"code":"73722","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":581.54,"maximum":1496.49,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":775.38,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":1032.76},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":997.11},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":1032.76},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1496.49,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":581.54,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":790.89,"additional_payer_notes":"APC"}]}]},{"description":"Ct lower extremity w/o dye","code_information":[{"code":"73700","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":77.56,"maximum":442.55,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":103.41,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":442.55},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":427.26},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":442.55},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":199.58,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":77.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":105.48,"additional_payer_notes":"APC"}]}]},{"description":"X-ray exam of leg infant","code_information":[{"code":"73592","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":64.56,"maximum":166.13,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":86.08,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":67.2},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":64.88},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":67.2},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":166.13,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":64.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":87.8,"additional_payer_notes":"APC"}]}]},{"description":"X-ray exam of femur 1","code_information":[{"code":"73551","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":63.69,"maximum":166.13,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":86.08,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":65.95},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":63.69},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":65.95},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":166.13,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":64.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":87.8,"additional_payer_notes":"APC"}]}]},{"description":"Mr angio upr extr w/o&w/dye","code_information":[{"code":"73225","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1060.06,"maximum":1098.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":1098.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1060.06},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":1098.0}]}]},{"description":"Ct uppr extremity w/o&w/dye","code_information":[{"code":"73202","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":130.12,"maximum":744.06,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":173.49,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":744.06},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":718.37},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":744.06},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":334.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":130.12,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":176.96,"additional_payer_notes":"APC"}]}]},{"description":"X-ray exam of wrist","code_information":[{"code":"73100","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":64.56,"maximum":166.13,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":86.08,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":70.88},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":68.42},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":70.88},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":166.13,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":64.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":87.8,"additional_payer_notes":"APC"}]}]},{"description":"Contrast x-ray of shoulder","code_information":[{"code":"73040","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":240.73,"maximum":665.99,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":345.07,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":249.33},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":240.73},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":249.33},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":665.99,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":258.81,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":351.98,"additional_payer_notes":"APC"}]}]},{"description":"Myelography l-s spine","code_information":[{"code":"72265","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":165.86,"maximum":1496.49,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":775.38,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":171.8},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":165.86},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":171.8},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1496.49,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":581.54,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":790.89,"additional_payer_notes":"APC"}]}]},{"description":"Mri pelvis w/dye","code_information":[{"code":"72196","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":258.81,"maximum":1115.2,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":345.07,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":1115.2},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1076.71},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":1115.2},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":665.99,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":258.81,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":351.98,"additional_payer_notes":"APC"}]}]},{"description":"Mr angio spine w/o&w/dye","code_information":[{"code":"72159","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1082.64,"maximum":1121.36,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":1121.36},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1082.64},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":1121.36}]}]},{"description":"Mri neck spine w/dye","code_information":[{"code":"72142","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":258.81,"maximum":806.33,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":345.07,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":806.33},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":778.46},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":806.33},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":665.99,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":258.81,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":351.98,"additional_payer_notes":"APC"}]}]},{"description":"Ct neck spine w/o & w/dye","code_information":[{"code":"72127","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":130.12,"maximum":712.06,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":173.49,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":712.06},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":687.47},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":712.06},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":334.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":130.12,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":176.96,"additional_payer_notes":"APC"}]}]},{"description":"X-ray exam entire spi 4/5 vw","code_information":[{"code":"72083","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":77.56,"maximum":199.58,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":103.41,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":171.8},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":165.86},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":171.8},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":199.58,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":77.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":105.48,"additional_payer_notes":"APC"}]}]},{"description":"X-ray exam thoracolmb 2/> vw","code_information":[{"code":"72080","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":64.56,"maximum":166.13,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":86.08,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":67.2},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":64.88},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":67.2},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":166.13,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":64.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":87.8,"additional_payer_notes":"APC"}]}]},{"description":"Mri angio chest w or w/o dye","code_information":[{"code":"71555","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1020.86,"maximum":1057.39,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":1057.39},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1020.86},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":1057.39}]}]},{"description":"Ct thorax w/o dye","code_information":[{"code":"71250","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":77.56,"maximum":442.55,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":103.41,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":442.55},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":427.26},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":442.55},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":199.58,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":77.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":105.48,"additional_payer_notes":"APC"}]}]},{"description":"X-ray exam chest 3 views","code_information":[{"code":"71047","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":64.56,"maximum":166.13,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":86.08,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":85.53},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":82.6},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":85.53},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":166.13,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":64.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":87.8,"additional_payer_notes":"APC"}]}]},{"description":"Mri brain stem w/o & w/dye","code_information":[{"code":"70553","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":258.81,"maximum":901.1,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":345.07,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":901.1},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":869.97},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":901.1},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":665.99,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":258.81,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":351.98,"additional_payer_notes":"APC"}]}]},{"description":"Mr Angiography Head W/O Dye","code_information":[{"code":"70544","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":177.0,"maximum":1141.06,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":236.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":1141.06},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1101.66},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":1141.06},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":455.49,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":177.0,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":240.72,"additional_payer_notes":"APC"}]}]},{"description":"Ct soft tissue neck w/o dye","code_information":[{"code":"70490","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":77.56,"maximum":441.31,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":103.41,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":441.31},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":426.08},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":441.31},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":199.58,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":77.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":105.48,"additional_payer_notes":"APC"}]}]},{"description":"Ct head/brain w/dye","code_information":[{"code":"70460","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":130.12,"maximum":360.08,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":173.49,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":360.08},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":347.65},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":360.08},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":334.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":130.12,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":176.96,"additional_payer_notes":"APC"}]}]},{"description":"X-ray head for orthodontia","code_information":[{"code":"70350","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":31.6,"maximum":166.13,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":86.08,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":32.72},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":31.6},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":32.72},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":166.13,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":64.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":87.8,"additional_payer_notes":"APC"}]}]},{"description":"X-ray exam of skull","code_information":[{"code":"70260","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":77.56,"maximum":199.58,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":103.41,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":95.5},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":92.2},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":95.5},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":199.58,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":77.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":105.48,"additional_payer_notes":"APC"}]}]},{"description":"X-ray exam of nasal bones","code_information":[{"code":"70160","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":64.56,"maximum":166.13,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":86.08,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":80.72},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":77.94},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":80.72},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":166.13,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":64.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":87.8,"additional_payer_notes":"APC"}]}]},{"description":"X-ray eye for foreign body","code_information":[{"code":"70030","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":63.69,"maximum":166.13,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":86.08,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":65.95},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":63.69},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":65.95},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":166.13,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":64.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":87.8,"additional_payer_notes":"APC"}]}]},{"description":"B1 str & fx rsk vrt fx assmt","code_information":[{"code":"0743T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":138.54,"maximum":455.49,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":236.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":151.13},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":138.54},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":151.13},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":455.49,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":177.0,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":240.72,"additional_payer_notes":"APC"}]}]},{"description":"Ct breast w/3d uni c-","code_information":[{"code":"0633T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":77.56,"maximum":464.85,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":103.41,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":464.85},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":450.31},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":464.85},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":199.58,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":77.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":105.48,"additional_payer_notes":"APC"}]}]},{"description":"Ncntc r-t fluor wnd img ea","code_information":[{"code":"0599T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":255.48,"maximum":259.4,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":259.4},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":255.48},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":259.4}]}]},{"description":"B1 str & fx rsk analysis","code_information":[{"code":"0554T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":177.22,"maximum":179.95,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":179.95},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":177.22},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":179.95}]}]},{"description":"Tactile breast img uni/bi","code_information":[{"code":"0422T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":64.56,"maximum":401.85,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":86.08,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":401.85},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":395.77},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":401.85},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":166.13,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":64.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":87.8,"additional_payer_notes":"APC"}]}]},{"description":"RSA spine exam","code_information":[{"code":"0348T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":77.56,"maximum":199.58,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":103.41,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":154.97},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":152.62},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":154.97},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":199.58,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":77.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":105.48,"additional_payer_notes":"APC"}]}]},{"description":"Acne surgery","code_information":[{"code":"10040","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":148.84,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":198.45,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":383.01,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":148.84,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":202.42,"additional_payer_notes":"APC"}]}]},{"description":"Puncture drainage of lesion","code_information":[{"code":"10160","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":301.57,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":402.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":776.03,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":301.57,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":410.13,"additional_payer_notes":"APC"}]}]},{"description":"Debride skin at fx site","code_information":[{"code":"11010","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":525.32,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":700.42,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1351.81,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":525.32,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":714.43,"additional_payer_notes":"APC"}]}]},{"description":"Deb bone add-on","code_information":[{"code":"11047","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Shave skin lesion 1.1-2.0 cm","code_information":[{"code":"11302","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":148.84,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":198.45,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":383.01,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":148.84,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":202.42,"additional_payer_notes":"APC"}]}]},{"description":"Shave skin lesion 1.1-2.0 cm","code_information":[{"code":"11312","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":301.57,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":402.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":776.03,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":301.57,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":410.13,"additional_payer_notes":"APC"}]}]},{"description":"Exc h-f-nk-sp b9+marg 0.5/<","code_information":[{"code":"11420","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1225.21,"maximum":4106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1633.61,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3152.87,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1225.21,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1666.28,"additional_payer_notes":"APC"}]}]},{"description":"Exc face-mm b9+marg 1.1-2 cm","code_information":[{"code":"11442","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":525.32,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":700.42,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1351.81,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":525.32,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":714.43,"additional_payer_notes":"APC"}]}]},{"description":"Removal sweat gland lesion","code_information":[{"code":"11470","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2154.81,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2873.08,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5545.05,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2154.81,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2930.54,"additional_payer_notes":"APC"}]}]},{"description":"Exc h-f-nk-sp mal+marg 0.5/<","code_information":[{"code":"11620","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1225.21,"maximum":4106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1633.61,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3152.87,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1225.21,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1666.28,"additional_payer_notes":"APC"}]}]},{"description":"Exc f/e/e/n/l mal+mrg 1.1-2","code_information":[{"code":"11642","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":525.32,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":700.42,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1351.81,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":525.32,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":714.43,"additional_payer_notes":"APC"}]}]},{"description":"Remove nail plate add-on","code_information":[{"code":"11732","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Remove pilonidal cyst exten","code_information":[{"code":"11771","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2154.81,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2873.08,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5545.05,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2154.81,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2930.54,"additional_payer_notes":"APC"}]}]},{"description":"Tx contour defects 1.1-5.0cc","code_information":[{"code":"11951","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":548.27,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":731.02,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1410.87,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":548.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":745.64,"additional_payer_notes":"APC"}]}]},{"description":"Insert drug implant device","code_information":[{"code":"11981","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":98.7,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":131.6,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":253.99,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":98.7,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":134.23,"additional_payer_notes":"APC"}]}]},{"description":"Rpr s/n/ax/gen/trnk >30.0 cm","code_information":[{"code":"12007","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":148.84,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":198.45,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":383.01,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":148.84,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":202.42,"additional_payer_notes":"APC"}]}]},{"description":"Closure of split wound","code_information":[{"code":"12020","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":548.27,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":731.02,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1410.87,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":548.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":745.64,"additional_payer_notes":"APC"}]}]},{"description":"Treat thumb fracture","code_information":[{"code":"26650","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Treat knuckle dislocation","code_information":[{"code":"26705","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1192.86,"maximum":4106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1590.48,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3069.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1192.86,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1622.29,"additional_payer_notes":"APC"}]}]},{"description":"Treat finger fracture each","code_information":[{"code":"26742","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1192.86,"maximum":4106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1590.48,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3069.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1192.86,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1622.29,"additional_payer_notes":"APC"}]}]},{"description":"Pin finger dislocation","code_information":[{"code":"26776","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Fusion of knuckle with graft","code_information":[{"code":"26852","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":13851.98,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Hand/finger surgery","code_information":[{"code":"26989","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":182.99,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":243.98,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":470.88,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":182.99,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":248.86,"additional_payer_notes":"APC"}]}]},{"description":"Incision of hip tendons","code_information":[{"code":"27006","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Biopsy of soft tissues","code_information":[{"code":"27041","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1225.21,"maximum":4106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1633.61,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3152.87,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1225.21,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1666.28,"additional_payer_notes":"APC"}]}]},{"description":"Removal of hip joint lining","code_information":[{"code":"27054","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Part remove hip bone super","code_information":[{"code":"27070","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Remove hip foreign body","code_information":[{"code":"27087","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Transfer of abdominal muscle","code_information":[{"code":"27100","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Total hip arthroplasty","code_information":[{"code":"27132","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6779.0,"maximum":27583.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12698.86,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":24508.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9524.15,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":27583.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12952.84,"additional_payer_notes":"APC"}]}]},{"description":"Revision of hip bones","code_information":[{"code":"27156","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Treat slipped epiphysis","code_information":[{"code":"27178","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Treat pelvic ring fracture","code_information":[{"code":"27216","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0}]}]},{"description":"Treat thigh fracture","code_information":[{"code":"27230","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":182.99,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":243.98,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":470.88,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":182.99,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":248.86,"additional_payer_notes":"APC"}]}]},{"description":"Treat thigh fracture","code_information":[{"code":"27246","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":182.99,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":243.98,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":470.88,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":182.99,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":248.86,"additional_payer_notes":"APC"}]}]},{"description":"Treat hip dislocation","code_information":[{"code":"27258","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Arthrodesis sacroiliac joint","code_information":[{"code":"27279","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8923.0,"maximum":33471.73,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17342.86,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":10765.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":8923.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":10765.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":33471.73,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13007.15,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":27583.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17689.72,"additional_payer_notes":"APC"}]}]},{"description":"Drain thigh/knee lesion","code_information":[{"code":"27301","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2154.81,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2873.08,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5545.05,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2154.81,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2930.54,"additional_payer_notes":"APC"}]}]},{"description":"Neurectomy hamstring","code_information":[{"code":"27325","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1448.59,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1931.46,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3727.72,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1448.59,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1970.09,"additional_payer_notes":"APC"}]}]},{"description":"Removal of knee cartilage","code_information":[{"code":"27333","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Removal of kneecap","code_information":[{"code":"27350","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":13851.98,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Removal of foreign body","code_information":[{"code":"27372","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2154.81,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2873.08,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5545.05,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2154.81,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2930.54,"additional_payer_notes":"APC"}]}]},{"description":"Lengthening of thigh tendon","code_information":[{"code":"27393","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":13851.98,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Repair of knee ligament","code_information":[{"code":"27407","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Revision/removal of kneecap","code_information":[{"code":"27424","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Revise kneecap with implant","code_information":[{"code":"27438","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":24508.8,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12698.86,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":24508.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9524.15,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12952.84,"additional_payer_notes":"APC"}]}]},{"description":"Incision of thigh","code_information":[{"code":"27448","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Repair of thigh","code_information":[{"code":"27470","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Removal of knee prosthesis","code_information":[{"code":"27488","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6779.0,"maximum":24508.8,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12698.86,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":24508.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9524.15,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12952.84,"additional_payer_notes":"APC"}]}]},{"description":"Treatment of thigh fracture","code_information":[{"code":"27502","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1192.86,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1590.48,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3069.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1192.86,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1622.29,"additional_payer_notes":"APC"}]}]},{"description":"Treatment of thigh fracture","code_information":[{"code":"27513","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":24508.8,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12698.86,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":24508.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9524.15,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12952.84,"additional_payer_notes":"APC"}]}]},{"description":"Treat knee fracture","code_information":[{"code":"27532","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":6246.19,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Treat knee dislocation","code_information":[{"code":"27557","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"X-ray exam neck spine 4/5vws","code_information":[{"code":"72050","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":77.56,"maximum":199.58,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":103.41,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":99.2},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":95.75},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":99.2},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":199.58,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":77.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":105.48,"additional_payer_notes":"APC"}]}]},{"description":"Ct thorax lung cancer scr c-","code_information":[{"code":"71271","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":77.56,"maximum":345.82,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":103.41,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":345.82},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":337.24},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":345.82},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":199.58,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":77.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":105.48,"additional_payer_notes":"APC"}]}]},{"description":"X-ray exam unilat ribs/chest","code_information":[{"code":"71101","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":74.37,"maximum":199.58,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":103.41,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":77.03},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":74.37},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":77.03},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":199.58,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":77.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":105.48,"additional_payer_notes":"APC"}]}]},{"description":"Mri brain w/o dye","code_information":[{"code":"70557","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":405.35,"maximum":4517.04,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":540.46,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4517.04},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4448.67},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4517.04},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1043.1,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":405.35,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":551.27,"additional_payer_notes":"APC"}]}]},{"description":"Mr Angiography Neck W/O Dye","code_information":[{"code":"70547","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":177.0,"maximum":1145.98,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":236.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":1145.98},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1106.41},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":1145.98},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":455.49,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":177.0,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":240.72,"additional_payer_notes":"APC"}]}]},{"description":"Ct angiography head","code_information":[{"code":"70496","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":130.12,"maximum":710.31,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":173.49,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":710.31},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":685.81},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":710.31},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":334.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":130.12,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":176.96,"additional_payer_notes":"APC"}]}]},{"description":"Ct orbit/ear/fossa w/dye","code_information":[{"code":"70481","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":130.12,"maximum":710.82,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":173.49,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":710.82},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":686.28},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":710.82},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":334.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":130.12,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":176.96,"additional_payer_notes":"APC"}]}]},{"description":"Throat x-ray & fluoroscopy","code_information":[{"code":"70370","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":64.56,"maximum":213.64,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":86.08,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":213.64},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":206.25},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":213.64},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":166.13,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":64.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":87.8,"additional_payer_notes":"APC"}]}]},{"description":"Full mouth x-ray of teeth","code_information":[{"code":"70320","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":133.79,"maximum":455.49,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":236.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":138.57},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":133.79},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":138.57},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":455.49,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":177.0,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":240.72,"additional_payer_notes":"APC"}]}]},{"description":"X-ray exam of eye sockets","code_information":[{"code":"70200","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":77.56,"maximum":199.58,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":103.41,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":95.5},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":92.2},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":95.5},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":199.58,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":77.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":105.48,"additional_payer_notes":"APC"}]}]},{"description":"X-ray exam of mastoids","code_information":[{"code":"70120","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":77.56,"maximum":199.58,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":103.41,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":84.41},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":81.49},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":84.41},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":199.58,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":77.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":105.48,"additional_payer_notes":"APC"}]}]},{"description":"Opto-acoustic img breast uni","code_information":[{"code":"0857T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":77.56,"maximum":199.58,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":103.41,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":87.91},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":80.58},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":87.91},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":199.58,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":77.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":105.48,"additional_payer_notes":"APC"}]}]},{"description":"3d vol img&rcnstj brst/ax","code_information":[{"code":"0694T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":111.87,"maximum":115.48,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":115.48},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":111.87},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":115.48}]}]},{"description":"Ct breast w/3d bi c-","code_information":[{"code":"0636T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":177.0,"maximum":464.85,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":236.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":464.85},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":450.31},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":464.85},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":455.49,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":177.0,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":240.72,"additional_payer_notes":"APC"}]}]},{"description":"Rem oct rta phys/qhp ea 30d","code_information":[{"code":"0606T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":100.65,"maximum":102.2,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":102.2},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":100.65},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":102.2}]}]},{"description":"Antmc mdl 3d print 1st cmpnt","code_information":[{"code":"0559T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":51.74,"maximum":253.99,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":131.6,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":52.53},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":51.74},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":52.53},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":253.99,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":98.7,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":134.23,"additional_payer_notes":"APC"}]}]},{"description":"Oct mid ear i&r bilateral","code_information":[{"code":"0486T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":27.71,"maximum":307.37,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":36.94,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":307.37},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":302.71},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":307.37},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":71.3,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27.71,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":37.68,"additional_payer_notes":"APC"}]}]},{"description":"Intraop oct brst/node spec","code_information":[{"code":"0351T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3401.23,"maximum":3453.5,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3453.5},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3401.23},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3453.5}]}]},{"description":"Waterjet prostate abltj cmpl","code_information":[{"code":"0421T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0}]}]},{"description":"Remove foreign body","code_information":[{"code":"10120","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":301.57,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":402.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":776.03,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":301.57,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":410.13,"additional_payer_notes":"APC"}]}]},{"description":"Debride abdom wall","code_information":[{"code":"11005","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2654.0,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0}]}]},{"description":"Deb bone 20 sq cm/<","code_information":[{"code":"11044","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1225.21,"maximum":4106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1633.61,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3152.87,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1225.21,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1666.28,"additional_payer_notes":"APC"}]}]},{"description":"Remove skin tags add-on","code_information":[{"code":"11201","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Shave skin lesion >2.0 cm","code_information":[{"code":"11308","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":301.57,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":402.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":776.03,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":301.57,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":410.13,"additional_payer_notes":"APC"}]}]},{"description":"Exc tr-ext b9+marg 2.1-3cm/<","code_information":[{"code":"11403","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":525.32,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":700.42,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1351.81,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":525.32,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":714.43,"additional_payer_notes":"APC"}]}]},{"description":"Exc h-f-nk-sp b9+marg >4 cm","code_information":[{"code":"11426","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2154.81,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2873.08,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5545.05,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2154.81,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2930.54,"additional_payer_notes":"APC"}]}]},{"description":"Removal sweat gland lesion","code_information":[{"code":"11451","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2154.81,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2873.08,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5545.05,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2154.81,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2930.54,"additional_payer_notes":"APC"}]}]},{"description":"Exc tr-ext mal+marg 2.1-3 cm","code_information":[{"code":"11603","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":525.32,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":700.42,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1351.81,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":525.32,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":714.43,"additional_payer_notes":"APC"}]}]},{"description":"Exc s/n/h/f/g mal+mrg >4 cm","code_information":[{"code":"11626","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2154.81,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2873.08,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5545.05,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2154.81,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2930.54,"additional_payer_notes":"APC"}]}]},{"description":"Debride nail 1-5","code_information":[{"code":"11720","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":43.76,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":58.35,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":112.62,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":43.76,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":59.52,"additional_payer_notes":"APC"}]}]},{"description":"Reconstruction of nail bed","code_information":[{"code":"11762","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1530.61,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2040.81,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3938.76,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1530.61,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2081.63,"additional_payer_notes":"APC"}]}]},{"description":"Correct skn color 6.1-20.0cm","code_information":[{"code":"11921","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":548.27,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":731.02,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1410.87,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":548.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":745.64,"additional_payer_notes":"APC"}]}]},{"description":"Remove tissue expander(s)","code_information":[{"code":"11971","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2154.81,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2873.08,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5545.05,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2154.81,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2930.54,"additional_payer_notes":"APC"}]}]},{"description":"Rpr s/n/ax/gen/trk7.6-12.5cm","code_information":[{"code":"12004","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":148.84,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":198.45,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":383.01,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":148.84,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":202.42,"additional_payer_notes":"APC"}]}]},{"description":"Rpr fe/e/en/l/m 12.6-20.0 cm","code_information":[{"code":"12016","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":301.57,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":402.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":776.03,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":301.57,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":410.13,"additional_payer_notes":"APC"}]}]},{"description":"Intmd rpr s/a/t/ext 12.6-20","code_information":[{"code":"12035","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":301.57,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":402.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":776.03,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":301.57,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":410.13,"additional_payer_notes":"APC"}]}]},{"description":"Cystouretero w/stone remove","code_information":[{"code":"52352","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2614.94,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3486.59,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6729.12,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2614.94,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3556.32,"additional_payer_notes":"APC"}]}]},{"description":"Cystourethro w/addl implant","code_information":[{"code":"52442","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Prostate laser enucleation","code_information":[{"code":"52649","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3977.55,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5303.4,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":10235.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3977.55,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5409.47,"additional_payer_notes":"APC"}]}]},{"description":"Drainage of urinary leakage","code_information":[{"code":"53080","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":517.28,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":689.7,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1331.13,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":517.28,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":703.5,"additional_payer_notes":"APC"}]}]},{"description":"Surgery for urethra pouch","code_information":[{"code":"53240","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2614.94,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3486.59,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6729.12,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2614.94,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3556.32,"additional_payer_notes":"APC"}]}]},{"description":"Reconstruction of urethra","code_information":[{"code":"53410","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3977.55,"maximum":10235.57,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5303.4,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":10235.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3977.55,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5409.47,"additional_payer_notes":"APC"}]}]},{"description":"Insert tandem cuff","code_information":[{"code":"53444","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8923.0,"maximum":39565.78,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20500.4,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":10765.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":8923.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":10765.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":39565.78,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15375.3,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":27583.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20910.41,"additional_payer_notes":"APC"}]}]},{"description":"Urethrlys transvag w/ scope","code_information":[{"code":"53500","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2614.94,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3486.59,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6729.12,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2614.94,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3556.32,"additional_payer_notes":"APC"}]}]},{"description":"Dilate urethra stricture","code_information":[{"code":"53605","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2614.94,"maximum":6729.12,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3486.59,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6729.12,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2614.94,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3556.32,"additional_payer_notes":"APC"}]}]},{"description":"Insert prost urethral stent","code_information":[{"code":"53855","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1550.71,"maximum":4106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2067.62,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3990.5,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1550.71,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2108.97,"additional_payer_notes":"APC"}]}]},{"description":"Cryosurgery penis lesion(s)","code_information":[{"code":"54056","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":148.84,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":198.45,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":383.01,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":148.84,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":202.42,"additional_payer_notes":"APC"}]}]},{"description":"Treat penis lesion graft","code_information":[{"code":"54112","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7022.52,"maximum":18071.3,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9363.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":18071.3,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7022.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9550.63,"additional_payer_notes":"APC"}]}]},{"description":"Circum 28 days or older","code_information":[{"code":"54161","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1550.71,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2067.62,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3990.5,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1550.71,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2108.97,"additional_payer_notes":"APC"}]}]},{"description":"Dynamic cavernosometry","code_information":[{"code":"54231","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":185.35,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":247.13,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":476.96,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":185.35,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":252.07,"additional_payer_notes":"APC"}]}]},{"description":"Reconstruction of urethra","code_information":[{"code":"54316","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":18071.3,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9363.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":18071.3,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7022.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9550.63,"additional_payer_notes":"APC"}]}]},{"description":"Secondary urethral surgery","code_information":[{"code":"54340","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2614.94,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3486.59,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6729.12,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2614.94,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3556.32,"additional_payer_notes":"APC"}]}]},{"description":"Insert semi-rigid prosthesis","code_information":[{"code":"54400","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8923.0,"maximum":27583.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13049.77,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":10765.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":8923.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":10765.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":25186.06,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9787.33,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":27583.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13310.77,"additional_payer_notes":"APC"}]}]},{"description":"Remv/repl penis contain pros","code_information":[{"code":"54416","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8923.0,"maximum":43643.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20500.4,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":10765.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":8923.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":10765.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43643.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43643.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43643.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":39565.78,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15375.3,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":41120.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20910.41,"additional_payer_notes":"APC"}]}]},{"description":"Biopsy of testis","code_information":[{"code":"54500","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2154.81,"maximum":5545.05,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2873.08,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5545.05,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2154.81,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2930.54,"additional_payer_notes":"APC"}]}]},{"description":"Exploration for testis","code_information":[{"code":"54560","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1550.71,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2067.62,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3990.5,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1550.71,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2108.97,"additional_payer_notes":"APC"}]}]},{"description":"Laparoscopy orchiectomy","code_information":[{"code":"54690","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4484.77,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5979.69,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5257.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11540.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4484.77,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6099.28,"additional_payer_notes":"APC"}]}]},{"description":"Removal of epididymis","code_information":[{"code":"54861","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2614.94,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3486.59,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6729.12,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2614.94,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3556.32,"additional_payer_notes":"APC"}]}]},{"description":"Drainage of scrotum abscess","code_information":[{"code":"55100","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1225.21,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1633.61,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3152.87,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1225.21,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1666.28,"additional_payer_notes":"APC"}]}]},{"description":"Prepare sperm duct x-ray","code_information":[{"code":"55300","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Laparo proc spermatic cord","code_information":[{"code":"55559","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4484.77,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5979.69,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5257.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11540.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4484.77,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6099.28,"additional_payer_notes":"APC"}]}]},{"description":"Drainage of prostate abscess","code_information":[{"code":"55720","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2614.94,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3486.59,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6729.12,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2614.94,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3556.32,"additional_payer_notes":"APC"}]}]},{"description":"Extensive prostate surgery","code_information":[{"code":"55840","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Cryoablate Prostate","code_information":[{"code":"55873","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7022.52,"maximum":27583.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9363.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":18071.3,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7022.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":27583.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9550.63,"additional_payer_notes":"APC"}]}]},{"description":"Drainage of gland abscess","code_information":[{"code":"56420","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":149.98,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":199.97,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":385.94,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":149.98,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":203.97,"additional_payer_notes":"APC"}]}]},{"description":"Partial removal of vulva","code_information":[{"code":"56620","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2401.4,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3201.87,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6179.61,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2401.4,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3265.91,"additional_payer_notes":"APC"}]}]},{"description":"Extensive vulva surgery","code_information":[{"code":"56640","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Exploration of vagina","code_information":[{"code":"57000","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2401.4,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3201.87,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6179.61,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2401.4,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3265.91,"additional_payer_notes":"APC"}]}]},{"description":"Biopsy of vagina","code_information":[{"code":"57105","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2401.4,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3201.87,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6179.61,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2401.4,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3265.91,"additional_payer_notes":"APC"}]}]},{"description":"Remove vagina lesion","code_information":[{"code":"57135","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2401.4,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3201.87,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6179.61,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2401.4,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3265.91,"additional_payer_notes":"APC"}]}]},{"description":"Repair vagina/perineum","code_information":[{"code":"57210","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2401.4,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3201.87,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6179.61,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2401.4,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3265.91,"additional_payer_notes":"APC"}]}]},{"description":"Repair of bowel bulge","code_information":[{"code":"57268","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3388.0,"maximum":9549.58,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4947.97,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":9549.58,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3710.98,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5046.93,"additional_payer_notes":"APC"}]}]},{"description":"Breast reconstruction","code_information":[{"code":"19364","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6019.0,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":7398.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6019.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":7398.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0}]}]},{"description":"Removal of breast implant","code_information":[{"code":"19328","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2904.59,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3872.79,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7474.49,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2904.59,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3950.25,"additional_payer_notes":"APC"}]}]},{"description":"P-Mastectomy w/LN Removal","code_information":[{"code":"19302","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4925.89,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6567.85,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":7398.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6019.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":7398.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":12675.95,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4925.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6699.21,"additional_payer_notes":"APC"}]}]},{"description":"Perq dev breast add us imag","code_information":[{"code":"19286","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Removal of breast lesion","code_information":[{"code":"19120","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2904.59,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3872.79,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7474.49,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2904.59,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3950.25,"additional_payer_notes":"APC"}]}]},{"description":"Bx breast add lesion us imag","code_information":[{"code":"19084","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Skin tissue procedure","code_information":[{"code":"17999","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":148.84,"maximum":13249.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":198.45,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":13249.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":10779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":13249.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":383.01,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":148.84,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":202.42,"additional_payer_notes":"APC"}]}]},{"description":"Mohs 1 stage h/n/hf/g","code_information":[{"code":"17311","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":548.27,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":731.02,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1410.87,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":548.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":745.64,"additional_payer_notes":"APC"}]}]},{"description":"Destruction of skin lesions","code_information":[{"code":"17274","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":301.57,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":402.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":776.03,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":301.57,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":410.13,"additional_payer_notes":"APC"}]}]},{"description":"Destruction of skin lesions","code_information":[{"code":"17262","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":148.84,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":198.45,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":383.01,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":148.84,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":202.42,"additional_payer_notes":"APC"}]}]},{"description":"Prepare face/oral prosthesis","code_information":[{"code":"21079","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2459.51,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3279.35,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6329.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2459.51,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3344.94,"additional_payer_notes":"APC"}]}]},{"description":"Prepare face/oral prosthesis","code_information":[{"code":"21087","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Reconstruction of chin","code_information":[{"code":"21122","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":11300.84,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Lefort i-2 piece w/o graft","code_information":[{"code":"21142","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Lefort iii w/ lefort i","code_information":[{"code":"21155","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Reconstruct cranial bone","code_information":[{"code":"21182","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Reconstr lwr jaw segment","code_information":[{"code":"21198","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":11300.84,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Ear cartilage graft","code_information":[{"code":"21235","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3579.0,"maximum":11300.84,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Reconstruction of jaw","code_information":[{"code":"21248","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Revise eye sockets","code_information":[{"code":"21268","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Closed tx nose fx w/o stablj","code_information":[{"code":"21315","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1151.01,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1534.69,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2961.94,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1151.01,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1565.38,"additional_payer_notes":"APC"}]}]},{"description":"Open nasoethmoid fx w/ fixj","code_information":[{"code":"21339","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":11300.84,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Perq tx malar fracture","code_information":[{"code":"21355","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2459.51,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3279.35,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6329.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2459.51,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3344.94,"additional_payer_notes":"APC"}]}]},{"description":"Opn tx orbit periorbtl implt","code_information":[{"code":"21390","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Treat mouth roof fracture","code_information":[{"code":"21422","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Treat dental ridge fracture","code_information":[{"code":"21445","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Treat lower jaw fracture","code_information":[{"code":"21465","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Drain chest lesion","code_information":[{"code":"21502","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Resect neck tumor 5 cm/>","code_information":[{"code":"21558","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2154.81,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2873.08,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5545.05,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2154.81,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2930.54,"additional_payer_notes":"APC"}]}]},{"description":"Hyoid myotomy & suspension","code_information":[{"code":"21685","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":11300.84,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Repair of sternum separation","code_information":[{"code":"21750","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Biopsy soft tissue of back","code_information":[{"code":"21925","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1225.21,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1633.61,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3152.87,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1225.21,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1666.28,"additional_payer_notes":"APC"}]}]},{"description":"I&d abscess p-spine l/s/ls","code_information":[{"code":"22015","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3388.0,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Remove extra spine segment","code_information":[{"code":"22116","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Incis w/discectomy cervical","code_information":[{"code":"22220","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Treat spine fracture","code_information":[{"code":"22325","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":24508.8,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12698.86,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":24508.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9524.15,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12952.84,"additional_payer_notes":"APC"}]}]},{"description":"Radiation treatment delivery","code_information":[{"code":"G6013","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":879.96,"maximum":911.44,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":911.44},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":879.96},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":911.44}]}]},{"description":"Radiation treatment delivery","code_information":[{"code":"G6005","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":480.73,"maximum":497.91,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":497.91},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":480.73},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":497.91}]}]},{"description":"PET imaging initial dx","code_information":[{"code":"G0252","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":257.18,"maximum":266.37,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":266.37},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":257.18},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":266.37}]}]},{"description":"Vaccinia vrs vac 0.3 ml perq","code_information":[{"code":"90622","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":0.0075,"maximum":0.03,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":0.01,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":0.01},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":0.01},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":0.01},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":0.02,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":0.0075,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.03},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":0.01,"additional_payer_notes":"APC"}]}]},{"description":"Nuclear rx oral admin","code_information":[{"code":"79005","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":164.18,"maximum":445.43,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":230.79,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":170.06},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":164.18},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":170.06},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":445.43,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":173.1,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":235.41,"additional_payer_notes":"APC"}]}]},{"description":"Pet image full body","code_information":[{"code":"78813","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1060.78,"maximum":2729.74,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1414.38,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":2323.26},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2288.09},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":2323.26},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2729.74,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1060.78,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1442.66,"additional_payer_notes":"APC"}]}]},{"description":"Tumor imaging limited area","code_information":[{"code":"78800","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":296.56,"maximum":763.16,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":395.42,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":564.62},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":545.12},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":564.62},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":763.16,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":296.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":403.33,"additional_payer_notes":"APC"}]}]},{"description":"Kidney imaging with flow","code_information":[{"code":"78701","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":296.56,"maximum":763.16,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":395.42,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":670.46},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":647.31},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":670.46},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":763.16,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":296.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":403.33,"additional_payer_notes":"APC"}]}]},{"description":"Brain imaging (PET)","code_information":[{"code":"78609","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":257.18,"maximum":266.37,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":266.37},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":257.18},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":266.37}]}]},{"description":"Lung ventilat&perfus imaging","code_information":[{"code":"78582","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":402.79,"maximum":1036.52,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":537.06,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":1012.08},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":977.12},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":1012.08},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1036.52,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":402.79,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":547.8,"additional_payer_notes":"APC"}]}]},{"description":"Heart first pass single","code_information":[{"code":"78481","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":402.79,"maximum":1036.52,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":537.06,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":454.35},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":438.66},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":454.35},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1036.52,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":402.79,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":547.8,"additional_payer_notes":"APC"}]}]},{"description":"Venous thrombosis imaging","code_information":[{"code":"78457","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":402.79,"maximum":1036.52,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":537.06,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":536.3},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":517.78},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":536.3},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1036.52,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":402.79,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":547.8,"additional_payer_notes":"APC"}]}]},{"description":"Myocrd img pet 2rtracer ct","code_information":[{"code":"78433","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1634.1,"maximum":4205.08,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2178.8,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":2262.49},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2228.24},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":2262.49},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4205.08,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1634.1,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2222.38,"additional_payer_notes":"APC"}]}]},{"description":"Bone mineral single photon","code_information":[{"code":"78350","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":73.17,"maximum":75.8,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":75.8},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":73.17},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":75.8}]}]},{"description":"Acute GI blood loss imaging","code_information":[{"code":"78278","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":296.56,"maximum":1074.84,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":395.42,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":1074.84},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1037.71},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":1074.84},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":763.16,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":296.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":403.33,"additional_payer_notes":"APC"}]}]},{"description":"Serial salivary imaging","code_information":[{"code":"78231","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":296.56,"maximum":763.16,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":395.42,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":371.41},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":358.57},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":371.41},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":763.16,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":296.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":403.33,"additional_payer_notes":"APC"}]}]},{"description":"Lymph system imaging","code_information":[{"code":"78195","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":402.79,"maximum":1065.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":537.06,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":1065.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1028.2},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":1065.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1036.52,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":402.79,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":547.8,"additional_payer_notes":"APC"}]}]},{"description":"Plasma volume multiple","code_information":[{"code":"78111","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":293.22,"maximum":2471.46,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1280.55,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":303.71},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":293.22},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":303.71},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2471.46,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":960.41,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1306.16,"additional_payer_notes":"APC"}]}]},{"description":"Parathyroid planar imaging","code_information":[{"code":"78070","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":296.56,"maximum":932.59,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":395.42,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":932.59},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":900.38},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":932.59},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":763.16,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":296.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":403.33,"additional_payer_notes":"APC"}]}]},{"description":"Radiation handling","code_information":[{"code":"77790","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":49.43,"maximum":51.18,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":51.18},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":49.43},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":51.18}]}]},{"description":"Apply intrcav radiat compl","code_information":[{"code":"77763","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":516.67,"maximum":1329.56,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":688.89,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":987.43},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":953.31},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":987.43},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1329.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":516.67,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":702.67,"additional_payer_notes":"APC"}]}]},{"description":"Hyperthermia treatment","code_information":[{"code":"77600","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":286.12,"maximum":1174.52,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":381.5,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":1174.52},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1133.96},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":1174.52},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":736.29,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":286.12,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":389.13,"additional_payer_notes":"APC"}]}]},{"description":"Stereotactic radiation trmt","code_information":[{"code":"77432","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1417.12,"maximum":1467.82,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":1467.82},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1417.12},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":1467.82}]}]},{"description":"Radiation treatment delivery","code_information":[{"code":"77401","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":81.49,"maximum":84.41,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":84.41},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":81.49},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":84.41}]}]},{"description":"Design mlc device for imrt","code_information":[{"code":"77338","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":277.76,"maximum":988.93,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":370.35,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":988.93},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":954.77},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":988.93},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":714.78,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":277.76,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":377.76,"additional_payer_notes":"APC"}]}]},{"description":"Brachytx isodose intermed","code_information":[{"code":"77317","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":277.76,"maximum":714.78,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":370.35,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":521.05},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":503.02},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":521.05},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":714.78,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":277.76,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":377.76,"additional_payer_notes":"APC"}]}]},{"description":"Set radiation therapy field","code_information":[{"code":"77290","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":277.76,"maximum":1505.86,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":370.35,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":1505.86},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1453.86},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":1505.86},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":714.78,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":277.76,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":377.76,"additional_payer_notes":"APC"}]}]},{"description":"Tbs techl prep&transmis data","code_information":[{"code":"77090","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7.7,"maximum":166.13,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":86.08,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":7.82},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7.7},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":7.82},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":166.13,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":64.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":87.8,"additional_payer_notes":"APC"}]}]},{"description":"Joint survey single view","code_information":[{"code":"77077","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":69.62,"maximum":199.58,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":103.41,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":72.1},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":69.62},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":72.1},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":199.58,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":77.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":105.48,"additional_payer_notes":"APC"}]}]},{"description":"Breast tomosynthesis bi","code_information":[{"code":"77062","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":406.43,"maximum":412.67,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":412.67},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":406.43},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":412.67}]}]},{"description":"MRI for Tissue Ablation","code_information":[{"code":"77022","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1564.47,"maximum":1620.45,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":1620.45},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1564.47},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":1620.45}]}]},{"description":"Fluoroguide for Vein Device","code_information":[{"code":"77001","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":171.09,"maximum":177.21,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":177.21},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":171.09},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":177.21}]}]},{"description":"Use parenchyma","code_information":[{"code":"76981","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":77.56,"maximum":269.29,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":103.41,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":269.29},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":262.6},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":269.29},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":199.58,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":77.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":105.48,"additional_payer_notes":"APC"}]}]},{"description":"Echo guide villus sampling","code_information":[{"code":"76945","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":204.77,"maximum":212.1,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":212.1},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":204.77},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":212.1}]}]},{"description":"Us exam infant hips dynamic","code_information":[{"code":"76885","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":64.56,"maximum":376.08,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":86.08,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":376.08},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":363.1},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":376.08},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":166.13,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":64.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":87.8,"additional_payer_notes":"APC"}]}]},{"description":"Us exam pelvic complete","code_information":[{"code":"76856","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":77.56,"maximum":261.62,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":103.41,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":261.62},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":252.6},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":261.62},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":199.58,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":77.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":105.48,"additional_payer_notes":"APC"}]}]},{"description":"Repair bladder defect","code_information":[{"code":"57288","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3710.98,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4947.97,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":9549.58,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3710.98,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5046.93,"additional_payer_notes":"APC"}]}]},{"description":"Fistula repair & colostomy","code_information":[{"code":"57307","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Pelvic examination","code_information":[{"code":"57410","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2401.4,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3201.87,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6179.61,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2401.4,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3265.91,"additional_payer_notes":"APC"}]}]},{"description":"Bx/curett of cervix w/scope","code_information":[{"code":"57454","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":226.06,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":301.41,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":581.72,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":226.06,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":307.44,"additional_payer_notes":"APC"}]}]},{"description":"Cryocautery of cervix","code_information":[{"code":"57511","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":226.06,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":301.41,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":581.72,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":226.06,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":307.44,"additional_payer_notes":"APC"}]}]},{"description":"Removal of residual cervix","code_information":[{"code":"57550","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3388.0,"maximum":9549.58,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4947.97,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":9549.58,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3710.98,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5046.93,"additional_payer_notes":"APC"}]}]},{"description":"Bx done w/colposcopy add-on","code_information":[{"code":"58110","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Extensive hysterectomy","code_information":[{"code":"58200","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5257.0,"maximum":6462.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5257.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6462.0}]}]},{"description":"Hysterectomy/revise vagina","code_information":[{"code":"58275","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5257.0,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5257.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0}]}]},{"description":"Remove intrauterine device","code_information":[{"code":"58301","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":226.06,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":301.41,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":581.72,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":226.06,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":307.44,"additional_payer_notes":"APC"}]}]},{"description":"Endometr ablate thermal","code_information":[{"code":"58353","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3710.98,"maximum":9549.58,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4947.97,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":9549.58,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3710.98,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5046.93,"additional_payer_notes":"APC"}]}]},{"description":"LSH Uterus Above 250 g","code_information":[{"code":"58543","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":20292.15,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10514.07,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":20292.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7885.55,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10724.35,"additional_payer_notes":"APC"}]}]},{"description":"Laparo-vag hyst w/t/o compl","code_information":[{"code":"58554","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":20292.15,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10514.07,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":20292.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7885.55,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10724.35,"additional_payer_notes":"APC"}]}]},{"description":"Hysteroscopy sterilization","code_information":[{"code":"58565","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3710.98,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4947.97,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":9549.58,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3710.98,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5046.93,"additional_payer_notes":"APC"}]}]},{"description":"Division of fallopian tube","code_information":[{"code":"58605","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3579.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0}]}]},{"description":"Laparoscopy fimbrioplasty","code_information":[{"code":"58672","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4484.77,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5979.69,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5257.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11540.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4484.77,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6099.28,"additional_payer_notes":"APC"}]}]},{"description":"Fimbrioplasty","code_information":[{"code":"58760","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0}]}]},{"description":"Partial removal of ovary(s)","code_information":[{"code":"58920","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5501.01,"maximum":14155.93,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7334.68,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":14155.93,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5501.01,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7481.37,"additional_payer_notes":"APC"}]}]},{"description":"Tah rad debulk/lymph remove","code_information":[{"code":"58954","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Amniocentesis diagnostic","code_information":[{"code":"59000","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":683.26,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":911.02,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1758.27,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":683.26,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":929.24,"additional_payer_notes":"APC"}]}]},{"description":"Fetal monitor/interpret only","code_information":[{"code":"59051","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5512.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0}]}]},{"description":"Treat ectopic pregnancy","code_information":[{"code":"59130","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Revision of cervix","code_information":[{"code":"59320","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2401.4,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3201.87,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6179.61,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2401.4,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3265.91,"additional_payer_notes":"APC"}]}]},{"description":"Antepartum care only","code_information":[{"code":"59425","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5512.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0}]}]},{"description":"Vbac delivery only","code_information":[{"code":"59612","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2401.4,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3201.87,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6179.61,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2401.4,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3265.91,"additional_payer_notes":"APC"}]}]},{"description":"Treat uterus infection","code_information":[{"code":"59830","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3388.0,"maximum":4106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0}]}]},{"description":"Abortion","code_information":[{"code":"59857","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3388.0,"maximum":4106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0}]}]},{"description":"Biopsy of thyroid","code_information":[{"code":"60100","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":525.32,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":700.42,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1351.81,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":525.32,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":714.43,"additional_payer_notes":"APC"}]}]},{"description":"Extensive thyroid surgery","code_information":[{"code":"60254","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0}]}]},{"description":"Re-explore parathyroids","code_information":[{"code":"60502","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Remove carotid body lesion","code_information":[{"code":"60600","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Injection into brain canal","code_information":[{"code":"61026","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":523.65,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":698.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1347.51,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":523.65,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":712.16,"additional_payer_notes":"APC"}]}]},{"description":"Pierce skull for biopsy","code_information":[{"code":"61140","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Pierce skull & explore","code_information":[{"code":"61253","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3388.0,"maximum":4106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0}]}]},{"description":"Open skull for drainage","code_information":[{"code":"61320","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6779.0,"maximum":8333.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0}]}]},{"description":"Relieve cranial pressure","code_information":[{"code":"61345","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6779.0,"maximum":8333.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0}]}]},{"description":"Amputate leg at thigh","code_information":[{"code":"27591","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":27583.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":27583.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Decompression of lower leg","code_information":[{"code":"27602","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Biopsy lower leg soft tissue","code_information":[{"code":"27613","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1225.21,"maximum":4106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1633.61,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3152.87,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1225.21,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1666.28,"additional_payer_notes":"APC"}]}]},{"description":"Remove ankle joint lining","code_information":[{"code":"27626","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Partial removal of fibula","code_information":[{"code":"27641","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Repair leg fascia defect","code_information":[{"code":"27656","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Release of lower leg tendons","code_information":[{"code":"27681","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Repair of ankle ligaments","code_information":[{"code":"27696","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":13851.98,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Incision of tibia & fibula","code_information":[{"code":"27709","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":24508.8,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12698.86,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":24508.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9524.15,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12952.84,"additional_payer_notes":"APC"}]}]},{"description":"Repair of lower leg","code_information":[{"code":"27727","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Treatment of tibia fracture","code_information":[{"code":"27752","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1192.86,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1590.48,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3069.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1192.86,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1622.29,"additional_payer_notes":"APC"}]}]},{"description":"Cltx post ankle fx w/mnpj","code_information":[{"code":"27768","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1192.86,"maximum":4106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1590.48,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3069.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1192.86,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1622.29,"additional_payer_notes":"APC"}]}]},{"description":"Treatment of ankle fracture","code_information":[{"code":"27808","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":182.99,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":243.98,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":470.88,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":182.99,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":248.86,"additional_payer_notes":"APC"}]}]},{"description":"Treat lower leg fracture","code_information":[{"code":"27825","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1192.86,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1590.48,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3069.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1192.86,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1622.29,"additional_payer_notes":"APC"}]}]},{"description":"Treat ankle dislocation","code_information":[{"code":"27840","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":182.99,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":243.98,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":470.88,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":182.99,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":248.86,"additional_payer_notes":"APC"}]}]},{"description":"Amputation of lower leg","code_information":[{"code":"27881","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Decompression of leg","code_information":[{"code":"27894","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Incision of toe tendons","code_information":[{"code":"28011","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1192.86,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1590.48,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3069.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1192.86,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1622.29,"additional_payer_notes":"APC"}]}]},{"description":"Exc foot/toe tum deep <1.5cm","code_information":[{"code":"28045","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2154.81,"maximum":5545.05,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2873.08,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5545.05,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2154.81,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2930.54,"additional_payer_notes":"APC"}]}]},{"description":"Removal of foot fascia","code_information":[{"code":"28062","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Shoulder arthroscopy/surgery","code_information":[{"code":"29826","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":8265.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8265.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Shoulder arthroscopy/surgery","code_information":[{"code":"29807","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Windowing of cast","code_information":[{"code":"29730","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":120.55,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":160.73,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":310.21,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":120.55,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":163.95,"additional_payer_notes":"APC"}]}]},{"description":"Strapping of toes","code_information":[{"code":"29550","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":43.76,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":58.35,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":112.62,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":43.76,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":59.52,"additional_payer_notes":"APC"}]}]},{"description":"Addition of walker to cast","code_information":[{"code":"29440","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":120.55,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":160.73,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":310.21,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":120.55,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":163.95,"additional_payer_notes":"APC"}]}]},{"description":"Application of hip casts","code_information":[{"code":"29325","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":207.48,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":276.65,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":533.93,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":207.48,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":282.18,"additional_payer_notes":"APC"}]}]},{"description":"Apply forearm splint","code_information":[{"code":"29126","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":98.7,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":131.6,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":253.99,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":98.7,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":134.23,"additional_payer_notes":"APC"}]}]},{"description":"Application of shoulder cast","code_information":[{"code":"29055","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":207.48,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":276.65,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":533.93,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":207.48,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":282.18,"additional_payer_notes":"APC"}]}]},{"description":"Application of body cast","code_information":[{"code":"29000","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":207.48,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":276.65,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":533.93,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":207.48,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":282.18,"additional_payer_notes":"APC"}]}]},{"description":"Fusion of big toe joint","code_information":[{"code":"28760","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Fusion of foot bones","code_information":[{"code":"28715","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":24508.8,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12698.86,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":24508.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9524.15,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12952.84,"additional_payer_notes":"APC"}]}]},{"description":"Treat toe dislocation","code_information":[{"code":"28635","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1192.86,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1590.48,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3069.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1192.86,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1622.29,"additional_payer_notes":"APC"}]}]},{"description":"Treat foot dislocation","code_information":[{"code":"28575","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":6246.19,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Treat toe fracture","code_information":[{"code":"28525","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Treat metatarsal fracture","code_information":[{"code":"28476","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Treat ankle fracture","code_information":[{"code":"28445","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Intmd rpr n-hf/genit 2.5cm/<","code_information":[{"code":"12041","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":301.57,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":402.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":776.03,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":301.57,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":410.13,"additional_payer_notes":"APC"}]}]},{"description":"Intmd rpr face/mm 5.1-7.5 cm","code_information":[{"code":"12053","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":301.57,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":402.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":776.03,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":301.57,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":410.13,"additional_payer_notes":"APC"}]}]},{"description":"Cmplx rpr s/a/l 1.1-2.5 cm","code_information":[{"code":"13120","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":301.57,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":402.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":776.03,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":301.57,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":410.13,"additional_payer_notes":"APC"}]}]},{"description":"Cmplx rpr e/n/e/l addl 5cm/<","code_information":[{"code":"13153","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Tis trnfr e/n/e/l 10 sq cm/<","code_information":[{"code":"14060","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1530.61,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2040.81,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3938.76,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1530.61,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2081.63,"additional_payer_notes":"APC"}]}]},{"description":"Wnd prep f/n/hf/g addl cm","code_information":[{"code":"15005","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Epidrm a-grft f/n/hf/g addl","code_information":[{"code":"15116","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Cult skin grft t/a/l addl","code_information":[{"code":"15151","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Skin full graft add-on","code_information":[{"code":"15221","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Skn sub grft t/a/l child add","code_information":[{"code":"15274","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Pedicle e/n/e/l/ntroral","code_information":[{"code":"15576","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1530.61,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2040.81,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3938.76,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1530.61,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2081.63,"additional_payer_notes":"APC"}]}]},{"description":"Muscle-skin graft arm","code_information":[{"code":"15736","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1530.61,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2040.81,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3938.76,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1530.61,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2081.63,"additional_payer_notes":"APC"}]}]},{"description":"Derma-fat-fascia graft","code_information":[{"code":"15770","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2628.85,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3505.13,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6764.9,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2628.85,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3575.23,"additional_payer_notes":"APC"}]}]},{"description":"Abrasion lesion single","code_information":[{"code":"15786","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":148.84,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":198.45,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":383.01,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":148.84,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":202.42,"additional_payer_notes":"APC"}]}]},{"description":"Revision of upper eyelid","code_information":[{"code":"15822","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1530.61,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2040.81,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3938.76,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1530.61,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2081.63,"additional_payer_notes":"APC"}]}]},{"description":"Excise excessive skin thigh","code_information":[{"code":"15832","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2154.81,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2873.08,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5545.05,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2154.81,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2930.54,"additional_payer_notes":"APC"}]}]},{"description":"Nerve palsy fascial graft","code_information":[{"code":"15840","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2628.85,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3505.13,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6764.9,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2628.85,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3575.23,"additional_payer_notes":"APC"}]}]},{"description":"Suction lipectomy head&neck","code_information":[{"code":"15876","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2628.85,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3505.13,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6764.9,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2628.85,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3575.23,"additional_payer_notes":"APC"}]}]},{"description":"Remove sacrum pressure sore","code_information":[{"code":"15934","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2628.85,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3505.13,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6764.9,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2628.85,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3575.23,"additional_payer_notes":"APC"}]}]},{"description":"Remove hip pressure sore","code_information":[{"code":"15946","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1530.61,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2040.81,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3938.76,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1530.61,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2081.63,"additional_payer_notes":"APC"}]}]},{"description":"Initial treatment of burn(s)","code_information":[{"code":"16000","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":148.84,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":198.45,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":383.01,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":148.84,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":202.42,"additional_payer_notes":"APC"}]}]},{"description":"Destroy premal lesions 15/>","code_information":[{"code":"17004","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":301.57,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":402.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":776.03,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":301.57,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":410.13,"additional_payer_notes":"APC"}]}]},{"description":"Exc face les sc <2 cm","code_information":[{"code":"21011","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1225.21,"maximum":4106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1633.61,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3152.87,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1225.21,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1666.28,"additional_payer_notes":"APC"}]}]},{"description":"Contour of face bone lesion","code_information":[{"code":"21029","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2459.51,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3279.35,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6329.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2459.51,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3344.94,"additional_payer_notes":"APC"}]}]},{"description":"Remove mandible cyst complex","code_information":[{"code":"21046","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Prepare face/oral prosthesis","code_information":[{"code":"21076","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1151.01,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1534.69,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2961.94,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1151.01,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1565.38,"additional_payer_notes":"APC"}]}]},{"description":"Other bone graft microvasc","code_information":[{"code":"20962","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Sp bone algrft struct add-on","code_information":[{"code":"20931","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Removal of bone for graft","code_information":[{"code":"20900","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":13851.98,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Replantation arm complete","code_information":[{"code":"20802","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6779.0,"maximum":33471.73,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17342.86,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":33471.73,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13007.15,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":27583.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17689.72,"additional_payer_notes":"APC"}]}]},{"description":"Removal of support implant","code_information":[{"code":"20670","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1225.21,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1633.61,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3152.87,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1225.21,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1666.28,"additional_payer_notes":"APC"}]}]},{"description":"Treatment of bone cyst","code_information":[{"code":"20615","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":525.32,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":700.42,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1351.81,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":525.32,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":714.43,"additional_payer_notes":"APC"}]}]},{"description":"Place ndl musc/tis for rt","code_information":[{"code":"20555","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Removal of foreign body","code_information":[{"code":"20520","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1225.21,"maximum":4106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1633.61,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3152.87,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1225.21,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1666.28,"additional_payer_notes":"APC"}]}]},{"description":"Bone biopsy trocar/needle","code_information":[{"code":"20220","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1225.21,"maximum":4106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1633.61,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3152.87,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1225.21,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1666.28,"additional_payer_notes":"APC"}]}]},{"description":"Explore wound neck","code_information":[{"code":"20100","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":400.09,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":533.45,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1029.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":400.09,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":544.12,"additional_payer_notes":"APC"}]}]},{"description":"Intmd rpr n-hf/genit >30.0cm","code_information":[{"code":"12047","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1530.61,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2040.81,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3938.76,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1530.61,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2081.63,"additional_payer_notes":"APC"}]}]},{"description":"Cmplx rpr trunk 1.1-2.5 cm","code_information":[{"code":"13100","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":548.27,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":731.02,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1410.87,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":548.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":745.64,"additional_payer_notes":"APC"}]}]},{"description":"Cmplx rpr f/c/c/m/n/ax/g/h/f","code_information":[{"code":"13133","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Tis trnfr s/a/l 10.1-30 sqcm","code_information":[{"code":"14021","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1530.61,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2040.81,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3938.76,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1530.61,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2081.63,"additional_payer_notes":"APC"}]}]},{"description":"Wound prep trk/arm/leg","code_information":[{"code":"15002","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":548.27,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":731.02,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1410.87,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":548.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":745.64,"additional_payer_notes":"APC"}]}]},{"description":"Epidrm autogrft trnk/arm/leg","code_information":[{"code":"15110","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1530.61,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2040.81,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3938.76,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1530.61,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2081.63,"additional_payer_notes":"APC"}]}]},{"description":"Derm autograft face/nck/hf/g","code_information":[{"code":"15135","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2628.85,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3505.13,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6764.9,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2628.85,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3575.23,"additional_payer_notes":"APC"}]}]},{"description":"Skin full graft trunk","code_information":[{"code":"15200","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1530.61,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2040.81,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3938.76,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1530.61,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2081.63,"additional_payer_notes":"APC"}]}]},{"description":"Skin sub graft trnk/arm/leg","code_information":[{"code":"15271","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":548.27,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":731.02,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1410.87,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":548.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":745.64,"additional_payer_notes":"APC"}]}]},{"description":"Skin pedicle flap trunk","code_information":[{"code":"15570","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1530.61,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2040.81,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3938.76,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1530.61,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2081.63,"additional_payer_notes":"APC"}]}]},{"description":"Transfer skin pedicle flap","code_information":[{"code":"15650","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1530.61,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2040.81,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3938.76,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1530.61,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2081.63,"additional_payer_notes":"APC"}]}]},{"description":"Free skin flap microvasc","code_information":[{"code":"15757","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0}]}]},{"description":"Dermabrasion segmental face","code_information":[{"code":"15781","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":525.32,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":700.42,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1351.81,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":525.32,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":714.43,"additional_payer_notes":"APC"}]}]},{"description":"Chemical peel nonfacial","code_information":[{"code":"15793","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":301.57,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":402.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":776.03,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":301.57,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":410.13,"additional_payer_notes":"APC"}]}]},{"description":"Removal of face wrinkles","code_information":[{"code":"15828","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2628.85,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3505.13,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6764.9,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2628.85,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3575.23,"additional_payer_notes":"APC"}]}]},{"description":"Excise excess skin arm/hand","code_information":[{"code":"15837","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2154.81,"maximum":5545.05,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2873.08,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5545.05,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2154.81,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2930.54,"additional_payer_notes":"APC"}]}]},{"description":"Remove sutures diff surgeon","code_information":[{"code":"15851","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1530.61,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2040.81,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3938.76,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1530.61,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2081.63,"additional_payer_notes":"APC"}]}]},{"description":"Removal of tail bone ulcer","code_information":[{"code":"15922","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2628.85,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3505.13,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6764.9,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2628.85,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3575.23,"additional_payer_notes":"APC"}]}]},{"description":"Remove hip pressure sore","code_information":[{"code":"15941","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2154.81,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2873.08,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5545.05,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2154.81,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2930.54,"additional_payer_notes":"APC"}]}]},{"description":"Remove thigh pressure sore","code_information":[{"code":"15956","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1530.61,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2040.81,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3938.76,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1530.61,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2081.63,"additional_payer_notes":"APC"}]}]},{"description":"Escharotomy addl incision","code_information":[{"code":"16036","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2654.0,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0}]}]},{"description":"Cptr-asst dir ms px","code_information":[{"code":"20985","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Resect face/scalp tum 2 cm/>","code_information":[{"code":"21016","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2154.81,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2873.08,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5545.05,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2154.81,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2930.54,"additional_payer_notes":"APC"}]}]},{"description":"Excise mandible lesion","code_information":[{"code":"21040","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2459.51,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3279.35,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6329.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2459.51,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3344.94,"additional_payer_notes":"APC"}]}]},{"description":"Remove jaw joint cartilage","code_information":[{"code":"21060","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Bone/skin graft metatarsal","code_information":[{"code":"20972","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Sp bone agrft struct add-on","code_information":[{"code":"20938","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5512.0,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0}]}]},{"description":"Remove cartilage for graft","code_information":[{"code":"20912","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2628.85,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3505.13,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6764.9,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2628.85,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3575.23,"additional_payer_notes":"APC"}]}]},{"description":"Replantation digit complete","code_information":[{"code":"20816","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1192.86,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1590.48,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3069.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1192.86,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1622.29,"additional_payer_notes":"APC"}]}]},{"description":"Apply bone fixation device","code_information":[{"code":"20692","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":24508.8,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12698.86,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":24508.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9524.15,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12952.84,"additional_payer_notes":"APC"}]}]},{"description":"Application of head brace","code_information":[{"code":"20661","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1192.86,"maximum":4106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1590.48,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3069.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1192.86,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1622.29,"additional_payer_notes":"APC"}]}]},{"description":"Drain/inj joint/bursa w/o us","code_information":[{"code":"20605","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":227.71,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":303.61,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":585.96,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":227.71,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":309.68,"additional_payer_notes":"APC"}]}]},{"description":"Inj dupuytren cord w/enzyme","code_information":[{"code":"20527","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":227.71,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":303.61,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":585.96,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":227.71,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":309.68,"additional_payer_notes":"APC"}]}]},{"description":"Bone biopsy open deep","code_information":[{"code":"20245","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2154.81,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2873.08,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5545.05,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2154.81,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2930.54,"additional_payer_notes":"APC"}]}]},{"description":"Explore wound extremity","code_information":[{"code":"20103","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1225.21,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1633.61,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3152.87,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1225.21,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1666.28,"additional_payer_notes":"APC"}]}]},{"description":"Surgery of breast capsule","code_information":[{"code":"19370","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2904.59,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3872.79,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7474.49,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2904.59,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3950.25,"additional_payer_notes":"APC"}]}]},{"description":"Breast reconstruction","code_information":[{"code":"19367","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6019.0,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":7398.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6019.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":7398.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0}]}]},{"description":"Removal of implant material","code_information":[{"code":"19330","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2904.59,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3872.79,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7474.49,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2904.59,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3950.25,"additional_payer_notes":"APC"}]}]},{"description":"Mast simple complete","code_information":[{"code":"19303","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4925.89,"maximum":12675.95,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6567.85,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":7398.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6019.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":7398.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":12675.95,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4925.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6699.21,"additional_payer_notes":"APC"}]}]},{"description":"Perq dev breast 1st mr guide","code_information":[{"code":"19287","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":525.32,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":700.42,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1351.81,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":525.32,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":714.43,"additional_payer_notes":"APC"}]}]},{"description":"Excision breast lesion","code_information":[{"code":"19125","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2904.59,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3872.79,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7474.49,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2904.59,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3950.25,"additional_payer_notes":"APC"}]}]},{"description":"Bx breast 1st lesion mr imag","code_information":[{"code":"19085","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1225.21,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1633.61,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3152.87,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1225.21,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1666.28,"additional_payer_notes":"APC"}]}]},{"description":"Drainage of breast lesion","code_information":[{"code":"19000","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":525.32,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":700.42,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1351.81,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":525.32,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":714.43,"additional_payer_notes":"APC"}]}]},{"description":"Mohs Addl Stage","code_information":[{"code":"17312","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Destruction of skin lesions","code_information":[{"code":"17276","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":301.57,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":402.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":776.03,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":301.57,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":410.13,"additional_payer_notes":"APC"}]}]},{"description":"Destruction of skin lesions","code_information":[{"code":"17263","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":148.84,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":198.45,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":383.01,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":148.84,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":202.42,"additional_payer_notes":"APC"}]}]},{"description":"Destruction of skin lesions","code_information":[{"code":"17107","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":548.27,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":731.02,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1410.87,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":548.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":745.64,"additional_payer_notes":"APC"}]}]},{"description":"Prepare face/oral prosthesis","code_information":[{"code":"21086","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2459.51,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3279.35,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6329.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2459.51,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3344.94,"additional_payer_notes":"APC"}]}]},{"description":"Reconstruction of chin","code_information":[{"code":"21121","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2459.51,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3279.35,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6329.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2459.51,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3344.94,"additional_payer_notes":"APC"}]}]},{"description":"Lefort i-1 piece w/o graft","code_information":[{"code":"21141","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Lefort iii w/o lefort i","code_information":[{"code":"21154","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Contour cranial bone lesion","code_information":[{"code":"21181","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":11300.84,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Reconst lwr jaw w/fixation","code_information":[{"code":"21196","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Rib cartilage graft","code_information":[{"code":"21230","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Reconstruct lower jaw bone","code_information":[{"code":"21247","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Revise eye sockets","code_information":[{"code":"21267","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Cranio/maxillofacial surgery","code_information":[{"code":"21299","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":175.7,"maximum":13249.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":234.27,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":13249.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":10779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":13249.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":452.14,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":175.7,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":238.96,"additional_payer_notes":"APC"}]}]},{"description":"Open nasoethmoid fx w/o fixj","code_information":[{"code":"21338","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":11300.84,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Opn tx nasomax fx w/graft","code_information":[{"code":"21348","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Opn tx orbit fx combined","code_information":[{"code":"21387","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Treat mouth roof fracture","code_information":[{"code":"21421","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2459.51,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3279.35,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6329.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2459.51,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3344.94,"additional_payer_notes":"APC"}]}]},{"description":"Treat dental ridge fracture","code_information":[{"code":"21440","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2459.51,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3279.35,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6329.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2459.51,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3344.94,"additional_payer_notes":"APC"}]}]},{"description":"Treat lower jaw fracture","code_information":[{"code":"21462","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Drain neck/chest lesion","code_information":[{"code":"21501","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2154.81,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2873.08,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5545.05,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2154.81,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2930.54,"additional_payer_notes":"APC"}]}]},{"description":"Resect neck thorax tumor<5cm","code_information":[{"code":"21557","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2154.81,"maximum":5545.05,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2873.08,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5545.05,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2154.81,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2930.54,"additional_payer_notes":"APC"}]}]},{"description":"Extensive sternum surgery","code_information":[{"code":"21630","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Repair sternum/nuss w/scope","code_information":[{"code":"21743","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Biopsy soft tissue of back","code_information":[{"code":"21920","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1225.21,"maximum":4106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1633.61,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3152.87,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1225.21,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1666.28,"additional_payer_notes":"APC"}]}]},{"description":"I&d p-spine c/t/cerv-thor","code_information":[{"code":"22010","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3388.0,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Remove part lumbar vertebra","code_information":[{"code":"22114","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Incis addl spine segment","code_information":[{"code":"22216","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Treat odontoid fx w/graft","code_information":[{"code":"22319","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":24508.8,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12698.86,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":24508.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9524.15,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12952.84,"additional_payer_notes":"APC"}]}]},{"description":"Vertebroplasty addl inject","code_information":[{"code":"22512","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Lat thor/lumb addl seg","code_information":[{"code":"22534","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":8333.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Prescrl fuse w/ instr l5-s1","code_information":[{"code":"22586","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":33471.73,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17342.86,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":33471.73,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13007.15,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":27583.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17689.72,"additional_payer_notes":"APC"}]}]},{"description":"Spine fusion extra segment","code_information":[{"code":"22632","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":9356.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Ant fusion 8/> vert seg","code_information":[{"code":"22812","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6779.0,"maximum":33471.73,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17342.86,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":33471.73,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13007.15,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":27583.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17689.72,"additional_payer_notes":"APC"}]}]},{"description":"Insert spine fixation device","code_information":[{"code":"22844","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":4106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Remove spine fixation device","code_information":[{"code":"22855","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3388.0,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Spine surgery procedure","code_information":[{"code":"22899","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":182.99,"maximum":13249.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":243.98,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":13249.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":10779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":13249.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":470.88,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":182.99,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":248.86,"additional_payer_notes":"APC"}]}]},{"description":"Removal of calcium deposits","code_information":[{"code":"23000","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2154.81,"maximum":5545.05,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2873.08,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5545.05,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2154.81,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2930.54,"additional_payer_notes":"APC"}]}]},{"description":"Biopsy shoulder tissues","code_information":[{"code":"23066","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2154.81,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2873.08,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5545.05,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2154.81,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2930.54,"additional_payer_notes":"APC"}]}]},{"description":"Shoulder joint surgery","code_information":[{"code":"23101","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Removal of bone lesion","code_information":[{"code":"23145","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Remove collar bone lesion","code_information":[{"code":"23180","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":13851.98,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Remove shoulder foreign body","code_information":[{"code":"23330","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1225.21,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1633.61,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3152.87,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1225.21,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1666.28,"additional_payer_notes":"APC"}]}]},{"description":"Incision of tendon & muscle","code_information":[{"code":"23405","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":13851.98,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Repair shoulder capsule","code_information":[{"code":"23450","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Revis reconst shoulder joint","code_information":[{"code":"23473","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":24508.8,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12698.86,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":24508.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9524.15,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12952.84,"additional_payer_notes":"APC"}]}]},{"description":"Treat clavicle fracture","code_information":[{"code":"23515","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Treat clavicle dislocation","code_information":[{"code":"23552","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Treat humerus fracture","code_information":[{"code":"23620","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":182.99,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":243.98,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":470.88,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":182.99,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":248.86,"additional_payer_notes":"APC"}]}]},{"description":"Treat dislocation/fracture","code_information":[{"code":"23675","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1192.86,"maximum":4106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1590.48,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3069.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1192.86,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1622.29,"additional_payer_notes":"APC"}]}]},{"description":"Shoulder surgery procedure","code_information":[{"code":"23929","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":182.99,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":243.98,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":470.88,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":182.99,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":248.86,"additional_payer_notes":"APC"}]}]},{"description":"Exc arm/elbow les sc 3 cm/>","code_information":[{"code":"24071","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2154.81,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2873.08,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5545.05,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2154.81,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2930.54,"additional_payer_notes":"APC"}]}]},{"description":"Remove elbow joint lining","code_information":[{"code":"24102","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Removal of head of radius","code_information":[{"code":"24130","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Resect distal humerus tumor","code_information":[{"code":"24150","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Manipulate elbow w/anesth","code_information":[{"code":"24300","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1192.86,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1590.48,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3069.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1192.86,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1622.29,"additional_payer_notes":"APC"}]}]},{"description":"Repair of biceps tendon","code_information":[{"code":"24340","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Repair elbow w/deb open","code_information":[{"code":"24358","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Revise reconst elbow joint","code_information":[{"code":"24370","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":27583.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12698.86,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":24508.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9524.15,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":27583.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12952.84,"additional_payer_notes":"APC"}]}]},{"description":"Decompression of forearm","code_information":[{"code":"24495","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":13851.98,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Treat humerus fracture","code_information":[{"code":"24538","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":13851.98,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Treat humerus fracture","code_information":[{"code":"24577","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1192.86,"maximum":4106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1590.48,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3069.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1192.86,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1622.29,"additional_payer_notes":"APC"}]}]},{"description":"Treat elbow fracture","code_information":[{"code":"24620","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1192.86,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1590.48,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3069.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1192.86,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1622.29,"additional_payer_notes":"APC"}]}]},{"description":"Treat ulnar fracture","code_information":[{"code":"24675","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1192.86,"maximum":4106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1590.48,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3069.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1192.86,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1622.29,"additional_payer_notes":"APC"}]}]},{"description":"Amputate upper arm & implant","code_information":[{"code":"24931","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":24508.8,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12698.86,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":24508.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9524.15,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12952.84,"additional_payer_notes":"APC"}]}]},{"description":"Removal of brain abscess","code_information":[{"code":"61514","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6779.0,"maximum":8333.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0}]}]},{"description":"Removal of brain lesion","code_information":[{"code":"61524","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6779.0,"maximum":8333.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0}]}]},{"description":"Removal of brain tissue","code_information":[{"code":"61537","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6779.0,"maximum":8333.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0}]}]},{"description":"Removal of pituitary gland","code_information":[{"code":"61546","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6779.0,"maximum":8333.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0}]}]},{"description":"Excision of skull tumor","code_information":[{"code":"61563","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6779.0,"maximum":8333.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0}]}]},{"description":"Craniofacial approach skull","code_information":[{"code":"61580","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6779.0,"maximum":8333.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0}]}]},{"description":"Infratemporal approach/skull","code_information":[{"code":"61591","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6779.0,"maximum":8333.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0}]}]},{"description":"Resect/excise cranial lesion","code_information":[{"code":"61605","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6779.0,"maximum":8333.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0}]}]},{"description":"Repair dura","code_information":[{"code":"61618","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6779.0,"maximum":8333.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0}]}]},{"description":"Dilate ic vasospasm add-on","code_information":[{"code":"61641","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6779.0,"maximum":8333.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0}]}]},{"description":"Intracranial vessel surgery","code_information":[{"code":"61686","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6779.0,"maximum":8333.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0}]}]},{"description":"Revise circulation to head","code_information":[{"code":"61705","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6779.0,"maximum":8333.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0}]}]},{"description":"Implant brain electrodes","code_information":[{"code":"61760","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3579.0,"maximum":8333.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0}]}]},{"description":"Srs cran les simple addl","code_information":[{"code":"61797","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3388.0,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0}]}]},{"description":"Implant neuroelectrode","code_information":[{"code":"61867","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6779.0,"maximum":8333.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0}]}]},{"description":"Treatment of head injury","code_information":[{"code":"62010","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6779.0,"maximum":8333.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0}]}]},{"description":"Remove skull plate/flap","code_information":[{"code":"62142","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Remove colloid cyst w/scope","code_information":[{"code":"62162","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6779.0,"maximum":8333.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0}]}]},{"description":"Brain cavity shunt w/scope","code_information":[{"code":"62201","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Epidural lysis mult sessions","code_information":[{"code":"62263","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":656.13,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":874.84,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1688.44,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":656.13,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":892.34,"additional_payer_notes":"APC"}]}]},{"description":"Treat spinal cord lesion","code_information":[{"code":"62280","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":656.13,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":874.84,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1688.44,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":656.13,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":892.34,"additional_payer_notes":"APC"}]}]},{"description":"Injection into spinal artery","code_information":[{"code":"62294","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":656.13,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":874.84,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1688.44,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":656.13,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":892.34,"additional_payer_notes":"APC"}]}]},{"description":"Insert spine infusion device","code_information":[{"code":"62360","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8923.0,"maximum":34407.2,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17827.56,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":10765.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":8923.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":10765.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":34407.2,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13370.67,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18184.11,"additional_payer_notes":"APC"}]}]},{"description":"Remove spine lamina 1/2 crvl","code_information":[{"code":"63001","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Neck spine disk surgery","code_information":[{"code":"63020","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Remove spine lamina 1 thrc","code_information":[{"code":"63046","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Decompress spinal cord thrc","code_information":[{"code":"63064","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Remove vert body dcmprn thrc","code_information":[{"code":"63085","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6779.0,"maximum":8333.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0}]}]},{"description":"Remove vertebral body add-on","code_information":[{"code":"63103","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3388.0,"maximum":4106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0}]}]},{"description":"Release spinal cord lumbar","code_information":[{"code":"63200","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6779.0,"maximum":27583.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":27583.0}]}]},{"description":"Excise intrspinl lesion crvl","code_information":[{"code":"63270","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6779.0,"maximum":8333.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0}]}]},{"description":"Bx/exc idrl spine lesn crvl","code_information":[{"code":"63280","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6779.0,"maximum":8333.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0}]}]},{"description":"Repair laminectomy defect","code_information":[{"code":"63295","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6779.0,"maximum":8333.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0}]}]},{"description":"Remov vert idrl bdy lmbr/sac","code_information":[{"code":"63307","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6779.0,"maximum":8333.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0}]}]},{"description":"Remove spine eltrd perq aray","code_information":[{"code":"63661","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1448.59,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1931.46,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3727.72,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1448.59,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1970.09,"additional_payer_notes":"APC"}]}]},{"description":"Repair of spinal herniation","code_information":[{"code":"63704","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6779.0,"maximum":8333.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0}]}]},{"description":"Decompress forearm 2 spaces","code_information":[{"code":"25024","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Exc forearm les sc 3 cm/>","code_information":[{"code":"25071","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1225.21,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1633.61,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3152.87,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1225.21,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1666.28,"additional_payer_notes":"APC"}]}]},{"description":"Explore/treat wrist joint","code_information":[{"code":"25101","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Remove wrist/forearm lesion","code_information":[{"code":"25116","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Remove & graft wrist lesion","code_information":[{"code":"25136","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":13851.98,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Partial removal of ulna","code_information":[{"code":"25240","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Repair forearm tendon/muscle","code_information":[{"code":"25265","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Fusion of tendons at wrist","code_information":[{"code":"25300","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Realignment of hand","code_information":[{"code":"25335","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Shorten radius or ulna","code_information":[{"code":"25390","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Repair/graft radius & ulna","code_information":[{"code":"25420","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Reconstruct wrist joint","code_information":[{"code":"25443","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Reinforce radius","code_information":[{"code":"25490","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Treat fracture of radius","code_information":[{"code":"25526","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Treat fracture radius/ulna","code_information":[{"code":"25600","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":182.99,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":243.98,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":470.88,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":182.99,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":248.86,"additional_payer_notes":"APC"}]}]},{"description":"Treat wrist bone fracture","code_information":[{"code":"25628","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Treat wrist dislocation","code_information":[{"code":"25670","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":13851.98,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Fusion of wrist joint","code_information":[{"code":"25800","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Amputation follow-up surgery","code_information":[{"code":"25907","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Amputation follow-up surgery","code_information":[{"code":"25931","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Decompress fingers/hand","code_information":[{"code":"26035","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":6246.19,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Explore/treat finger joint","code_information":[{"code":"26080","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1192.86,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1590.48,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3069.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1192.86,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1622.29,"additional_payer_notes":"APC"}]}]},{"description":"Rad resect hand tumor < 3 cm","code_information":[{"code":"26117","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2154.81,"maximum":5545.05,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2873.08,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5545.05,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2154.81,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2930.54,"additional_payer_notes":"APC"}]}]},{"description":"Tendon excision palm/finger","code_information":[{"code":"26145","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1192.86,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1590.48,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3069.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1192.86,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1622.29,"additional_payer_notes":"APC"}]}]},{"description":"Remove/graft finger lesion","code_information":[{"code":"26215","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":6246.19,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Manipulate finger w/anesth","code_information":[{"code":"26340","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1192.86,"maximum":4106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1590.48,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3069.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1192.86,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1622.29,"additional_payer_notes":"APC"}]}]},{"description":"Repair/graft hand tendon","code_information":[{"code":"26372","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":13851.98,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Repair finger tendon","code_information":[{"code":"26418","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1192.86,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1590.48,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3069.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1192.86,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1622.29,"additional_payer_notes":"APC"}]}]},{"description":"Release palm/finger tendon","code_information":[{"code":"26440","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1192.86,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1590.48,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3069.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1192.86,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1622.29,"additional_payer_notes":"APC"}]}]},{"description":"Fusion of finger tendons","code_information":[{"code":"26474","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1192.86,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1590.48,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3069.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1192.86,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1622.29,"additional_payer_notes":"APC"}]}]},{"description":"Transplant/graft palm tendon","code_information":[{"code":"26489","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Hand tendon reconstruction","code_information":[{"code":"26500","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3579.0,"maximum":13851.98,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Release finger contracture","code_information":[{"code":"26525","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1192.86,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1590.48,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3069.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1192.86,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1622.29,"additional_payer_notes":"APC"}]}]},{"description":"Reconstruct finger joint","code_information":[{"code":"26545","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Toe joint transfer","code_information":[{"code":"26556","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Reconstruct extra finger","code_information":[{"code":"26587","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":6246.19,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Removal of spinal shunt","code_information":[{"code":"63746","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1448.59,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1931.46,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3727.72,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1448.59,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1970.09,"additional_payer_notes":"APC"}]}]},{"description":"N block inj intercost sng","code_information":[{"code":"64420","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":523.65,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":698.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1347.51,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":523.65,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":712.16,"additional_payer_notes":"APC"}]}]},{"description":"N block inj fem cont inf","code_information":[{"code":"64448","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":656.13,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":874.84,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1688.44,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":656.13,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":892.34,"additional_payer_notes":"APC"}]}]},{"description":"Inj foramen epidural add-on","code_information":[{"code":"64480","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Inj paravert f jnt c/t 2 lev","code_information":[{"code":"64491","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"N block lumbar/thoracic","code_information":[{"code":"64520","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":656.13,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":874.84,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1688.44,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":656.13,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":892.34,"additional_payer_notes":"APC"}]}]},{"description":"Remove vagus n eltrd","code_information":[{"code":"64570","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2534.21,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3378.94,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6521.36,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2534.21,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3446.52,"additional_payer_notes":"APC"}]}]},{"description":"Injection treatment of nerve","code_information":[{"code":"64605","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1448.59,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1931.46,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3727.72,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1448.59,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1970.09,"additional_payer_notes":"APC"}]}]},{"description":"Injection treatment of nerve","code_information":[{"code":"64630","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":656.13,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":874.84,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1688.44,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":656.13,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":892.34,"additional_payer_notes":"APC"}]}]},{"description":"Chemodenerv 1 extrem 1-4 ea","code_information":[{"code":"64643","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Injection treatment of nerve","code_information":[{"code":"64681","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":656.13,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":874.84,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1688.44,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":656.13,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":892.34,"additional_payer_notes":"APC"}]}]},{"description":"Revise ulnar nerve at elbow","code_information":[{"code":"64718","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1448.59,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1931.46,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3727.72,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1448.59,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1970.09,"additional_payer_notes":"APC"}]}]},{"description":"Incision of chin nerve","code_information":[{"code":"64736","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1448.59,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1931.46,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3727.72,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1448.59,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1970.09,"additional_payer_notes":"APC"}]}]},{"description":"Incise hip/thigh nerve","code_information":[{"code":"64763","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1448.59,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1931.46,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3727.72,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1448.59,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1970.09,"additional_payer_notes":"APC"}]}]},{"description":"Limb nerve surgery add-on","code_information":[{"code":"64783","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Sympathectomy cervical","code_information":[{"code":"64802","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1448.59,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1931.46,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3727.72,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1448.59,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1970.09,"additional_payer_notes":"APC"}]}]},{"description":"Repair of digit nerve","code_information":[{"code":"64831","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1448.59,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1931.46,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3727.72,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1448.59,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1970.09,"additional_payer_notes":"APC"}]}]},{"description":"Repair arm/leg nerve","code_information":[{"code":"64857","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2534.21,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3378.94,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6521.36,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2534.21,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3446.52,"additional_payer_notes":"APC"}]}]},{"description":"Fusion of facial/other nerve","code_information":[{"code":"64868","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Nerve graft arm/leg <4 cm","code_information":[{"code":"64892","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":16752.93,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8680.28,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":16752.93,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6510.21,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8853.88,"additional_payer_notes":"APC"}]}]},{"description":"Nerve pedicle transfer","code_information":[{"code":"64905","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":16752.93,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8680.28,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":16752.93,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6510.21,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8853.88,"additional_payer_notes":"APC"}]}]},{"description":"Remove eye/insert implant","code_information":[{"code":"65103","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2916.44,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3888.58,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7504.96,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2916.44,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3966.35,"additional_payer_notes":"APC"}]}]},{"description":"Attach ocular implant","code_information":[{"code":"65140","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2916.44,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3888.58,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7504.96,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2916.44,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3966.35,"additional_payer_notes":"APC"}]}]},{"description":"Remove foreign body from eye","code_information":[{"code":"65235","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1712.02,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2282.69,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4405.59,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1712.02,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2328.34,"additional_payer_notes":"APC"}]}]},{"description":"Repair of eye wound","code_information":[{"code":"65285","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3947.51,"maximum":10158.27,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5263.35,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":10158.27,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3947.51,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5368.62,"additional_payer_notes":"APC"}]}]},{"description":"Curette/treat cornea","code_information":[{"code":"65435","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":739.52,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":986.02,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1903.02,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":739.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1005.74,"additional_payer_notes":"APC"}]}]},{"description":"Corneal trnspl endothelial","code_information":[{"code":"65756","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3066.31,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4088.41,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7890.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3066.31,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4170.17,"additional_payer_notes":"APC"}]}]},{"description":"Correction of astigmatism","code_information":[{"code":"65775","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1763.69,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2351.59,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4538.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1763.69,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2398.62,"additional_payer_notes":"APC"}]}]},{"description":"Drainage of eye","code_information":[{"code":"65810","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1712.02,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2282.69,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4405.59,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1712.02,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2328.34,"additional_payer_notes":"APC"}]}]},{"description":"Incise inner eye adhesions","code_information":[{"code":"65875","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1712.02,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2282.69,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4405.59,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1712.02,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2328.34,"additional_payer_notes":"APC"}]}]},{"description":"Glaucoma surgery","code_information":[{"code":"66150","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3066.31,"maximum":7890.63,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4088.41,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7890.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3066.31,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4170.17,"additional_payer_notes":"APC"}]}]},{"description":"Aqueous shunt eye w/graft","code_information":[{"code":"66180","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3947.51,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5263.35,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":10158.27,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3947.51,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5368.62,"additional_payer_notes":"APC"}]}]},{"description":"Remove iris and lesion","code_information":[{"code":"66600","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3066.31,"maximum":7890.63,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4088.41,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7890.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3066.31,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4170.17,"additional_payer_notes":"APC"}]}]},{"description":"Ciliary transsleral therapy","code_information":[{"code":"66710","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1763.69,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2351.59,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4538.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1763.69,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2398.62,"additional_payer_notes":"APC"}]}]},{"description":"After cataract laser surgery","code_information":[{"code":"66821","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":408.01,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":544.01,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1049.93,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":408.01,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":554.89,"additional_payer_notes":"APC"}]}]},{"description":"Extraction of lens","code_information":[{"code":"66940","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1712.02,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2282.69,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4405.59,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1712.02,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2328.34,"additional_payer_notes":"APC"}]}]},{"description":"Treat metacarpal fracture","code_information":[{"code":"26608","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Pin hand dislocation","code_information":[{"code":"26676","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Treat finger fracture each","code_information":[{"code":"26725","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":182.99,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":243.98,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":470.88,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":182.99,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":248.86,"additional_payer_notes":"APC"}]}]},{"description":"Pin finger fracture each","code_information":[{"code":"26756","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Thumb fusion with graft","code_information":[{"code":"26842","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":13851.98,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Fuse/graft added joint","code_information":[{"code":"26863","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Incision of hip tendon","code_information":[{"code":"27000","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1192.86,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1590.48,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3069.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1192.86,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1622.29,"additional_payer_notes":"APC"}]}]},{"description":"Exploration of hip joint","code_information":[{"code":"27033","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Exc hip/pelv tum deep < 5 cm","code_information":[{"code":"27048","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2154.81,"maximum":5545.05,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2873.08,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5545.05,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2154.81,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2930.54,"additional_payer_notes":"APC"}]}]},{"description":"Remove femur lesion/bursa","code_information":[{"code":"27062","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Resect hip tum w/innom bone","code_information":[{"code":"27077","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Injection for hip x-ray","code_information":[{"code":"27095","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Reconstruction of hip socket","code_information":[{"code":"27120","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":24508.8,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12698.86,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":24508.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9524.15,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12952.84,"additional_payer_notes":"APC"}]}]},{"description":"Transplant femur ridge","code_information":[{"code":"27140","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Repair/graft femur head/neck","code_information":[{"code":"27170","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Reinforce hip bones","code_information":[{"code":"27187","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Treat hip socket fracture","code_information":[{"code":"27222","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":182.99,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":243.98,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":470.88,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":182.99,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":248.86,"additional_payer_notes":"APC"}]}]},{"description":"Treat thigh fracture","code_information":[{"code":"27238","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1192.86,"maximum":4106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1590.48,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3069.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1192.86,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1622.29,"additional_payer_notes":"APC"}]}]},{"description":"Treat hip dislocation","code_information":[{"code":"27253","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Cltx thigh fx","code_information":[{"code":"27267","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":6246.19,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Fusion of hip joint","code_information":[{"code":"27286","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":27583.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12698.86,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":24508.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9524.15,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":27583.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12952.84,"additional_payer_notes":"APC"}]}]},{"description":"Incision of thigh tendons","code_information":[{"code":"27307","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Resect thigh/knee tum < 5 cm","code_information":[{"code":"27329","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2154.81,"maximum":5545.05,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2873.08,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5545.05,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2154.81,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2930.54,"additional_payer_notes":"APC"}]}]},{"description":"Exc thigh/knee tum dep 5cm/>","code_information":[{"code":"27339","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2154.81,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2873.08,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5545.05,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2154.81,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2930.54,"additional_payer_notes":"APC"}]}]},{"description":"Remove femur lesion/fixation","code_information":[{"code":"27358","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Repair/graft of thigh muscle","code_information":[{"code":"27386","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":13851.98,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Transplants of thigh tendons","code_information":[{"code":"27397","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Osteochondral knee autograft","code_information":[{"code":"27416","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Reconstruction knee","code_information":[{"code":"27429","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":24508.8,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12698.86,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":24508.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9524.15,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12952.84,"additional_payer_notes":"APC"}]}]},{"description":"Revision of knee joint","code_information":[{"code":"27443","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":24508.8,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12698.86,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":24508.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9524.15,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12952.84,"additional_payer_notes":"APC"}]}]},{"description":"Realignment of knee","code_information":[{"code":"27457","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Surgery to stop leg growth","code_information":[{"code":"27479","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":13851.98,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Decompression of thigh/knee","code_information":[{"code":"27498","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1192.86,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1590.48,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3069.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1192.86,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1622.29,"additional_payer_notes":"APC"}]}]},{"description":"Treatment of thigh fracture","code_information":[{"code":"27508","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":182.99,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":243.98,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":470.88,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":182.99,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":248.86,"additional_payer_notes":"APC"}]}]},{"description":"Treat thigh fx growth plate","code_information":[{"code":"27519","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Treat knee fracture","code_information":[{"code":"27540","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Partial removal of eye fluid","code_information":[{"code":"67005","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1712.02,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2282.69,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4405.59,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1712.02,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2328.34,"additional_payer_notes":"APC"}]}]},{"description":"Removal of inner eye fluid","code_information":[{"code":"67036","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3066.31,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4088.41,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7890.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3066.31,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4170.17,"additional_payer_notes":"APC"}]}]},{"description":"Repair detached retina","code_information":[{"code":"67107","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3066.31,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4088.41,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7890.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3066.31,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4170.17,"additional_payer_notes":"APC"}]}]},{"description":"Treatment of retina","code_information":[{"code":"67145","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":408.01,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":544.01,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1049.93,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":408.01,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":554.89,"additional_payer_notes":"APC"}]}]},{"description":"Treatment x10sv retinopathy","code_information":[{"code":"67228","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":408.01,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":544.01,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1049.93,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":408.01,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":554.89,"additional_payer_notes":"APC"}]}]},{"description":"Revise two eye muscles","code_information":[{"code":"67316","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1763.69,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2351.59,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4538.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1763.69,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2398.62,"additional_payer_notes":"APC"}]}]},{"description":"Release eye tissue","code_information":[{"code":"67343","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1763.69,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2351.59,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4538.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1763.69,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2398.62,"additional_payer_notes":"APC"}]}]},{"description":"Explr/decompress eye socket","code_information":[{"code":"67414","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2916.44,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3888.58,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7504.96,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2916.44,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3966.35,"additional_payer_notes":"APC"}]}]},{"description":"Inject/treat eye socket","code_information":[{"code":"67505","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":235.46,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":313.95,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":605.92,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":235.46,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":320.23,"additional_payer_notes":"APC"}]}]},{"description":"Incision of eyelid fold","code_information":[{"code":"67715","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1763.69,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2351.59,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4538.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1763.69,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2398.62,"additional_payer_notes":"APC"}]}]},{"description":"Revise eyelashes","code_information":[{"code":"67830","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":739.52,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":986.02,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1903.02,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":739.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1005.74,"additional_payer_notes":"APC"}]}]},{"description":"Repair eyelid defect","code_information":[{"code":"67901","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1763.69,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2351.59,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4538.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1763.69,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2398.62,"additional_payer_notes":"APC"}]}]},{"description":"Correction eyelid w/implant","code_information":[{"code":"67912","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1763.69,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2351.59,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4538.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1763.69,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2398.62,"additional_payer_notes":"APC"}]}]},{"description":"Repair eyelid defect","code_information":[{"code":"67924","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1763.69,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2351.59,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4538.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1763.69,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2398.62,"additional_payer_notes":"APC"}]}]},{"description":"Reconstruction of eyelid","code_information":[{"code":"67973","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1763.69,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2351.59,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4538.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1763.69,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2398.62,"additional_payer_notes":"APC"}]}]},{"description":"Remove eyelid lining lesion","code_information":[{"code":"68115","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1763.69,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2351.59,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4538.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1763.69,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2398.62,"additional_payer_notes":"APC"}]}]},{"description":"Revise eyelid lining","code_information":[{"code":"68330","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1712.02,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2282.69,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4405.59,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1712.02,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2328.34,"additional_payer_notes":"APC"}]}]},{"description":"Incise/drain tear sac","code_information":[{"code":"68420","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1763.69,"maximum":4538.57,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2351.59,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4538.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1763.69,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2398.62,"additional_payer_notes":"APC"}]}]},{"description":"Remove tear gland lesion","code_information":[{"code":"68540","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1763.69,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2351.59,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4538.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1763.69,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2398.62,"additional_payer_notes":"APC"}]}]},{"description":"Close tear duct opening","code_information":[{"code":"68761","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":235.46,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":313.95,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":605.92,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":235.46,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":320.23,"additional_payer_notes":"APC"}]}]},{"description":"Injection for tear sac x-ray","code_information":[{"code":"68850","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Remove external ear partial","code_information":[{"code":"69110","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2154.81,"maximum":5545.05,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2873.08,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5545.05,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2154.81,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2930.54,"additional_payer_notes":"APC"}]}]},{"description":"Remove impacted ear wax uni","code_information":[{"code":"69209","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":43.76,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":58.35,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":112.62,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":43.76,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":59.52,"additional_payer_notes":"APC"}]}]},{"description":"Incision of eardrum","code_information":[{"code":"69420","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":175.7,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":234.27,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":452.14,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":175.7,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":238.96,"additional_payer_notes":"APC"}]}]},{"description":"Mastoidectomy","code_information":[{"code":"69502","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":11300.84,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Remove ear lesion","code_information":[{"code":"69554","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Rebuild eardrum structures","code_information":[{"code":"69632","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Revise middle ear & mastoid","code_information":[{"code":"69644","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Repair middle ear structures","code_information":[{"code":"69667","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2459.51,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3279.35,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6329.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2459.51,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3344.94,"additional_payer_notes":"APC"}]}]},{"description":"Release facial nerve","code_information":[{"code":"69720","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Remove inner ear","code_information":[{"code":"69905","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Remove inner ear lesion","code_information":[{"code":"69970","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"R hrt coronary artery angio","code_information":[{"code":"93456","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2404.97,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3206.62,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6188.79,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2404.97,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3270.76,"additional_payer_notes":"APC"}]}]},{"description":"Biopsy of heart lining","code_information":[{"code":"93505","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2342.32,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3123.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6027.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2342.32,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3185.56,"additional_payer_notes":"APC"}]}]},{"description":"Perc d-e cor revasc chro sin","code_information":[{"code":"C9607","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8923.0,"maximum":34994.75,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18131.99,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":10765.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":8923.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":10765.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":34994.75,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13599.0,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":27583.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18494.63,"additional_payer_notes":"APC"}]}]},{"description":"Root surgery bicuspid","code_information":[{"code":"D3421","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":479.59,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":639.45,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1234.13,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":479.59,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":652.24,"additional_payer_notes":"APC"}]}]},{"description":"Treat kneecap dislocation","code_information":[{"code":"27566","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Amputate lower leg at knee","code_information":[{"code":"27598","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Incision of achilles tendon","code_information":[{"code":"27606","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Exc leg/ankle tum < 3 cm","code_information":[{"code":"27618","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1225.21,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1633.61,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3152.87,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1225.21,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1666.28,"additional_payer_notes":"APC"}]}]},{"description":"Remove lower leg bone lesion","code_information":[{"code":"27635","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Injection for ankle x-ray","code_information":[{"code":"27648","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Repair of leg tendon each","code_information":[{"code":"27665","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":13851.98,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Revise lower leg tendon","code_information":[{"code":"27690","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Reconstruction ankle joint","code_information":[{"code":"27703","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6779.0,"maximum":33471.73,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17342.86,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":33471.73,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13007.15,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17689.72,"additional_payer_notes":"APC"}]}]},{"description":"Repair/graft of tibia","code_information":[{"code":"27722","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Repair of leg epiphyses","code_information":[{"code":"27740","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Cltx medial ankle fx","code_information":[{"code":"27760","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":182.99,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":243.98,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":470.88,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":182.99,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":248.86,"additional_payer_notes":"APC"}]}]},{"description":"Treatment of fibula fracture","code_information":[{"code":"27784","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Treatment of ankle fracture","code_information":[{"code":"27818","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1192.86,"maximum":4106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1590.48,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3069.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1192.86,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1622.29,"additional_payer_notes":"APC"}]}]},{"description":"Treat lower leg joint","code_information":[{"code":"27829","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Fixation of ankle joint","code_information":[{"code":"27860","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":6246.19,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Amputation of foot at ankle","code_information":[{"code":"27888","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Treatment of foot infection","code_information":[{"code":"28003","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Decompression of tibia nerve","code_information":[{"code":"28035","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1448.59,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1931.46,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3727.72,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1448.59,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1970.09,"additional_payer_notes":"APC"}]}]},{"description":"Biopsy of foot joint lining","code_information":[{"code":"28052","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Elbow arthroscopy/surgery","code_information":[{"code":"29834","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Shoulder arthroscopy/surgery","code_information":[{"code":"29822","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Jaw arthroscopy/surgery","code_information":[{"code":"29800","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Removal/revision of cast","code_information":[{"code":"29700","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":207.48,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":276.65,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":533.93,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":207.48,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":282.18,"additional_payer_notes":"APC"}]}]},{"description":"Application lower leg splint","code_information":[{"code":"29515","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":120.55,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":160.73,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":310.21,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":120.55,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":163.95,"additional_payer_notes":"APC"}]}]},{"description":"Application of long leg cast","code_information":[{"code":"29365","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":207.48,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":276.65,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":533.93,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":207.48,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":282.18,"additional_payer_notes":"APC"}]}]},{"description":"Strapping of shoulder","code_information":[{"code":"29240","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":98.7,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":131.6,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":253.99,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":98.7,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":134.23,"additional_payer_notes":"APC"}]}]},{"description":"Apply hand/wrist cast","code_information":[{"code":"29085","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":120.55,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":160.73,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":310.21,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":120.55,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":163.95,"additional_payer_notes":"APC"}]}]},{"description":"Application of body cast","code_information":[{"code":"29040","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":207.48,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":276.65,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":533.93,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":207.48,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":282.18,"additional_payer_notes":"APC"}]}]},{"description":"Amputation of toe","code_information":[{"code":"28820","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Revision of foot bones","code_information":[{"code":"28737","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":24508.8,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12698.86,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":24508.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9524.15,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12952.84,"additional_payer_notes":"APC"}]}]},{"description":"Treat toe dislocation","code_information":[{"code":"28665","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":207.48,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":276.65,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":533.93,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":207.48,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":282.18,"additional_payer_notes":"APC"}]}]},{"description":"Treat foot dislocation","code_information":[{"code":"28605","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":182.99,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":243.98,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":470.88,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":182.99,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":248.86,"additional_payer_notes":"APC"}]}]},{"description":"Treat foot dislocation","code_information":[{"code":"28545","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Treat big toe fracture","code_information":[{"code":"28496","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Treat midfoot fracture","code_information":[{"code":"28456","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":13851.98,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Tooth splitting","code_information":[{"code":"D3920","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":479.59,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":639.45,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1234.13,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":479.59,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":652.24,"additional_payer_notes":"APC"}]}]},{"description":"Gngvl flap w rootplan 1-3 th","code_information":[{"code":"D4241","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1151.01,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1534.69,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2961.94,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1151.01,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1565.38,"additional_payer_notes":"APC"}]}]},{"description":"Guided tiss regen nonresorb","code_information":[{"code":"D4267","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1151.01,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1534.69,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2961.94,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1151.01,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1565.38,"additional_payer_notes":"APC"}]}]},{"description":"Soft tissue graft addl tooth","code_information":[{"code":"D4278","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5512.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0}]}]},{"description":"Bone graft repair perimplant","code_information":[{"code":"D6103","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5512.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0}]}]},{"description":"Impact tooth rem bony w/comp","code_information":[{"code":"D7241","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":479.59,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":639.45,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1234.13,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":479.59,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":652.24,"additional_payer_notes":"APC"}]}]},{"description":"Mobilize erupted/malpos toot","code_information":[{"code":"D7282","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5512.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0}]}]},{"description":"Screw retained plate","code_information":[{"code":"D7292","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5512.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0}]}]},{"description":"Vestibuloplasty ridge extens","code_information":[{"code":"D7340","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":11300.84,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Malig tumor exc to 1.25 cm","code_information":[{"code":"D7440","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2459.51,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3279.35,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6329.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2459.51,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3344.94,"additional_payer_notes":"APC"}]}]},{"description":"Removal of torus palatinus","code_information":[{"code":"D7472","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":479.59,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":639.45,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1234.13,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":479.59,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":652.24,"additional_payer_notes":"APC"}]}]},{"description":"Removal fb skin/areolar tiss","code_information":[{"code":"D7530","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":479.59,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":639.45,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1234.13,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":479.59,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":652.24,"additional_payer_notes":"APC"}]}]},{"description":"Reduct simple facial bone fx","code_information":[{"code":"D7680","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5512.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0}]}]},{"description":"Removal of tmj condyle","code_information":[{"code":"D7840","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5512.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0}]}]},{"description":"Tmj aspiration joint fluid","code_information":[{"code":"D7870","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5512.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0}]}]},{"description":"Dent sutur recent wnd to 5cm","code_information":[{"code":"D7910","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5512.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0}]}]},{"description":"Bone cutting segmented","code_information":[{"code":"D7944","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5512.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0}]}]},{"description":"Sinus augmentation vertical","code_information":[{"code":"D7952","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5512.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0}]}]},{"description":"Excision of salivary gland","code_information":[{"code":"D7981","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5512.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0}]}]},{"description":"Intraoral place of fix dev","code_information":[{"code":"D7998","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5512.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0}]}]},{"description":"Occlusive device in vein art","code_information":[{"code":"G0269","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Pelvic ring fx treat int fix","code_information":[{"code":"G0414","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Phototherapeutic keratectomy (PTK)","code_information":[{"code":"S0812","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5512.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0}]}]},{"description":"Breast reconstruct, stacked DEIP or GAP","code_information":[{"code":"S2067","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5512.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0}]}]},{"description":"Adrenal tissue transplant to brain","code_information":[{"code":"S2103","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5512.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0}]}]},{"description":"Minimally invasive direct co","code_information":[{"code":"S2209","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5512.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0}]}]},{"description":"Fetal surg urin trac obstr","code_information":[{"code":"S2401","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5512.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0}]}]},{"description":"Njx interlaminar crv/thrc","code_information":[{"code":"62320","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":523.65,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":698.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1347.51,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":523.65,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":712.16,"additional_payer_notes":"APC"}]}]},{"description":"Fna bx w/ct gdn ea addl","code_information":[{"code":"10010","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Fxjl abl lsr ea addl 100sqcm","code_information":[{"code":"0480T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Musc myoq/fscq flp h&n pedcl","code_information":[{"code":"15733","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2628.85,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3505.13,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6764.9,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2628.85,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3575.23,"additional_payer_notes":"APC"}]}]},{"description":"Ablate pulm tumor perq crybl","code_information":[{"code":"32994","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5257.0,"maximum":20292.15,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10514.07,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5257.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":20292.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7885.55,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10724.35,"additional_payer_notes":"APC"}]}]},{"description":"Treat/graft heel fracture","code_information":[{"code":"28420","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":24508.8,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12698.86,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":24508.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9524.15,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12952.84,"additional_payer_notes":"APC"}]}]},{"description":"Resect enlarged toe","code_information":[{"code":"28341","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Incision of metatarsals","code_information":[{"code":"28309","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Correction hallux valgus","code_information":[{"code":"28299","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":13851.98,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":13249.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":10779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":13249.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Repair of hammertoe","code_information":[{"code":"28285","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Revision of foot fascia","code_information":[{"code":"28250","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Release of foot tendons","code_information":[{"code":"28222","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Removal of foot foreign body","code_information":[{"code":"28190","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":525.32,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":700.42,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1351.81,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":525.32,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":714.43,"additional_payer_notes":"APC"}]}]},{"description":"Removal of ankle bone","code_information":[{"code":"28130","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":13851.98,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Removal of metatarsal heads","code_information":[{"code":"28114","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Removal of foot lesion","code_information":[{"code":"28104","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Revision of nose","code_information":[{"code":"30435","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Lyse chest fibrin init day","code_information":[{"code":"32561","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":465.35,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":620.47,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1197.51,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":465.35,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":632.88,"additional_payer_notes":"APC"}]}]},{"description":"Thoracoscopy w/pleurodesis","code_information":[{"code":"32650","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5257.0,"maximum":27583.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5257.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":27583.0}]}]},{"description":"Thoracoscopy w/sac drainage","code_information":[{"code":"32659","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5257.0,"maximum":6462.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5257.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6462.0}]}]},{"description":"Thoracoscopy w/w resect diag","code_information":[{"code":"32668","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5257.0,"maximum":6462.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5257.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6462.0}]}]},{"description":"Insert nasal septal button","code_information":[{"code":"30220","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1151.01,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1534.69,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2961.94,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1151.01,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1565.38,"additional_payer_notes":"APC"}]}]},{"description":"Removal of nose lesion","code_information":[{"code":"30124","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1151.01,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1534.69,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2961.94,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1151.01,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1565.38,"additional_payer_notes":"APC"}]}]},{"description":"Drainage of nose lesion","code_information":[{"code":"30000","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":175.7,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":234.27,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":452.14,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":175.7,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":238.96,"additional_payer_notes":"APC"}]}]},{"description":"Subtalar arthro w/fb rmvl","code_information":[{"code":"29904","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Ankle arthroscopy/surgery","code_information":[{"code":"29894","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Knee arthroscopy/surgery","code_information":[{"code":"29885","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Knee arthroscopy/surgery","code_information":[{"code":"29876","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Autgrft implnt knee w/scope","code_information":[{"code":"29866","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Knee arthroscopy/surgery","code_information":[{"code":"29850","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1192.86,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1590.48,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3069.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1192.86,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1622.29,"additional_payer_notes":"APC"}]}]},{"description":"Elbow arthroscopy/surgery","code_information":[{"code":"29838","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Repair of nasal septum","code_information":[{"code":"30520","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2459.51,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3279.35,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6329.15,"additional_payer_notes":"APC"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":4226.0},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2459.51,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3344.94,"additional_payer_notes":"APC"}]}]},{"description":"Ablate inf turbinate superf","code_information":[{"code":"30801","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1151.01,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1534.69,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2961.94,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1151.01,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1565.38,"additional_payer_notes":"APC"}]}]},{"description":"Ther fx nasal inf turbinate","code_information":[{"code":"30930","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2459.51,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3279.35,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6329.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2459.51,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3344.94,"additional_payer_notes":"APC"}]}]},{"description":"Exploration sphenoid sinus","code_information":[{"code":"31050","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Removal of frontal sinus","code_information":[{"code":"31086","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Nasal endoscopy dx","code_information":[{"code":"31231","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":148.07,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":197.43,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":381.05,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":148.07,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":201.38,"additional_payer_notes":"APC"}]}]},{"description":"Removal of ethmoid sinus","code_information":[{"code":"31255","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4956.0,"maximum":13472.56,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6980.6,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":7398.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6019.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":7398.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13472.56,"additional_payer_notes":"APC"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":4956.0},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5235.45,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7120.21,"additional_payer_notes":"APC"}]}]},{"description":"Nasal/sinus endoscopy surg","code_information":[{"code":"31292","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5235.45,"maximum":13472.56,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6980.6,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":7398.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6019.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":7398.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13472.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5235.45,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7120.21,"additional_payer_notes":"APC"}]}]},{"description":"Removal of larynx","code_information":[{"code":"31360","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Removal of larynx & pharynx","code_information":[{"code":"31390","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Remove foreign body larynx","code_information":[{"code":"31511","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":148.07,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":197.43,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":381.05,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":148.07,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":201.38,"additional_payer_notes":"APC"}]}]},{"description":"Laryngoscopy and dilation","code_information":[{"code":"31528","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2765.81,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3687.74,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7117.34,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2765.81,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3761.5,"additional_payer_notes":"APC"}]}]},{"description":"Remove vc lesion w/scope","code_information":[{"code":"31545","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2765.81,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3687.74,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7117.34,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2765.81,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3761.5,"additional_payer_notes":"APC"}]}]},{"description":"Largsc w/rmvl foreign bdy(s)","code_information":[{"code":"31577","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":290.14,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":386.86,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":746.64,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":290.14,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":394.6,"additional_payer_notes":"APC"}]}]},{"description":"Incision of windpipe","code_information":[{"code":"31600","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2459.51,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3279.35,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6329.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2459.51,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3344.94,"additional_payer_notes":"APC"}]}]},{"description":"Repair windpipe opening","code_information":[{"code":"31614","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Bronchoscopy/lung bx each","code_information":[{"code":"31628","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2765.81,"maximum":7117.34,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3687.74,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7117.34,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2765.81,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3761.5,"additional_payer_notes":"APC"}]}]},{"description":"Bronchoscopy bronch stents","code_information":[{"code":"31636","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5235.45,"maximum":13472.56,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6980.6,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":7398.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6019.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":7398.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13472.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5235.45,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7120.21,"additional_payer_notes":"APC"}]}]},{"description":"Bronchial valve init insert","code_information":[{"code":"31647","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5235.45,"maximum":13472.56,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6980.6,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":7398.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6019.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":7398.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13472.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5235.45,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7120.21,"additional_payer_notes":"APC"}]}]},{"description":"Bronch thermoplsty 2/> lobes","code_information":[{"code":"31661","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5235.45,"maximum":13472.56,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6980.6,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":7398.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6019.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":7398.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13472.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5235.45,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7120.21,"additional_payer_notes":"APC"}]}]},{"description":"Reconstruction of windpipe","code_information":[{"code":"31766","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Repair of windpipe injury","code_information":[{"code":"31805","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Open wedge/bx lung nodule","code_information":[{"code":"32097","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5257.0,"maximum":6462.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5257.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6462.0}]}]},{"description":"Removal of lung lesion(s)","code_information":[{"code":"32150","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6019.0,"maximum":7398.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":7398.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6019.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":7398.0}]}]},{"description":"Free/remove chest lining","code_information":[{"code":"32320","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5257.0,"maximum":6462.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5257.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6462.0}]}]},{"description":"Sleeve lobectomy","code_information":[{"code":"32486","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":9356.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0}]}]},{"description":"Wedge resect of lung diag","code_information":[{"code":"32507","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":9356.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0}]}]},{"description":"Thoracoscopy w/thymus resect","code_information":[{"code":"32673","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5257.0,"maximum":6462.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5257.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6462.0}]}]},{"description":"Lung transplant single","code_information":[{"code":"32851","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8923.0,"maximum":10765.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":10765.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":8923.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":10765.0}]}]},{"description":"Revise & repair chest wall","code_information":[{"code":"32906","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":9356.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0}]}]},{"description":"Partial removal of heart sac","code_information":[{"code":"33030","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6019.0,"maximum":7398.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":7398.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6019.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":7398.0}]}]},{"description":"Insert epicard eltrd endo","code_information":[{"code":"33203","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":9356.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0}]}]},{"description":"Upgrade of pacemaker system","code_information":[{"code":"33214","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":43643.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10338.17,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43643.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43643.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43643.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":19952.66,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7753.63,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":41120.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10544.93,"additional_payer_notes":"APC"}]}]},{"description":"Relocate pocket for defib","code_information":[{"code":"33223","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1530.61,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2040.81,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3938.76,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1530.61,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2081.63,"additional_payer_notes":"APC"}]}]},{"description":"Insrt pulse gen w/mult leads","code_information":[{"code":"33231","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8923.0,"maximum":59920.75,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":31047.02,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":10765.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":8923.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":10765.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":54996.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":54996.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":54996.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":59920.75,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23285.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":51942.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":31667.96,"additional_payer_notes":"APC"}]}]},{"description":"Remove pulse generator","code_information":[{"code":"33241","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2772.2,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3696.26,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7133.79,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2772.2,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3770.19,"additional_payer_notes":"APC"}]}]},{"description":"Ablate atria w/bypass exten","code_information":[{"code":"33256","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6019.0,"maximum":7398.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":7398.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6019.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":7398.0}]}]},{"description":"Ablate atria lmtd endo","code_information":[{"code":"33265","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6019.0,"maximum":7398.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":7398.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6019.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":7398.0}]}]},{"description":"Exploratory heart surgery","code_information":[{"code":"33310","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":9356.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0}]}]},{"description":"Replace aortic valve open","code_information":[{"code":"33362","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":9356.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0}]}]},{"description":"Prepare heart-aorta conduit","code_information":[{"code":"33404","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6019.0,"maximum":7398.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":7398.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6019.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":7398.0}]}]},{"description":"Revision subvalvular tissue","code_information":[{"code":"33415","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":9356.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0}]}]},{"description":"Repair of mitral valve","code_information":[{"code":"33426","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":9356.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0}]}]},{"description":"Revision of pulmonary valve","code_information":[{"code":"33474","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":9356.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0}]}]},{"description":"Coronary artery correction","code_information":[{"code":"33502","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":9356.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0}]}]},{"description":"Cabg vein two","code_information":[{"code":"33511","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":9356.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0}]}]},{"description":"Cabg artery-vein four","code_information":[{"code":"33521","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":9356.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0}]}]},{"description":"Removal of heart lesion","code_information":[{"code":"33542","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":9356.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0}]}]},{"description":"Repair by enlargement","code_information":[{"code":"33610","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":9356.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0}]}]},{"description":"Redo compl cardiac anomaly","code_information":[{"code":"33622","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":9356.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0}]}]},{"description":"Close mult vsd w/resection","code_information":[{"code":"33676","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":9356.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0}]}]},{"description":"Repair of heart defects","code_information":[{"code":"33697","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":9356.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0}]}]},{"description":"Revision of heart chamber","code_information":[{"code":"33735","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":9356.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0}]}]},{"description":"Cavopulmonary shunting","code_information":[{"code":"33768","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6019.0,"maximum":7398.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":7398.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6019.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":7398.0}]}]},{"description":"Repair great vessels defect","code_information":[{"code":"33779","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6019.0,"maximum":7398.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":7398.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6019.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":7398.0}]}]},{"description":"Repair vessel defect","code_information":[{"code":"33802","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6019.0,"maximum":7398.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":7398.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6019.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":7398.0}]}]},{"description":"Remove aorta constriction","code_information":[{"code":"33851","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":9356.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0}]}]},{"description":"Endovasc taa repr w/o subcl","code_information":[{"code":"33881","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":9356.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0}]}]},{"description":"Surgery of great vessel","code_information":[{"code":"33916","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6019.0,"maximum":7398.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":7398.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6019.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":7398.0}]}]},{"description":"Prepare donor heart/lung","code_information":[{"code":"33933","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5257.0,"maximum":6462.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5257.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6462.0}]}]},{"description":"Ecmo/ecls daily mgmt artery","code_information":[{"code":"33949","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3388.0,"maximum":4106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0}]}]},{"description":"Ecmo/ecls repos perph cnula","code_information":[{"code":"33958","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3388.0,"maximum":4106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0}]}]},{"description":"Remove aortic assist device","code_information":[{"code":"33968","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":44873.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":44873.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":44873.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":44873.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":43285.0}]}]},{"description":"Remove ventricular device","code_information":[{"code":"33977","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":9356.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0}]}]},{"description":"Ecmo/ecls rmvl ctr cannula","code_information":[{"code":"33985","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3388.0,"maximum":4106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0}]}]},{"description":"Reposition vad diff session","code_information":[{"code":"33993","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":9356.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0}]}]},{"description":"Removal of leg artery clot","code_information":[{"code":"34203","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4127.91,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5503.89,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":10622.5,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4127.91,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5613.96,"additional_payer_notes":"APC"}]}]},{"description":"Transposition of vein valve","code_information":[{"code":"34510","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4127.91,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5503.89,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":10622.5,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4127.91,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5613.96,"additional_payer_notes":"APC"}]}]},{"description":"Open Aortoiliac Prosth Repr","code_information":[{"code":"34831","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":9356.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0}]}]},{"description":"Endovasc visc aorta 4 graft","code_information":[{"code":"34844","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6019.0,"maximum":7398.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":7398.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6019.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":7398.0}]}]},{"description":"Repair defect of artery","code_information":[{"code":"35011","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4127.91,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5503.89,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":10622.5,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4127.91,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5613.96,"additional_payer_notes":"APC"}]}]},{"description":"Repair artery rupture aorta","code_information":[{"code":"35092","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Repair artery rupture groin","code_information":[{"code":"35132","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Repair blood vessel lesion","code_information":[{"code":"35188","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4127.91,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5503.89,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":10622.5,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4127.91,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5613.96,"additional_payer_notes":"APC"}]}]},{"description":"Repair blood vessel lesion","code_information":[{"code":"35221","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Repair blood vessel lesion","code_information":[{"code":"35261","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2342.32,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3123.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6027.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2342.32,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3185.56,"additional_payer_notes":"APC"}]}]},{"description":"Rechanneling of Artery","code_information":[{"code":"35303","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Rechanneling of artery","code_information":[{"code":"35351","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Harvest vein for bypass","code_information":[{"code":"35500","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Art byp grft subclav-vertbrl","code_information":[{"code":"35515","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Art byp grft aorcel/aormesen","code_information":[{"code":"35531","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Art byp grft fem-popliteal","code_information":[{"code":"35556","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Harvest femoropopliteal vein","code_information":[{"code":"35572","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Art byp subclav-axillary","code_information":[{"code":"35616","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Art byp spenorenal","code_information":[{"code":"35636","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Art byp axill-fem-femoral","code_information":[{"code":"35654","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Composite byp grft 2 veins","code_information":[{"code":"35682","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Reimplant artery each","code_information":[{"code":"35697","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Removal of clot in graft","code_information":[{"code":"35875","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4127.91,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5503.89,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":10622.5,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4127.91,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5613.96,"additional_payer_notes":"APC"}]}]},{"description":"Excision graft thorax","code_information":[{"code":"35905","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Place catheter in artery","code_information":[{"code":"36013","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Place catheter in artery","code_information":[{"code":"36216","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Place cath vertebral art","code_information":[{"code":"36226","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4127.91,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5503.89,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":10622.5,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4127.91,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5613.96,"additional_payer_notes":"APC"}]}]},{"description":"Ins cath ren art 1st bilat","code_information":[{"code":"36252","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2342.32,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3123.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6027.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2342.32,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3185.56,"additional_payer_notes":"APC"}]}]},{"description":"Bl push transfuse 2 yr/<","code_information":[{"code":"36440","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":327.28,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":436.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":842.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":327.28,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":445.1,"additional_payer_notes":"APC"}]}]},{"description":"Endovenous rf vein add-on","code_information":[{"code":"36476","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Apheresis platelets","code_information":[{"code":"36513","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":327.28,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":436.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":842.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":327.28,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":445.1,"additional_payer_notes":"APC"}]}]},{"description":"Insert tunneled cv cath","code_information":[{"code":"36560","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2342.32,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3123.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6027.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2342.32,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3185.56,"additional_payer_notes":"APC"}]}]},{"description":"Insert picvad cath","code_information":[{"code":"36571","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2342.32,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3123.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6027.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2342.32,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3185.56,"additional_payer_notes":"APC"}]}]},{"description":"Replace picc cath","code_information":[{"code":"36584","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1167.76,"maximum":4106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1557.01,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3005.03,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1167.76,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1588.15,"additional_payer_notes":"APC"}]}]},{"description":"Insertion catheter artery","code_information":[{"code":"36620","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Av fuse uppr arm cephalic","code_information":[{"code":"36818","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4127.91,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5503.89,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":10622.5,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4127.91,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5613.96,"additional_payer_notes":"APC"}]}]},{"description":"Av fistula revision open","code_information":[{"code":"36832","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4127.91,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5503.89,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":10622.5,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4127.91,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5613.96,"additional_payer_notes":"APC"}]}]},{"description":"Revision of circulation","code_information":[{"code":"37160","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Venous mech thrombectomy","code_information":[{"code":"37187","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6019.0,"maximum":22037.64,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11418.47,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":7398.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6019.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":7398.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":22037.64,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8563.85,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11646.84,"additional_payer_notes":"APC"}]}]},{"description":"Thrombolytic art therapy","code_information":[{"code":"37211","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4127.91,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5503.89,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":10622.5,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4127.91,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5613.96,"additional_payer_notes":"APC"}]}]},{"description":"Iliac revasc","code_information":[{"code":"37220","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6019.0,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":7398.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6019.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":7398.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0}]}]},{"description":"Tib/per revasc w/tla","code_information":[{"code":"37228","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0}]}]},{"description":"Open/perq place stent 1st","code_information":[{"code":"37236","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":27583.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11418.47,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":22037.64,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8563.85,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":27583.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11646.84,"additional_payer_notes":"APC"}]}]},{"description":"Intrvasc us noncoronary 1st","code_information":[{"code":"37252","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Ligation of a-v fistula","code_information":[{"code":"37607","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2342.32,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3123.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6027.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2342.32,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3185.56,"additional_payer_notes":"APC"}]}]},{"description":"Revision of major vein","code_information":[{"code":"37660","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Phleb veins - extrem 20+","code_information":[{"code":"37766","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2342.32,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3123.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6027.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2342.32,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3185.56,"additional_payer_notes":"APC"}]}]},{"description":"Removal of spleen total","code_information":[{"code":"38102","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Cryopreserve stem cells","code_information":[{"code":"38207","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":327.28,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":436.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":842.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":327.28,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":445.1,"additional_payer_notes":"APC"}]}]},{"description":"Harvest stem cell concentrte","code_information":[{"code":"38215","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":327.28,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":436.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":842.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":327.28,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":445.1,"additional_payer_notes":"APC"}]}]},{"description":"Transplj hematopoietic boost","code_information":[{"code":"38243","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1155.35,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1540.47,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2973.1,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1155.35,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1571.27,"additional_payer_notes":"APC"}]}]},{"description":"Needle biopsy lymph nodes","code_information":[{"code":"38505","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1225.21,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1633.61,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3152.87,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1225.21,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1666.28,"additional_payer_notes":"APC"}]}]},{"description":"Scoliosis dna alys","code_information":[{"code":"0004M","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":59.25,"maximum":152.47,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":79.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":117.35},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":98.75},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":98.75},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":98.75},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":152.47,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":59.25,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":138.25},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":80.58,"additional_payer_notes":"APC"}]}]},{"description":"Onc prst8 ca mrna 12 gen alg","code_information":[{"code":"0011M","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":570.0,"maximum":1466.8,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":760.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1128.96},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":950.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":950.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":950.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1466.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":570.0,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1330.0},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":760.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":775.2,"additional_payer_notes":"APC"}]}]},{"description":"Onc hmtlmf neo jak2 mut dna","code_information":[{"code":"0017U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":68.74,"maximum":176.9,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":91.66,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":168.11},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":114.58},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":114.58},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":114.58},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":176.9,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":68.74,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":160.41},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":91.66},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":93.49,"additional_payer_notes":"APC"}]}]},{"description":"Onc aml dna detcj/nondetcj","code_information":[{"code":"0023U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":186.38,"maximum":479.62,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":248.51,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":310.64},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":310.64},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":310.64},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":479.62,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":186.38,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":434.89},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":248.51},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":253.48,"additional_payer_notes":"APC"}]}]},{"description":"Comt gene","code_information":[{"code":"0032U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":131.11,"maximum":337.38,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":174.81,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":259.67},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":218.51},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":218.51},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":218.51},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":337.38,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":131.11,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":305.92},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":174.81},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":178.31,"additional_payer_notes":"APC"}]}]},{"description":"Bcr/abl1 gene major bp quan","code_information":[{"code":"0040U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":307.42,"maximum":791.11,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":409.9,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":676.56},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":512.38},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":512.38},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":512.38},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":791.11,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":307.42,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":717.33},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":409.9},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":418.1,"additional_payer_notes":"APC"}]}]},{"description":"Onc sld org neo dna 468 gene","code_information":[{"code":"0048U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2189.7,"maximum":5634.83,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2919.6,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3649.5},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3649.5},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3649.5},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5634.83,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2189.7,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5109.3},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2919.6},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2977.99,"additional_payer_notes":"APC"}]}]},{"description":"Onc merkel cll carc srm +/-","code_information":[{"code":"0059U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":242.22,"maximum":623.31,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":322.96,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":533.06},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":403.7},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":403.7},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":403.7},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":623.31,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":242.22,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":565.18},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":322.96},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":329.42,"additional_payer_notes":"APC"}]}]},{"description":"Onc brst imhchem prfl 4 bmrk","code_information":[{"code":"0067U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1422.75,"maximum":3661.21,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1897.0,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2371.25},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2371.25},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2371.25},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3661.21,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1422.75,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3319.75},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1897.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1934.94,"additional_payer_notes":"APC"}]}]},{"description":"Cyp2d6 5' gene dup/mlt","code_information":[{"code":"0075U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":338.18,"maximum":870.26,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":450.91,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":669.83},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":563.64},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":563.64},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":563.64},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":870.26,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":338.18,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":789.09},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":450.91},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":459.93,"additional_payer_notes":"APC"}]}]},{"description":"Nfct ds bact&fng org id 6+","code_information":[{"code":"0086U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":150.0,"maximum":386.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":200.0,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":250.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":250.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":250.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":386.0,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":150.0,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":350.0},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":200.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":204.0,"additional_payer_notes":"APC"}]}]},{"description":"Inflm ee elisa alys alg","code_information":[{"code":"0095U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":578.98,"maximum":1489.92,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":771.98,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":964.98},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":964.98},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":964.98},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1489.92,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":578.98,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1350.97},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":771.98},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":787.42,"additional_payer_notes":"APC"}]}]},{"description":"Gi barrett esoph 9 prtn bmrk","code_information":[{"code":"0108U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2513.25,"maximum":9553.5,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4950.0,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":6187.5},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":6187.5},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":6187.5},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":9553.5,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3712.5,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8662.5},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2513.25},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5049.0,"additional_payer_notes":"APC"}]}]},{"description":"Rx mntr nzm ia 35+oral flu","code_information":[{"code":"0116U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":185.19,"maximum":476.56,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":246.92,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":366.8},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":308.65},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":308.65},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":308.65},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":476.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":185.19,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":432.11},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":246.92},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":251.86,"additional_payer_notes":"APC"}]}]},{"description":"Hered brst ca rltd do panel","code_information":[{"code":"0129U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":977.96,"maximum":2516.62,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1303.95,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1936.98},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1629.94},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1629.94},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1629.94},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2516.62,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":977.96,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2281.91},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1117.98},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1330.03,"additional_payer_notes":"APC"}]}]},{"description":"Palb2 mrna seq alys","code_information":[{"code":"0137U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":212.16,"maximum":545.96,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":282.88,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":353.6},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":353.6},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":353.6},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":545.96,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":212.16,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":495.04},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":282.88},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":288.54,"additional_payer_notes":"APC"}]}]},{"description":"Pik3ca gene analysis","code_information":[{"code":"0155U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":206.12,"maximum":530.42,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":274.83,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":343.54},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":343.54},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":343.54},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":530.42,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":206.12,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":480.95},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":274.83},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":280.33,"additional_payer_notes":"APC"}]}]},{"description":"Onc clrct scr 3 prtn alg","code_information":[{"code":"0163U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":390.75,"maximum":683.81,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":580.44},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":488.44},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":488.44},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":488.44},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":683.81},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":390.75}]}]},{"description":"Psyc gen alys panel 14 genes","code_information":[{"code":"0173U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":349.63,"maximum":899.71,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":466.17,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":692.47},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":582.71},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":582.71},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":582.71},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":899.71,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":349.63,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":815.8},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":466.17},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":475.49,"additional_payer_notes":"APC"}]}]},{"description":"Co gnotyp aqp1 exon 1","code_information":[{"code":"0181U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":138.9,"maximum":357.44,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":185.2,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":275.11},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":231.5},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":231.5},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":231.5},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":357.44,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":138.9,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":324.1},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":185.2},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":188.9,"additional_payer_notes":"APC"}]}]},{"description":"Gypa gnotyp ntrns 1 5 exon 2","code_information":[{"code":"0189U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":206.12,"maximum":530.42,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":274.83,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":408.24},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":343.54},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":343.54},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":343.54},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":530.42,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":206.12,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":480.95},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":274.83},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":280.33,"additional_payer_notes":"APC"}]}]},{"description":"Lw gnotyp icam4 exon 1","code_information":[{"code":"0197U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":138.9,"maximum":357.44,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":185.2,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":275.11},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":231.5},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":231.5},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":231.5},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":357.44,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":138.9,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":324.1},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":185.2},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":188.9,"additional_payer_notes":"APC"}]}]},{"description":"Neuro alzheimer cell aggregj","code_information":[{"code":"0206U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1661.55,"maximum":4275.72,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2215.4,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3290.92},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2769.25},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2769.25},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2769.25},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4275.72,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1661.55,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3876.95},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2215.4},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2259.71,"additional_payer_notes":"APC"}]}]},{"description":"Rare ds xom dna alys ea comp","code_information":[{"code":"0215U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1930.99,"maximum":4969.07,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2574.65,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3824.57},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3218.31},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3218.31},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3218.31},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4969.07,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1930.99,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":4505.64},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2574.65},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2626.14,"additional_payer_notes":"APC"}]}]},{"description":"Nfct ds 22 trgt sars-cov-2","code_information":[{"code":"0223U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":312.58,"maximum":804.39,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":416.78,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":619.1},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":520.98},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":520.98},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":520.98},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":804.39,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":312.58,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":729.37},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":416.77},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":425.12,"additional_payer_notes":"APC"}]}]},{"description":"Cacna1a full gene analysis","code_information":[{"code":"0231U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":634.7,"maximum":1633.3,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":846.27,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1257.11},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1057.84},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1057.84},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1057.84},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1633.3,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":634.7,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1480.97},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":846.27},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":863.2,"additional_payer_notes":"APC"}]}]},{"description":"Trgt gen seq alys pnl 311+","code_information":[{"code":"0239U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2625.0,"maximum":6755.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3500.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5199.14},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4375.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4375.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4375.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6755.0,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2625.0,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6125.0},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3500.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3570.0,"additional_payer_notes":"APC"}]}]},{"description":"Ob prtrm brth ibp4 shbg meas","code_information":[{"code":"0247U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":562.5,"maximum":1447.5,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":750.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1114.1},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":937.5},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":937.5},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":937.5},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1447.5,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":562.5,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1312.5},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":750.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":765.0,"additional_payer_notes":"APC"}]}]},{"description":"Andrology infertility assmt","code_information":[{"code":"0255U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":23.7,"maximum":60.99,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":31.6,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":46.8},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":39.5},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":39.5},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":39.5},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":60.99,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23.7,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":55.3},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31.6},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":32.23,"additional_payer_notes":"APC"}]}]},{"description":"Neuro asd meas 16 c metblt","code_information":[{"code":"0263U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":562.5,"maximum":1447.5,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":750.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1114.1},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":937.5},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":937.5},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":937.5},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1447.5,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":562.5,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1312.5},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":750.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":765.0,"additional_payer_notes":"APC"}]}]},{"description":"Hem cgen neutropenia 23 gen","code_information":[{"code":"0271U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":456.13,"maximum":1173.77,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":608.17,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":900.54},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":760.21},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":760.21},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":760.21},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1173.77,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":456.13,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1064.3},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":608.17},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":620.33,"additional_payer_notes":"APC"}]}]},{"description":"Hem vw factor&clgn iii bndg","code_information":[{"code":"0279U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8.65,"maximum":22.25,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11.53,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":17.12},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14.41},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14.41},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14.41},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":22.25,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8.65,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20.18},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11.53},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11.76,"additional_payer_notes":"APC"}]}]},{"description":"Onc thyr dna&mrna 112 genes","code_information":[{"code":"0287U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2700.0,"maximum":6948.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3600.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5330.71},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4500.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4500.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4500.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6948.0,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2700.0,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6300.0},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3600.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3672.0,"additional_payer_notes":"APC"}]}]},{"description":"Onc brst dux carc 7 proteins","code_information":[{"code":"0295U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1897.0,"maximum":10489.55,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5435.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2808.98},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":6793.75},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":6793.75},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":6793.75},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":10489.55,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4076.25,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9511.25},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1897.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5543.7,"additional_payer_notes":"APC"}]}]},{"description":"Hem rbc ads whl bld hypoxic","code_information":[{"code":"0303U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1651.22,"maximum":4249.13,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2201.62,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3297.14},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2752.03},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2752.03},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2752.03},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4249.13,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1651.22,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3852.84},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2201.62},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2245.65,"additional_payer_notes":"APC"}]}]},{"description":"Nfct ds bct quan antmcrb sc","code_information":[{"code":"0311U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6.06,"maximum":15.59,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8.08,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":11.96},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10.1},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10.1},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10.1},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":15.59,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6.06,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14.14},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8.08},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8.24,"additional_payer_notes":"APC"}]}]},{"description":"Neph rna pretrnspl perph bld","code_information":[{"code":"0319U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1987.5,"maximum":5114.5,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2650.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3968.64},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3312.5},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3312.5},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3312.5},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5114.5,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1987.5,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":4637.5},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2650.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2703.0,"additional_payer_notes":"APC"}]}]},{"description":"Onc neo xome&trns seq alys","code_information":[{"code":"0329U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2578.48,"maximum":6635.3,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3437.98,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5148.72},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4297.48},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4297.48},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4297.48},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6635.3,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2578.48,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6016.47},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3437.98},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3506.74,"additional_payer_notes":"APC"}]}]},{"description":"Onc plsm cell do&myeloma id","code_information":[{"code":"0337U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1826.25,"maximum":4699.55,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2435.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3646.66},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3043.75},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3043.75},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3043.75},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4699.55,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1826.25,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":4261.25},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2435.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2483.7,"additional_payer_notes":"APC"}]}]},{"description":"Psyc genom alys pnl 15 gen","code_information":[{"code":"0345U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1002.07,"maximum":2578.65,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1336.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1978.42},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1670.11},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1670.11},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1670.11},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2578.65,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1002.07,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2338.16},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1336.09},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1362.81,"additional_payer_notes":"APC"}]}]},{"description":"Neuro alys b-amyl 1-42&1-40","code_information":[{"code":"0358U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":195.38,"maximum":502.76,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":260.5,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":390.12},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":325.63},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":325.63},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":325.63},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":502.76,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":195.38,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":455.88},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":260.5},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":265.71,"additional_payer_notes":"APC"}]}]},{"description":"Onc bldr 10 prb recr bldr ca","code_information":[{"code":"0366U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":672.75,"maximum":1731.21,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":897.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1343.35},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1121.25},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1121.25},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1121.25},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1731.21,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":672.75,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1569.75},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":897.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":914.94,"additional_payer_notes":"APC"}]}]},{"description":"Removal pelvic lymph nodes","code_information":[{"code":"38562","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5257.0,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8084.38,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5257.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":15602.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6063.28,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8246.06,"additional_payer_notes":"APC"}]}]},{"description":"Removal of lymph nodes neck","code_information":[{"code":"38724","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5257.0,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5257.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0}]}]},{"description":"Remove abdomen lymph nodes","code_information":[{"code":"38780","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5257.0,"maximum":6462.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5257.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6462.0}]}]},{"description":"Resect mediastinal cyst","code_information":[{"code":"39200","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5257.0,"maximum":6462.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5257.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6462.0}]}]},{"description":"Repair of diaphragm hernia","code_information":[{"code":"39541","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5257.0,"maximum":6462.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5257.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6462.0}]}]},{"description":"Partial excision of lip","code_information":[{"code":"40520","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2459.51,"maximum":6329.15,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3279.35,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6329.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2459.51,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3344.94,"additional_payer_notes":"APC"}]}]},{"description":"Repair cleft lip/nasal","code_information":[{"code":"40701","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Removal foreign body mouth","code_information":[{"code":"40805","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":400.09,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":533.45,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1029.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":400.09,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":544.12,"additional_payer_notes":"APC"}]}]},{"description":"Excise lip or cheek fold","code_information":[{"code":"40819","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1151.01,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1534.69,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2961.94,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1151.01,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1565.38,"additional_payer_notes":"APC"}]}]},{"description":"Reconstruction of mouth","code_information":[{"code":"40845","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Incision of tongue fold","code_information":[{"code":"41010","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1151.01,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1534.69,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2961.94,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1151.01,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1565.38,"additional_payer_notes":"APC"}]}]},{"description":"Biopsy of floor of mouth","code_information":[{"code":"41108","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1225.21,"maximum":4106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1633.61,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3152.87,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1225.21,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1666.28,"additional_payer_notes":"APC"}]}]},{"description":"Partial removal of tongue","code_information":[{"code":"41130","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Repair tongue laceration","code_information":[{"code":"41251","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":175.7,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":234.27,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":452.14,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":175.7,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":238.96,"additional_payer_notes":"APC"}]}]},{"description":"Removal foreign body gum","code_information":[{"code":"41805","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1151.01,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1534.69,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2961.94,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1151.01,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1565.38,"additional_payer_notes":"APC"}]}]},{"description":"Excision of gum lesion","code_information":[{"code":"41827","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Drainage mouth roof lesion","code_information":[{"code":"42000","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":175.7,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":234.27,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":452.14,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":175.7,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":238.96,"additional_payer_notes":"APC"}]}]},{"description":"Treatment mouth roof lesion","code_information":[{"code":"42160","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2459.51,"maximum":6329.15,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3279.35,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6329.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2459.51,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3344.94,"additional_payer_notes":"APC"}]}]},{"description":"Reconstruct cleft palate","code_information":[{"code":"42225","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Drainage of salivary gland","code_information":[{"code":"42300","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1151.01,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1534.69,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2961.94,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1151.01,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1565.38,"additional_payer_notes":"APC"}]}]},{"description":"Biopsy of salivary gland","code_information":[{"code":"42405","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1151.01,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1534.69,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2961.94,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1151.01,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1565.38,"additional_payer_notes":"APC"}]}]},{"description":"Excise submaxillary gland","code_information":[{"code":"42440","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Closure of salivary fistula","code_information":[{"code":"42600","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2459.51,"maximum":6329.15,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3279.35,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6329.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2459.51,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3344.94,"additional_payer_notes":"APC"}]}]},{"description":"Biopsy of throat","code_information":[{"code":"42800","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1151.01,"maximum":4106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1534.69,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2961.94,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1151.01,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1565.38,"additional_payer_notes":"APC"}]}]},{"description":"Remove tonsils and adenoids","code_information":[{"code":"42821","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2459.51,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3279.35,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6329.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2459.51,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3344.94,"additional_payer_notes":"APC"}]}]},{"description":"Extensive surgery of throat","code_information":[{"code":"42844","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Reconstruction of throat","code_information":[{"code":"42950","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":11300.84,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Control nose/throat bleeding","code_information":[{"code":"42972","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2459.51,"maximum":6329.15,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3279.35,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6329.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2459.51,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3344.94,"additional_payer_notes":"APC"}]}]},{"description":"Removal of esophagus","code_information":[{"code":"43108","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Partial removal of esophagus","code_information":[{"code":"43123","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Esophagoscp rig trnso rem fb","code_information":[{"code":"43194","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1423.51,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1898.01,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3663.16,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1423.51,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1935.97,"additional_payer_notes":"APC"}]}]},{"description":"Esoph scope w/sclerosis inj","code_information":[{"code":"43204","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1423.51,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1898.01,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3663.16,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1423.51,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1935.97,"additional_payer_notes":"APC"}]}]},{"description":"Esophagoscopy flex remove fb","code_information":[{"code":"43215","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1423.51,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1898.01,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3663.16,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1423.51,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1935.97,"additional_payer_notes":"APC"}]}]},{"description":"Esophagoscopy w/us needle bx","code_information":[{"code":"43232","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1423.51,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1898.01,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3663.16,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1423.51,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1935.97,"additional_payer_notes":"APC"}]}]},{"description":"Egd tube/cath insertion","code_information":[{"code":"43241","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1423.51,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1898.01,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3663.16,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1423.51,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1935.97,"additional_payer_notes":"APC"}]}]},{"description":"Esoph egd dilation <30 mm","code_information":[{"code":"43249","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1423.51,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1898.01,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3663.16,"additional_payer_notes":"APC"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1484.0},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1423.51,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1935.97,"additional_payer_notes":"APC"}]}]},{"description":"Iadna gu pthgn 21 org&21arg","code_information":[{"code":"0374U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":416.78,"maximum":729.37,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":624.18},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":520.98},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":520.98},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":520.98},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":729.37},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":416.78}]}]},{"description":"Tyrosinemia typ i mntr quan","code_information":[{"code":"0383U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":39.04,"maximum":100.46,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":52.05,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":74.95},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":65.06},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":65.06},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":65.06},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":100.46,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":39.04,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":91.09},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":52.05},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":53.09,"additional_payer_notes":"APC"}]}]},{"description":"Rx metab genrx ia 16 genes","code_information":[{"code":"0392U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1002.07,"maximum":2578.65,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1336.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2000.93},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1670.11},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1670.11},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1670.11},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2578.65,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1002.07,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2338.16},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1336.09},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1362.81,"additional_payer_notes":"APC"}]}]},{"description":"Nfct agt sti mult amp prb tq","code_information":[{"code":"0402U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":106.97,"maximum":275.28,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":142.63,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":213.61},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":178.29},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":178.29},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":178.29},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":275.28,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":106.97,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":249.6},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":142.63},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":145.48,"additional_payer_notes":"APC"}]}]},{"description":"Onc pncrtc dna whl gn seq 5-","code_information":[{"code":"0410U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":870.0,"maximum":2238.8,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1160.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1737.22},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1450.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1450.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1450.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2238.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":870.0,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2030.0},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1160.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1183.2,"additional_payer_notes":"APC"}]}]},{"description":"Nrpsyc gen seq vrnt aly 13","code_information":[{"code":"0419U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1002.07,"maximum":2578.65,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1336.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2000.93},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1670.11},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1670.11},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1670.11},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2578.65,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1002.07,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2338.16},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1336.09},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1362.81,"additional_payer_notes":"APC"}]}]},{"description":"Monocyte dstrbj wdth whl bld","code_information":[{"code":"0427U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3.36,"maximum":8.65,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4.48,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6.46},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5.6},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5.6},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5.6},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":8.65,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3.36,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7.84},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":4.48},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4.57,"additional_payer_notes":"APC"}]}]},{"description":"Onc sld orgn neo tgsap 361","code_information":[{"code":"0444U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2189.7,"maximum":5634.83,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2919.6,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4204.22},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3649.5},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3649.5},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3649.5},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5634.83,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2189.7,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5109.3},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2919.6},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2977.99,"additional_payer_notes":"APC"}]}]},{"description":"Onc clrct ca cfdna qpcr asy","code_information":[{"code":"0453U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":144.0,"maximum":370.56,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":192.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":276.48},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":240.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":240.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":240.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":370.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":144.0,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":336.0},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":192.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":195.84,"additional_payer_notes":"APC"}]}]},{"description":"Melatonin lvl tst slp std7/9","code_information":[{"code":"0462U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":12.95,"maximum":33.33,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17.27,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":24.86},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21.59},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21.59},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21.59},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":33.33,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.95,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30.22},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17.27},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17.62,"additional_payer_notes":"APC"}]}]},{"description":"Rbc ag ftl rhd gene alys ngs","code_information":[{"code":"0494U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":569.29,"maximum":1464.97,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":759.05,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1093.03},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":948.81},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":948.81},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":948.81},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1464.97,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":569.29,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1328.34},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":759.05},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":774.23,"additional_payer_notes":"APC"}]}]},{"description":"Hpv e6/e7 mrk hi-rsk typ crv","code_information":[{"code":"0502U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":26.32,"maximum":67.72,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":35.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":50.53},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43.86},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43.86},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43.86},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":67.72,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26.32,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":61.41},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35.09},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":35.79,"additional_payer_notes":"APC"}]}]},{"description":"Ther rx mntr 90+ pn&mtl hlth","code_information":[{"code":"0518U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":185.19,"maximum":476.56,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":246.92,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":355.56},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":308.65},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":308.65},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":308.65},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":476.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":185.19,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":432.11},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":246.92},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":251.86,"additional_payer_notes":"APC"}]}]},{"description":"Electrolyte panel","code_information":[{"code":"80051","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5.26,"maximum":14.17,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7.01,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":14.17},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8.76},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8.76},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8.76},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13.53,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5.26,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12.27},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7.01},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7.15,"additional_payer_notes":"APC"}]}]},{"description":"Drug assay acetaminophen","code_information":[{"code":"80143","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":13.98,"maximum":35.98,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18.64,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":27.71},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23.3},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23.3},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23.3},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":35.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.98,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32.62},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18.64},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19.01,"additional_payer_notes":"APC"}]}]},{"description":"Drug assay clozapine","code_information":[{"code":"80159","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":15.11,"maximum":38.89,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20.15,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":37.43},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25.19},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25.19},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25.19},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":38.89,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15.11,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35.26},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20.15},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20.55,"additional_payer_notes":"APC"}]}]},{"description":"Drug assay everolimus","code_information":[{"code":"80169","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":10.3,"maximum":27.79,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.73,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":27.79},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17.16},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17.16},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17.16},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":26.5,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10.3,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24.03},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13.73},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14.0,"additional_payer_notes":"APC"}]}]},{"description":"Drug assay salicylate","code_information":[{"code":"80179","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":13.98,"maximum":35.98,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18.64,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":27.71},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23.3},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23.3},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23.3},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":35.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.98,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32.62},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18.64},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19.01,"additional_payer_notes":"APC"}]}]},{"description":"Assay of primidone","code_information":[{"code":"80188","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":12.44,"maximum":33.59,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16.59,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":33.59},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20.74},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20.74},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20.74},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":32.02,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.44,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29.03},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16.59},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16.92,"additional_payer_notes":"APC"}]}]},{"description":"Assay of theophylline","code_information":[{"code":"80198","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":10.6,"maximum":28.62,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14.14,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":28.62},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17.68},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17.68},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17.68},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":27.29,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10.6,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24.75},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14.14},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14.42,"additional_payer_notes":"APC"}]}]},{"description":"Drug asy hydroxychloroquine","code_information":[{"code":"80220","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":13.98,"maximum":35.98,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18.64,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":27.71},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23.3},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23.3},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23.3},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":35.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.98,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32.62},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18.64},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19.01,"additional_payer_notes":"APC"}]}]},{"description":"Drug test prsmv chem anlyzr","code_information":[{"code":"80307","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":46.6,"maximum":119.93,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":62.14,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":118.55},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":77.68},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":77.68},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":77.68},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":119.93,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":46.6,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":108.75},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":62.14},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":63.38,"additional_payer_notes":"APC"}]}]},{"description":"Estradiol response panel","code_information":[{"code":"80415","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":41.92,"maximum":113.11,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":55.89,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":113.11},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":69.86},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":69.86},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":69.86},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":107.87,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":41.92,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":97.81},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":55.89},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":57.01,"additional_payer_notes":"APC"}]}]},{"description":"Growth hormone panel","code_information":[{"code":"80428","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":50.02,"maximum":134.96,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":66.7,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":134.96},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":83.38},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":83.38},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":83.38},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":128.73,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":50.02,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":116.73},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":66.7},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":68.03,"additional_payer_notes":"APC"}]}]},{"description":"Urinalysis nonauto w/scope","code_information":[{"code":"81000","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3.02,"maximum":7.76,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4.02,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6.41},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5.03},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5.03},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5.03},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7.76,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3.02,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7.04},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":4.02},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4.1,"additional_payer_notes":"APC"}]}]},{"description":"Urine pregnancy test","code_information":[{"code":"81025","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6.46,"maximum":16.62,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8.61,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":12.79},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10.76},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10.76},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10.76},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":16.62,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6.46,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15.07},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8.61},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8.78,"additional_payer_notes":"APC"}]}]},{"description":"Hpa-9 genotyping","code_information":[{"code":"81111","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":91.66,"maximum":235.88,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":122.22,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":224.14},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":152.78},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":152.78},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":152.78},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":235.88,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":91.66,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":213.89},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":122.22},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":124.66,"additional_payer_notes":"APC"}]}]},{"description":"Brca1 gene full seq alys","code_information":[{"code":"81165","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":212.16,"maximum":565.76,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":282.88,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":420.22},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":353.6},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":353.6},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":353.6},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":545.96,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":212.16,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":495.04},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":565.76},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":288.54,"additional_payer_notes":"APC"}]}]},{"description":"Ar gene known famil variant","code_information":[{"code":"81174","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":138.9,"maximum":357.44,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":185.2,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":275.11},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":231.5},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":231.5},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":231.5},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":357.44,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":138.9,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":324.1},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":185.2},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":188.9,"additional_payer_notes":"APC"}]}]},{"description":"Atxn8os gen detc abnor allel","code_information":[{"code":"81182","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":102.75,"maximum":264.41,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":137.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":203.51},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":171.25},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":171.25},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":171.25},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":264.41,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":102.75,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":239.75},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":137.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":139.74,"additional_payer_notes":"APC"}]}]},{"description":"Egd us exam duodenum/jejunum","code_information":[{"code":"43259","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1423.51,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1898.01,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3663.16,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1423.51,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1935.97,"additional_payer_notes":"APC"}]}]},{"description":"Egd lesion ablation","code_information":[{"code":"43270","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1423.51,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1898.01,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3663.16,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1423.51,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1935.97,"additional_payer_notes":"APC"}]}]},{"description":"Laparoscopy fundoplasty","code_information":[{"code":"43280","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":20292.15,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10514.07,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":20292.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7885.55,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10724.35,"additional_payer_notes":"APC"}]}]},{"description":"Repair esophagus and fistula","code_information":[{"code":"43312","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Esophagomyotomy thoracic","code_information":[{"code":"43331","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Fuse esophagus & intestine","code_information":[{"code":"43340","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Repair esophagus wound","code_information":[{"code":"43410","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Esophagus surgery procedure","code_information":[{"code":"43499","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":672.83,"maximum":13249.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":897.11,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":13249.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":10779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":13249.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1731.42,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":672.83,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":915.05,"additional_payer_notes":"APC"}]}]},{"description":"Excision of stomach lesion","code_information":[{"code":"43611","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Removal of stomach partial","code_information":[{"code":"43635","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Laparoscopy vagus nerve","code_information":[{"code":"43652","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4484.77,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5979.69,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5257.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11540.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4484.77,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6099.28,"additional_payer_notes":"APC"}]}]},{"description":"Dx duod intub w/asp specs","code_information":[{"code":"43757","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":672.83,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":897.11,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1731.42,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":672.83,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":915.05,"additional_payer_notes":"APC"}]}]},{"description":"Reconstruction of pylorus","code_information":[{"code":"43800","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"V-band gastroplasty","code_information":[{"code":"43842","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Repair stomach opening","code_information":[{"code":"43870","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2860.11,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3813.48,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7360.02,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2860.11,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3889.75,"additional_payer_notes":"APC"}]}]},{"description":"Freeing of bowel adhesion","code_information":[{"code":"44005","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Biopsy of bowel","code_information":[{"code":"44100","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":672.83,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":897.11,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1731.42,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":672.83,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":915.05,"additional_payer_notes":"APC"}]}]},{"description":"Enterectomy cong add-on","code_information":[{"code":"44128","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Partial removal of colon","code_information":[{"code":"44140","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Removal of colon/ileostomy","code_information":[{"code":"44151","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Lap ileo/jejuno-stomy","code_information":[{"code":"44187","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5257.0,"maximum":6462.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5257.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6462.0}]}]},{"description":"L colectomy/coloproctostomy","code_information":[{"code":"44208","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5257.0,"maximum":6462.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5257.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6462.0}]}]},{"description":"Ileostomy/jejunostomy","code_information":[{"code":"44310","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Revision of colostomy","code_information":[{"code":"44346","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2628.85,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3505.13,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6764.9,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2628.85,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3575.23,"additional_payer_notes":"APC"}]}]},{"description":"Small Bowel Endoscopy/Stent","code_information":[{"code":"44370","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":11589.23,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6004.78,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11589.23,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4503.59,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6124.88,"additional_payer_notes":"APC"}]}]},{"description":"Small bowel endoscopy br/wa","code_information":[{"code":"44381","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1423.51,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1898.01,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3663.16,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1423.51,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1935.97,"additional_payer_notes":"APC"}]}]},{"description":"Colonoscopy for bleeding","code_information":[{"code":"44391","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":887.71,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1183.61,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2284.37,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":887.71,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1207.28,"additional_payer_notes":"APC"}]}]},{"description":"Colonoscopy w/ultrasound","code_information":[{"code":"44406","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":887.71,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1183.61,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2284.37,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":887.71,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1207.28,"additional_payer_notes":"APC"}]}]},{"description":"Intestinal stricturoplasty","code_information":[{"code":"44615","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Surgical revision intestine","code_information":[{"code":"44680","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Excision of bowel pouch","code_information":[{"code":"44800","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Laparoscopy appendectomy","code_information":[{"code":"44970","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4484.77,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5979.69,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5257.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11540.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4484.77,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6099.28,"additional_payer_notes":"APC"}]}]},{"description":"Partial removal of rectum","code_information":[{"code":"45111","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Partial proctectomy","code_information":[{"code":"45123","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0}]}]},{"description":"Exc rect tum transanal full","code_information":[{"code":"45172","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2059.07,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2745.43,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5298.68,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2059.07,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2800.34,"additional_payer_notes":"APC"}]}]},{"description":"Proctosigmoidoscopy removal","code_information":[{"code":"45315","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":887.71,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1183.61,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2284.37,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":887.71,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1207.28,"additional_payer_notes":"APC"}]}]},{"description":"Cstb gene known famil vrnt","code_information":[{"code":"81190","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":138.9,"maximum":357.44,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":185.2,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":275.11},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":231.5},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":231.5},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":231.5},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":357.44,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":138.9,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":324.1},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":185.2},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":188.9,"additional_payer_notes":"APC"}]}]},{"description":"Apc gene known fam variants","code_information":[{"code":"81202","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":210.0,"maximum":540.4,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":280.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":415.93},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":350.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":350.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":350.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":540.4,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":210.0,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":490.0},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":280.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":285.6,"additional_payer_notes":"APC"}]}]},{"description":"Braf gene","code_information":[{"code":"81210","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":131.55,"maximum":338.52,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":175.4,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":265.86},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":219.25},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":219.25},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":219.25},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":338.52,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":131.55,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":306.95},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":175.4},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":178.91,"additional_payer_notes":"APC"}]}]},{"description":"Cftr gene known fam variants","code_information":[{"code":"81221","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":72.92,"maximum":187.63,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":97.22,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":144.42},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":121.53},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":121.53},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":121.53},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":187.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":72.92,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":170.14},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":97.22},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":99.16,"additional_payer_notes":"APC"}]}]},{"description":"Cytogen m array copy no&snp","code_information":[{"code":"81229","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":870.0,"maximum":2238.8,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1160.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1723.15},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1450.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1450.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1450.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2238.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":870.0,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2030.0},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1160.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1183.2,"additional_payer_notes":"APC"}]}]},{"description":"Ezh2 gene common variants","code_information":[{"code":"81237","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":131.55,"maximum":338.52,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":175.4,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":260.56},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":219.25},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":219.25},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":219.25},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":338.52,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":131.55,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":306.95},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":175.4},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":178.91,"additional_payer_notes":"APC"}]}]},{"description":"Flt3 gene","code_information":[{"code":"81245","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":124.13,"maximum":319.43,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":165.51,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":246.12},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":206.89},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":206.89},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":206.89},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":319.43,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":124.13,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":289.64},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":165.51},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":168.82,"additional_payer_notes":"APC"}]}]},{"description":"Gjb2 gene known fam variants","code_information":[{"code":"81253","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":46.14,"maximum":118.73,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":61.52,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":91.39},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":76.9},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":76.9},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":76.9},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":118.73,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":46.14,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":107.66},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":61.52},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":62.75,"additional_payer_notes":"APC"}]}]},{"description":"Igh gene rearrange amp meth","code_information":[{"code":"81261","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":148.49,"maximum":400.63,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":197.99,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":400.63},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":247.49},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":247.49},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":247.49},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":382.12,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":148.49,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":346.48},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":197.99},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":201.95,"additional_payer_notes":"APC"}]}]},{"description":"Hba1/hba2 gene dup/del vrnts","code_information":[{"code":"81269","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":151.8,"maximum":390.63,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":202.4,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":300.67},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":253.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":253.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":253.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":390.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":151.8,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":354.2},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":202.4},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":206.45,"additional_payer_notes":"APC"}]}]},{"description":"Cytogenomic neo microra alys","code_information":[{"code":"81277","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":870.0,"maximum":2238.8,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1160.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1723.15},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1450.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1450.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1450.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2238.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":870.0,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2030.0},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1160.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1183.2,"additional_payer_notes":"APC"}]}]},{"description":"Mlh1 gene","code_information":[{"code":"81288","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":144.24,"maximum":371.18,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":192.32,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":237.14},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":240.4},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":240.4},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":240.4},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":371.18,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":144.24,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":336.56},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":192.32},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":196.17,"additional_payer_notes":"APC"}]}]},{"description":"Msh2 gene known variants","code_information":[{"code":"81296","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":192.13,"maximum":651.82,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":337.73,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":192.13},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":422.16},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":422.16},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":422.16},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":651.82,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":253.3,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":591.03},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":337.73},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":344.48,"additional_payer_notes":"APC"}]}]},{"description":"Mecp2 gene dup/delet variant","code_information":[{"code":"81304","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":112.5,"maximum":289.5,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":150.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":222.82},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":187.5},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":187.5},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":187.5},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":289.5,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":112.5,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":262.5},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":150.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":153.0,"additional_payer_notes":"APC"}]}]},{"description":"Pabpn1 gene detc abnor allel","code_information":[{"code":"81312","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":102.75,"maximum":264.41,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":137.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":203.51},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":171.25},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":171.25},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":171.25},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":264.41,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":102.75,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":239.75},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":137.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":139.74,"additional_payer_notes":"APC"}]}]},{"description":"Plcg2 gene common variants","code_information":[{"code":"81320","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":218.52,"maximum":562.32,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":291.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":432.79},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":364.2},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":364.2},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":364.2},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":562.32,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":218.52,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":509.88},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":291.36},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":297.19,"additional_payer_notes":"APC"}]}]},{"description":"Slco1b1 gene com variants","code_information":[{"code":"81328","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":131.11,"maximum":337.38,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":174.81,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":259.67},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":218.51},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":218.51},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":218.51},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":337.38,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":131.11,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":305.92},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":174.81},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":178.31,"additional_payer_notes":"APC"}]}]},{"description":"Smn1 gene full gene sequence","code_information":[{"code":"81336","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":226.01,"maximum":581.61,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":301.35,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":447.65},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":376.69},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":376.69},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":376.69},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":581.61,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":226.01,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":527.36},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":301.35},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":307.38,"additional_payer_notes":"APC"}]}]},{"description":"Tbp gene detc abnor alleles","code_information":[{"code":"81344","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":102.75,"maximum":264.41,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":137.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":203.51},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":171.25},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":171.25},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":171.25},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":264.41,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":102.75,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":239.75},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":137.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":139.74,"additional_payer_notes":"APC"}]}]},{"description":"Tp53 gene trgt sequence alys","code_information":[{"code":"81352","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":247.13,"maximum":635.95,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":329.51,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":489.48},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":411.89},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":411.89},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":411.89},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":635.95,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":247.13,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":576.64},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":329.51},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":336.1,"additional_payer_notes":"APC"}]}]},{"description":"Hbb full gene sequence","code_information":[{"code":"81364","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":243.44,"maximum":626.44,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":324.58,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":482.15},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":405.73},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":405.73},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":405.73},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":626.44,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":243.44,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":568.02},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":324.58},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":331.07,"additional_payer_notes":"APC"}]}]},{"description":"Hla ii type 1 ag equiv lr","code_information":[{"code":"81377","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":71.06,"maximum":185.77,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":94.74,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":185.77},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":118.43},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":118.43},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":118.43},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":182.85,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":71.06,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":165.8},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":94.74},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":96.63,"additional_payer_notes":"APC"}]}]},{"description":"Mopath procedure level 2","code_information":[{"code":"81401","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":102.75,"maximum":264.41,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":137.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":203.51},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":171.25},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":171.25},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":171.25},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":264.41,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":102.75,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":239.75},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":137.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":139.74,"additional_payer_notes":"APC"}]}]},{"description":"Aortic dysfunction/dilation","code_information":[{"code":"81410","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":378.0,"maximum":972.72,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":504.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":748.68},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":630.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":630.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":630.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":972.72,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":378.0,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":882.0},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":504.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":514.08,"additional_payer_notes":"APC"}]}]},{"description":"Rx metab gen seq alys pnl 6","code_information":[{"code":"81418","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":687.81,"maximum":1769.96,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":917.08,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1373.42},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1146.35},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1146.35},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1146.35},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1769.96,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":687.81,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1604.89},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":917.08},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":935.42,"additional_payer_notes":"APC"}]}]},{"description":"Hearing loss dup/del analys","code_information":[{"code":"81431","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":509.68,"maximum":1311.57,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":679.57,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1009.49},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":849.46},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":849.46},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":849.46},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1311.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":509.68,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1189.25},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":679.57},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":693.16,"additional_payer_notes":"APC"}]}]},{"description":"Inherited cardmypthy 5 gns","code_information":[{"code":"81439","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":438.68,"maximum":1191.84,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":584.9,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1191.84},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":731.13},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":731.13},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":731.13},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1128.86,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":438.68,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1023.58},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":584.9},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":596.6,"additional_payer_notes":"APC"}]}]},{"description":"Targeted genomic seq analys","code_information":[{"code":"81450","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":569.65,"maximum":1465.89,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":759.53,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":963.18},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":949.41},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":949.41},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":949.41},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1465.89,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":569.65,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1329.18},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":759.53},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":774.72,"additional_payer_notes":"APC"}]}]},{"description":"So gsap cll fr dna/dna&rna","code_information":[{"code":"81462","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":896.87,"maximum":2307.95,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1195.83,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1722.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1494.79},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1494.79},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1494.79},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2307.95,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":896.87,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2092.7},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1195.83},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1219.75,"additional_payer_notes":"APC"}]}]},{"description":"Onco (ovar) two proteins","code_information":[{"code":"81500","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":195.38,"maximum":502.76,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":260.5,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":386.96},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":325.63},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":325.63},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":325.63},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":502.76,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":195.38,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":455.88},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":260.5},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":265.71,"additional_payer_notes":"APC"}]}]},{"description":"Ftl cgen abnor four anal","code_information":[{"code":"81511","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":115.12,"maximum":296.26,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":153.5,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":228.02},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":191.88},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":191.88},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":191.88},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":296.26,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":115.12,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":268.63},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":153.5},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":156.57,"additional_payer_notes":"APC"}]}]},{"description":"Onc breast mrna 58 genes","code_information":[{"code":"81520","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1882.66,"maximum":4844.71,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2510.21,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4603.5},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3137.76},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3137.76},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3137.76},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4844.71,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1882.66,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":4392.87},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2510.21},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2560.41,"additional_payer_notes":"APC"}]}]},{"description":"Oncology gynecologic","code_information":[{"code":"81536","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":133.17,"maximum":342.69,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":177.56,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":263.75},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":221.95},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":221.95},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":221.95},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":342.69,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":133.17,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":310.73},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":177.56},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":181.11,"additional_payer_notes":"APC"}]}]},{"description":"Onc uveal mlnma mrna 15 gene","code_information":[{"code":"81552","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5832.0,"maximum":15007.68,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7776.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":11551.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":9720.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":9720.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":9720.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":15007.68,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5832.0,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13608.0},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7776.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7931.52,"additional_payer_notes":"APC"}]}]},{"description":"Acetylcholinesterase assay","code_information":[{"code":"82013","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":9.22,"maximum":23.72,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.29,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":22.58},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15.36},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15.36},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15.36},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":23.72,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9.22,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21.51},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12.29},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.54,"additional_payer_notes":"APC"}]}]},{"description":"Sigmoidoscopy & polypectomy","code_information":[{"code":"45333","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":689.87,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":919.83,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1775.27,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":689.87,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":938.23,"additional_payer_notes":"APC"}]}]},{"description":"Sigmoidoscopy w/ablation","code_information":[{"code":"45346","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":887.71,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1183.61,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2284.37,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":887.71,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1207.28,"additional_payer_notes":"APC"}]}]},{"description":"Colonoscopy w/control bleed","code_information":[{"code":"45382","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":887.71,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1183.61,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2284.37,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":887.71,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1207.28,"additional_payer_notes":"APC"}]}]},{"description":"Colonoscopy w/endoscopic fnb","code_information":[{"code":"45392","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":887.71,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1183.61,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2284.37,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":887.71,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1207.28,"additional_payer_notes":"APC"}]}]},{"description":"Laparoscope proc rectum","code_information":[{"code":"45499","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4484.77,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5979.69,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":13249.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":10779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":13249.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11540.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4484.77,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6099.28,"additional_payer_notes":"APC"}]}]},{"description":"Exploration/repair of rectum","code_information":[{"code":"45562","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Dilation of rectal narrowing","code_information":[{"code":"45910","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":887.71,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1183.61,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2284.37,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":887.71,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1207.28,"additional_payer_notes":"APC"}]}]},{"description":"Incision of anal abscess","code_information":[{"code":"46050","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":689.87,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":919.83,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1775.27,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":689.87,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":938.23,"additional_payer_notes":"APC"}]}]},{"description":"Removal of anal tags","code_information":[{"code":"46230","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2059.07,"maximum":5298.68,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2745.43,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5298.68,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2059.07,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2800.34,"additional_payer_notes":"APC"}]}]},{"description":"Remove anal fist subq","code_information":[{"code":"46270","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2059.07,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2745.43,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5298.68,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2059.07,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2800.34,"additional_payer_notes":"APC"}]}]},{"description":"Diagnostic anoscopy spx","code_information":[{"code":"46600","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":98.7,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":131.6,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":253.99,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":98.7,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":134.23,"additional_payer_notes":"APC"}]}]},{"description":"Anoscopy remove lesions","code_information":[{"code":"46612","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2059.07,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2745.43,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5298.68,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2059.07,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2800.34,"additional_payer_notes":"APC"}]}]},{"description":"Repr per/vag pouch dbl proc","code_information":[{"code":"46712","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Repair of cloacal anomaly","code_information":[{"code":"46746","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Destruction anal lesion(s)","code_information":[{"code":"46900","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":301.57,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":402.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":776.03,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":301.57,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":410.13,"additional_payer_notes":"APC"}]}]},{"description":"Treatment of anal fissure","code_information":[{"code":"46942","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":689.87,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":919.83,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1775.27,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":689.87,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":938.23,"additional_payer_notes":"APC"}]}]},{"description":"Inject/aspirate liver cyst","code_information":[{"code":"47015","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3388.0,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0}]}]},{"description":"Partial removal donor liver","code_information":[{"code":"47140","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Surgery for liver lesion","code_information":[{"code":"47300","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Open ablate liver tumor rf","code_information":[{"code":"47380","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Incise bile duct sphincter","code_information":[{"code":"47460","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Exchange biliary drg cath","code_information":[{"code":"47536","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2656.06,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3541.41,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6834.92,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2656.06,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3612.24,"additional_payer_notes":"APC"}]}]},{"description":"Removal duct glbldr calculi","code_information":[{"code":"47544","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Laparo cholecystectomy/graph","code_information":[{"code":"47563","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4484.77,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5979.69,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5257.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11540.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4484.77,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6099.28,"additional_payer_notes":"APC"}]}]},{"description":"Removal of gallbladder","code_information":[{"code":"47620","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Fuse gallbladder & bowel","code_information":[{"code":"47740","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Suture bile duct injury","code_information":[{"code":"47900","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Removal of pancreas lesion","code_information":[{"code":"48120","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Pancreatectomy","code_information":[{"code":"48154","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Pancreatorrhaphy","code_information":[{"code":"48545","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Pancreas surgery procedure","code_information":[{"code":"48999","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":525.32,"maximum":13249.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":700.42,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":13249.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":10779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":13249.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1351.81,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":525.32,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":714.43,"additional_payer_notes":"APC"}]}]},{"description":"Abd paracentesis","code_information":[{"code":"49082","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":672.83,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":897.11,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1731.42,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":672.83,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":915.05,"additional_payer_notes":"APC"}]}]},{"description":"Diag laparo separate proc","code_information":[{"code":"49320","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4484.77,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5979.69,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5257.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11540.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4484.77,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6099.28,"additional_payer_notes":"APC"}]}]},{"description":"Laparo proc abdm/per/oment","code_information":[{"code":"49329","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4484.77,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5979.69,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5257.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11540.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4484.77,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6099.28,"additional_payer_notes":"APC"}]}]},{"description":"Insert tun ip cath perc","code_information":[{"code":"49418","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2656.06,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3541.41,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6834.92,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2656.06,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3612.24,"additional_payer_notes":"APC"}]}]},{"description":"Injection abdominal shunt","code_information":[{"code":"49427","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Microalbumin semiquant","code_information":[{"code":"82044","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4.67,"maximum":12.02,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6.23,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6.14},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7.79},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7.79},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7.79},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":12.02,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4.67,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10.9},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6.23},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6.35,"additional_payer_notes":"APC"}]}]},{"description":"Alpha-fetoprotein serum","code_information":[{"code":"82105","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":12.58,"maximum":33.95,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16.77,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":33.95},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20.96},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20.96},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20.96},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":32.37,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.58,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29.35},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16.77},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17.11,"additional_payer_notes":"APC"}]}]},{"description":"Assay aminolevulinic acid","code_information":[{"code":"82135","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":12.34,"maximum":33.3,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16.45,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":33.3},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20.56},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20.56},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20.56},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":31.75,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.34,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28.79},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16.45},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16.78,"additional_payer_notes":"APC"}]}]},{"description":"Assay of androsterone","code_information":[{"code":"82160","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":19.16,"maximum":50.59,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25.55,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":50.59},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":31.94},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":31.94},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":31.94},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":49.31,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19.16,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":44.71},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25.55},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26.06,"additional_payer_notes":"APC"}]}]},{"description":"Assay of beta-2 protein","code_information":[{"code":"82232","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":12.14,"maximum":32.74,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16.18,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":32.74},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20.23},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20.23},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20.23},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":31.23,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.14,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28.32},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16.18},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16.5,"additional_payer_notes":"APC"}]}]},{"description":"Assay of biotinidase","code_information":[{"code":"82261","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":12.65,"maximum":32.56,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16.87,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":29.16},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21.09},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21.09},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21.09},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":32.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.65,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29.52},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16.87},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17.21,"additional_payer_notes":"APC"}]}]},{"description":"Assay of calcitonin","code_information":[{"code":"82308","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":20.09,"maximum":54.22,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26.79,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":54.22},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":33.49},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":33.49},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":33.49},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":51.7,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20.09,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":46.88},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26.79},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27.33,"additional_payer_notes":"APC"}]}]},{"description":"X-ray assay calculus","code_information":[{"code":"82370","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":9.39,"maximum":25.34,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.52,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":25.34},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15.65},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15.65},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15.65},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":24.16,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9.39,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21.91},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12.52},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.77,"additional_payer_notes":"APC"}]}]},{"description":"Assay urine catecholamines","code_information":[{"code":"82382","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":20.48,"maximum":52.69,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27.3,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":34.8},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":34.13},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":34.13},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":34.13},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":52.69,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20.48,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":47.78},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27.3},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27.85,"additional_payer_notes":"APC"}]}]},{"description":"Assay of urine chloride","code_information":[{"code":"82436","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4.31,"maximum":11.1,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5.75,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":10.18},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7.19},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7.19},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7.19},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11.1,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4.31,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10.06},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5.75},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5.86,"additional_payer_notes":"APC"}]}]},{"description":"Assay of citrate","code_information":[{"code":"82507","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":20.85,"maximum":56.24,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27.8,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":56.24},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":34.75},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":34.75},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":34.75},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":53.65,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20.85,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":48.65},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27.8},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":28.36,"additional_payer_notes":"APC"}]}]},{"description":"Assay of ck (cpk)","code_information":[{"code":"82550","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4.88,"maximum":13.16,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6.51,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":13.16},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8.14},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8.14},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8.14},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":12.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4.88,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11.39},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6.51},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6.64,"additional_payer_notes":"APC"}]}]},{"description":"Assay of cryoglobulin","code_information":[{"code":"82595","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4.85,"maximum":13.08,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6.47,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":13.08},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8.09},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8.09},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8.09},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":12.49,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4.85,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11.32},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6.47},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6.6,"additional_payer_notes":"APC"}]}]},{"description":"Desoxycorticosterone","code_information":[{"code":"82633","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":23.24,"maximum":62.69,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":30.98,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":62.69},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":38.73},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":38.73},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":38.73},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":59.79,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23.24,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":54.22},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30.98},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":31.6,"additional_payer_notes":"APC"}]}]},{"description":"Enzyme cell activity ra","code_information":[{"code":"82658","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":33.02,"maximum":84.98,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":44.03,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":36.53},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":55.04},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":55.04},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":55.04},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":84.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":33.02,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":77.05},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":44.03},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":44.91,"additional_payer_notes":"APC"}]}]},{"description":"Assay dir meas fr estradiol","code_information":[{"code":"82681","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":20.96,"maximum":53.92,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27.94,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":41.51},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":34.93},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":34.93},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":34.93},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":53.92,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20.96,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":48.9},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27.94},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":28.5,"additional_payer_notes":"APC"}]}]},{"description":"Assay of ferritin","code_information":[{"code":"82728","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":10.22,"maximum":27.58,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.63,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":27.58},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17.04},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17.04},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17.04},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":26.31,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10.22,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23.85},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13.63},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.9,"additional_payer_notes":"APC"}]}]},{"description":"Assay galactose transferase","code_information":[{"code":"82775","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":15.8,"maximum":42.65,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21.07,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":42.65},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26.34},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26.34},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26.34},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":40.67,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15.8,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36.87},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21.07},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21.49,"additional_payer_notes":"APC"}]}]},{"description":"Blood gases w/o2 saturation","code_information":[{"code":"82805","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":57.42,"maximum":152.03,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":78.77,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":57.42},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":98.46},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":98.46},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":98.46},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":152.03,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":59.08,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":137.85},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":78.77},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":80.35,"additional_payer_notes":"APC"}]}]},{"description":"Glucagon tolerance test","code_information":[{"code":"82946","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":13.33,"maximum":34.3,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17.77,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":15.02},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22.21},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22.21},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22.21},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":34.3,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.33,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31.1},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17.77},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18.13,"additional_payer_notes":"APC"}]}]},{"description":"Glucose blood test","code_information":[{"code":"82962","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2.46,"maximum":6.33,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3.28,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4.74},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4.1},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4.1},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4.1},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6.33,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2.46,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5.74},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3.28},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3.35,"additional_payer_notes":"APC"}]}]},{"description":"Assay of gonadotropin (lh)","code_information":[{"code":"83002","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":13.89,"maximum":37.46,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18.52,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":37.46},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23.15},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23.15},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23.15},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":35.74,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.89,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32.41},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18.52},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18.89,"additional_payer_notes":"APC"}]}]},{"description":"Heavy metal qual any anal","code_information":[{"code":"83015","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":15.7,"maximum":40.41,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20.94,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":38.1},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26.18},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26.18},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26.18},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":40.41,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15.7,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36.65},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20.94},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21.36,"additional_payer_notes":"APC"}]}]},{"description":"Glycosylated hb home device","code_information":[{"code":"83037","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7.28,"maximum":19.64,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9.71,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":19.64},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12.14},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12.14},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12.14},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":18.74,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7.28,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16.99},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9.71},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9.9,"additional_payer_notes":"APC"}]}]},{"description":"Assay of hemosiderin qual","code_information":[{"code":"83070","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3.56,"maximum":9.62,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4.75,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":9.62},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5.94},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5.94},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5.94},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":9.17,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3.56,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8.31},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":4.75},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4.84,"additional_payer_notes":"APC"}]}]},{"description":"Assay free hydroxyproline","code_information":[{"code":"83500","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":16.99,"maximum":45.83,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22.65,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":45.83},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28.31},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28.31},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28.31},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":43.71,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16.99,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":39.64},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22.65},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23.1,"additional_payer_notes":"APC"}]}]},{"description":"Assay of insulin","code_information":[{"code":"83527","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":9.71,"maximum":26.21,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.95,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":26.21},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16.19},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16.19},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16.19},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":24.99,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9.71,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22.66},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12.95},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.21,"additional_payer_notes":"APC"}]}]},{"description":"Fractionation ketosteroids","code_information":[{"code":"83593","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":21.38,"maximum":55.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":28.5,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":53.21},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":35.63},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":35.63},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":35.63},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":55.0,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21.38,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":49.88},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28.5},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":29.07,"additional_payer_notes":"APC"}]}]},{"description":"Assay of lead","code_information":[{"code":"83655","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":9.08,"maximum":24.48,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.11,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":24.48},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15.14},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15.14},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15.14},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":23.37,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9.08,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21.19},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12.11},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.35,"additional_payer_notes":"APC"}]}]},{"description":"Assay Lipoprotein Pla2","code_information":[{"code":"83698","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":34.73,"maximum":89.38,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":46.31,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":68.69},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":57.89},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":57.89},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":57.89},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":89.38,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":34.73,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":81.04},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":46.31},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":47.24,"additional_payer_notes":"APC"}]}]},{"description":"Assay of lrh hormone","code_information":[{"code":"83727","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":12.89,"maximum":34.8,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":34.8},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21.49},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21.49},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21.49},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":33.18,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.89,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30.08},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17.19},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17.53,"additional_payer_notes":"APC"}]}]},{"description":"Microfluid analy tears","code_information":[{"code":"83861","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":16.86,"maximum":43.39,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22.48,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":33.43},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28.1},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28.1},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28.1},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":43.39,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16.86,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":39.34},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22.48},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22.93,"additional_payer_notes":"APC"}]}]},{"description":"Assay of urine osmolality","code_information":[{"code":"83935","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5.12,"maximum":13.8,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6.82,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":13.8},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8.53},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8.53},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8.53},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13.16,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5.12,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11.94},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6.82},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6.96,"additional_payer_notes":"APC"}]}]},{"description":"Assay for calprotectin fecal","code_information":[{"code":"83993","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":14.72,"maximum":39.72,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19.63,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":39.72},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24.54},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24.54},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24.54},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":37.89,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14.72,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34.35},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19.63},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20.02,"additional_payer_notes":"APC"}]}]},{"description":"Change g-tube to g-j perc","code_information":[{"code":"49446","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1423.51,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1898.01,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3663.16,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1423.51,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1935.97,"additional_payer_notes":"APC"}]}]},{"description":"Rpr ing hernia baby reduc","code_information":[{"code":"49495","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2656.06,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3541.41,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6834.92,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2656.06,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3612.24,"additional_payer_notes":"APC"}]}]},{"description":"Repair ing hernia sliding","code_information":[{"code":"49525","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2656.06,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3541.41,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6834.92,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2656.06,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3612.24,"additional_payer_notes":"APC"}]}]},{"description":"Repair umbilical lesion","code_information":[{"code":"49606","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Omental flap intra-abdom","code_information":[{"code":"49905","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Incision of kidney","code_information":[{"code":"50065","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Removal of kidney stone","code_information":[{"code":"50130","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Partial removal of kidney","code_information":[{"code":"50240","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Prep renal graft/venous","code_information":[{"code":"50327","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Change ureter stent percut","code_information":[{"code":"50382","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1550.71,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2067.62,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3990.5,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1550.71,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2108.97,"additional_payer_notes":"APC"}]}]},{"description":"Measure kidney pressure","code_information":[{"code":"50396","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":517.28,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":689.7,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1331.13,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":517.28,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":703.5,"additional_payer_notes":"APC"}]}]},{"description":"Exchange nephrostomy cath","code_information":[{"code":"50435","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1550.71,"maximum":4106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2067.62,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3990.5,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1550.71,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2108.97,"additional_payer_notes":"APC"}]}]},{"description":"Laparo partial nephrectomy","code_information":[{"code":"50543","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":20292.15,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10514.07,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":20292.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7885.55,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10724.35,"additional_payer_notes":"APC"}]}]},{"description":"Kidney endoscopy","code_information":[{"code":"50553","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3977.55,"maximum":10235.57,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5303.4,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":10235.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3977.55,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5409.47,"additional_payer_notes":"APC"}]}]},{"description":"Kidney endoscopy","code_information":[{"code":"50575","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3977.55,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5303.4,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":10235.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3977.55,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5409.47,"additional_payer_notes":"APC"}]}]},{"description":"Endoluminal bx urtr rnl plvs","code_information":[{"code":"50606","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Change of ureter tube/stent","code_information":[{"code":"50688","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1550.71,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2067.62,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3990.5,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1550.71,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2108.97,"additional_payer_notes":"APC"}]}]},{"description":"Release of ureter","code_information":[{"code":"50715","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Splicing of ureters","code_information":[{"code":"50770","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Construct bowel bladder","code_information":[{"code":"50820","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Closure ureter/bowel fistula","code_information":[{"code":"50930","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Ureter endoscopy & biopsy","code_information":[{"code":"50955","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3977.55,"maximum":10235.57,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5303.4,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":10235.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3977.55,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5409.47,"additional_payer_notes":"APC"}]}]},{"description":"Incise & treat bladder","code_information":[{"code":"51020","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2614.94,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3486.59,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6729.12,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2614.94,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3556.32,"additional_payer_notes":"APC"}]}]},{"description":"Drain bladder by trocar/cath","code_information":[{"code":"51101","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":637.04,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":849.39,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1639.32,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":637.04,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":866.38,"additional_payer_notes":"APC"}]}]},{"description":"Partial removal of bladder","code_information":[{"code":"51555","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Remove bladder/create pouch","code_information":[{"code":"51596","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Insert bladder cath complex","code_information":[{"code":"51703","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":95.45,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":127.27,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":245.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":95.45,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":129.82,"additional_payer_notes":"APC"}]}]},{"description":"Cystometrogram w/vp","code_information":[{"code":"51728","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":517.28,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":689.7,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1331.13,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":517.28,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":703.5,"additional_payer_notes":"APC"}]}]},{"description":"Us urine capacity measure","code_information":[{"code":"51798","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":43.76,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":58.35,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":112.62,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":43.76,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":59.52,"additional_payer_notes":"APC"}]}]},{"description":"Repair of bladder opening","code_information":[{"code":"51880","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2614.94,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3486.59,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6729.12,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2614.94,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3556.32,"additional_payer_notes":"APC"}]}]},{"description":"Laparo sling operation","code_information":[{"code":"51992","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4484.77,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5979.69,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5257.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11540.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4484.77,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6099.28,"additional_payer_notes":"APC"}]}]},{"description":"Cystoscopy and treatment","code_information":[{"code":"52214","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2614.94,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3486.59,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6729.12,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2614.94,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3556.32,"additional_payer_notes":"APC"}]}]},{"description":"Cystoscopy & revise urethra","code_information":[{"code":"52270","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1550.71,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2067.62,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3990.5,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1550.71,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2108.97,"additional_payer_notes":"APC"}]}]},{"description":"Cystoscopy chemodenervation","code_information":[{"code":"52287","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1550.71,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2067.62,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3990.5,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1550.71,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2108.97,"additional_payer_notes":"APC"}]}]},{"description":"Remove bladder stone","code_information":[{"code":"52318","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2614.94,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3486.59,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6729.12,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2614.94,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3556.32,"additional_payer_notes":"APC"}]}]},{"description":"Cysto W/Up Stricture Tx","code_information":[{"code":"52342","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2614.94,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3486.59,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6729.12,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2614.94,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3556.32,"additional_payer_notes":"APC"}]}]},{"description":"Assay phosphatidylglycerol","code_information":[{"code":"84081","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":12.39,"maximum":33.43,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16.52,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":33.43},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20.65},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20.65},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20.65},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":31.88,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.39,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28.91},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16.52},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16.85,"additional_payer_notes":"APC"}]}]},{"description":"Test urine for porphyrins","code_information":[{"code":"84119","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":10.02,"maximum":25.78,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":17.45},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16.7},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16.7},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16.7},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":25.78,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10.02,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23.38},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13.36},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.63,"additional_payer_notes":"APC"}]}]},{"description":"Assay of pregnenolone","code_information":[{"code":"84140","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":15.5,"maximum":41.84,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20.67,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":41.84},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25.84},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25.84},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25.84},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":39.89,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15.5,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36.17},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20.67},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21.08,"additional_payer_notes":"APC"}]}]},{"description":"Assay of psa free","code_information":[{"code":"84154","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":13.79,"maximum":37.22,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18.39,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":37.22},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22.99},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22.99},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22.99},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":35.49,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.79,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32.18},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18.39},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18.76,"additional_payer_notes":"APC"}]}]},{"description":"Western blot test","code_information":[{"code":"84181","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":12.77,"maximum":34.46,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17.03,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":34.46},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21.29},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21.29},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21.29},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":32.87,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.77,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29.8},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17.03},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17.37,"additional_payer_notes":"APC"}]}]},{"description":"Assay of quinine","code_information":[{"code":"84228","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8.72,"maximum":23.53,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11.63,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":23.53},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14.54},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14.54},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14.54},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":22.45,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8.72,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20.35},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11.63},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11.86,"additional_payer_notes":"APC"}]}]},{"description":"Assay of serotonin","code_information":[{"code":"84260","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":23.24,"maximum":62.69,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":30.98,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":62.69},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":38.73},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":38.73},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":38.73},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":59.79,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23.24,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":54.22},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30.98},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":31.6,"additional_payer_notes":"APC"}]}]},{"description":"Assay of somatostatin","code_information":[{"code":"84307","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":13.71,"maximum":35.28,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18.28,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":17.96},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22.85},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22.85},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22.85},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":35.28,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.71,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31.99},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18.28},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18.65,"additional_payer_notes":"APC"}]}]},{"description":"Assay of urine sulfate","code_information":[{"code":"84392","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4.12,"maximum":10.6,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5.49,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":9.62},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":6.86},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":6.86},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":6.86},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":10.6,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4.12,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9.61},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5.49},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5.6,"additional_payer_notes":"APC"}]}]},{"description":"Thromboxane urine","code_information":[{"code":"84431","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":26.33,"maximum":67.76,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":35.11,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":34.01},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43.89},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43.89},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43.89},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":67.76,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26.33,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":61.44},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35.11},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":35.81,"additional_payer_notes":"APC"}]}]},{"description":"Assay of tsi globulin","code_information":[{"code":"84445","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":38.14,"maximum":98.16,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":50.86,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":47.08},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":63.58},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":63.58},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":63.58},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":98.16,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":38.14,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":89.01},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":50.86},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":51.88,"additional_payer_notes":"APC"}]}]},{"description":"Assay triiodothyronine (t3)","code_information":[{"code":"84480","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":10.64,"maximum":28.68,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14.18,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":28.68},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17.73},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17.73},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17.73},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":27.37,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10.64,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24.82},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14.18},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14.46,"additional_payer_notes":"APC"}]}]},{"description":"Assay of troponin qual","code_information":[{"code":"84512","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7.57,"maximum":19.47,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":15.58},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12.61},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12.61},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12.61},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":19.47,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7.57,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17.66},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10.09},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10.29,"additional_payer_notes":"APC"}]}]},{"description":"Test urine urobilinogen","code_information":[{"code":"84578","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3.35,"maximum":8.63,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4.47,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6.58},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5.59},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5.59},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5.59},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":8.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3.35,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7.82},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":4.47},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4.56,"additional_payer_notes":"APC"}]}]},{"description":"Assay of vitamin k","code_information":[{"code":"84597","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":10.29,"maximum":27.77,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.72,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":27.77},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17.15},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17.15},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17.15},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":26.48,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10.29,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24.01},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13.72},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.99,"additional_payer_notes":"APC"}]}]},{"description":"Ovulation tests","code_information":[{"code":"84830","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":9.52,"maximum":24.51,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.7,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":20.29},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15.88},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15.88},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15.88},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":24.51,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9.52,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22.23},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12.7},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.95,"additional_payer_notes":"APC"}]}]},{"description":"Hemoglobin","code_information":[{"code":"85018","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1.78,"maximum":4.79,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4.79},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2.96},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2.96},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2.96},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1.78,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":4.15},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2.37},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2.42,"additional_payer_notes":"APC"}]}]},{"description":"Automated leukocyte count","code_information":[{"code":"85048","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1.9,"maximum":5.14,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2.54,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5.14},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3.18},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3.18},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3.18},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4.9,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1.9,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":4.45},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2.54},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2.59,"additional_payer_notes":"APC"}]}]},{"description":"Clot factor vii proconvertin","code_information":[{"code":"85230","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":13.42,"maximum":36.23,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17.9,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":36.23},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22.38},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22.38},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22.38},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":34.55,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.42,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31.33},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17.9},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18.26,"additional_payer_notes":"APC"}]}]},{"description":"Clot factor xi pta","code_information":[{"code":"85270","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":13.42,"maximum":36.23,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17.9,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":36.23},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22.38},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22.38},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22.38},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":34.55,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.42,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31.33},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17.9},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18.26,"additional_payer_notes":"APC"}]}]},{"description":"Clot inhibit prot c antigen","code_information":[{"code":"85302","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":9.01,"maximum":24.31,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.01,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":24.31},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15.01},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15.01},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15.01},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":23.18,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9.01,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21.02},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12.01},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.25,"additional_payer_notes":"APC"}]}]},{"description":"Coagulation time activated","code_information":[{"code":"85347","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3.21,"maximum":8.62,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4.28,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":8.62},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5.35},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5.35},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5.35},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":8.26,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3.21,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7.49},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":4.28},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4.37,"additional_payer_notes":"APC"}]}]},{"description":"Fibrin degradj d-dimer","code_information":[{"code":"85380","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7.64,"maximum":19.65,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10.18,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":16.4},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12.73},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12.73},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12.73},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":19.65,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7.64,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17.82},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10.18},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10.38,"additional_payer_notes":"APC"}]}]},{"description":"Fibrinolytic plasminogen","code_information":[{"code":"85420","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4.9,"maximum":13.21,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6.53,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":13.21},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8.16},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8.16},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8.16},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":12.6,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4.9,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11.43},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6.53},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6.66,"additional_payer_notes":"APC"}]}]},{"description":"Heparin neutralization","code_information":[{"code":"85525","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8.88,"maximum":23.96,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11.84,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":23.96},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14.8},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14.8},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14.8},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":22.85,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8.88,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20.72},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11.84},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.08,"additional_payer_notes":"APC"}]}]},{"description":"Blood platelet aggregation","code_information":[{"code":"85576","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":18.68,"maximum":48.08,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":24.91,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":43.48},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":31.14},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":31.14},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":31.14},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":48.08,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18.68,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":43.59},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24.91},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25.41,"additional_payer_notes":"APC"}]}]},{"description":"Rbc sed rate nonautomated","code_information":[{"code":"85651","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3.2,"maximum":8.24,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4.27,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7.16},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5.34},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5.34},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5.34},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":8.24,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3.2,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7.47},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":4.27},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4.36,"additional_payer_notes":"APC"}]}]},{"description":"Blood viscosity examination","code_information":[{"code":"85810","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8.75,"maximum":23.63,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11.67,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":23.63},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14.59},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14.59},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14.59},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":22.52,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8.75,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20.42},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11.67},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11.9,"additional_payer_notes":"APC"}]}]},{"description":"Platelet antibodies","code_information":[{"code":"86022","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":13.78,"maximum":37.16,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":37.16},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22.96},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22.96},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22.96},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":35.45,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.78,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32.15},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18.37},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18.74,"additional_payer_notes":"APC"}]}]},{"description":"Acetylcholn rcptr modlg antb","code_information":[{"code":"86043","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":9.04,"maximum":23.26,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.05,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":18.05},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15.06},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15.06},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15.06},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":23.26,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9.04,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21.09},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12.05},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.29,"additional_payer_notes":"APC"}]}]},{"description":"Beta-2 glycoprotein antibody","code_information":[{"code":"86146","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":11.77,"maximum":49.12,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25.45,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":11.77},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":31.81},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":31.81},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":31.81},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":49.12,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19.09,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":44.54},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25.45},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25.96,"additional_payer_notes":"APC"}]}]},{"description":"Complement/function activity","code_information":[{"code":"86161","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":9.0,"maximum":24.29,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":24.29},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":23.16,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9.0,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21.0},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.24,"additional_payer_notes":"APC"}]}]},{"description":"Nuclear antigen antibody","code_information":[{"code":"86235","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":13.45,"maximum":36.3,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17.93,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":36.3},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22.41},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22.41},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22.41},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":34.6,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.45,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31.38},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17.93},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18.29,"additional_payer_notes":"APC"}]}]},{"description":"Immunoassay tumor ca 19-9","code_information":[{"code":"86301","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":15.61,"maximum":42.11,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20.81,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":42.11},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26.01},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26.01},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26.01},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":40.16,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15.61,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36.42},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20.81},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21.23,"additional_payer_notes":"APC"}]}]},{"description":"Immunoassay infectious agent","code_information":[{"code":"86318","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":13.57,"maximum":34.91,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":26.2},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22.61},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22.61},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22.61},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":34.91,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.57,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31.66},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18.09},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18.45,"additional_payer_notes":"APC"}]}]},{"description":"Cystouretero W/Biopsy","code_information":[{"code":"52354","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3977.55,"maximum":10235.57,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5303.4,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":10235.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3977.55,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5409.47,"additional_payer_notes":"APC"}]}]},{"description":"Revision of bladder neck","code_information":[{"code":"52500","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2614.94,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3486.59,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6729.12,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2614.94,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3556.32,"additional_payer_notes":"APC"}]}]},{"description":"Incision of urethra","code_information":[{"code":"53000","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1550.71,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2067.62,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3990.5,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1550.71,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2108.97,"additional_payer_notes":"APC"}]}]},{"description":"Biopsy of urethra","code_information":[{"code":"53200","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1550.71,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2067.62,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3990.5,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1550.71,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2108.97,"additional_payer_notes":"APC"}]}]},{"description":"Treatment of urethra lesion","code_information":[{"code":"53260","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2614.94,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3486.59,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6729.12,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2614.94,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3556.32,"additional_payer_notes":"APC"}]}]},{"description":"Reconstruct urethra stage 1","code_information":[{"code":"53420","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3977.55,"maximum":10235.57,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5303.4,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":10235.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3977.55,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5409.47,"additional_payer_notes":"APC"}]}]},{"description":"Remove uro sphincter","code_information":[{"code":"53446","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3977.55,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5303.4,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":10235.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3977.55,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5409.47,"additional_payer_notes":"APC"}]}]},{"description":"Repair of urethra injury","code_information":[{"code":"53505","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3977.55,"maximum":10235.57,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5303.4,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":10235.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3977.55,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5409.47,"additional_payer_notes":"APC"}]}]},{"description":"Dilate urethra stricture","code_information":[{"code":"53621","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":185.35,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":247.13,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":476.96,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":185.35,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":252.07,"additional_payer_notes":"APC"}]}]},{"description":"Urology surgery procedure","code_information":[{"code":"53899","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":185.35,"maximum":13249.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":247.13,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":13249.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":10779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":13249.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":476.96,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":185.35,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":252.07,"additional_payer_notes":"APC"}]}]},{"description":"Excision of penis lesion(s)","code_information":[{"code":"54060","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1530.61,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2040.81,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3938.76,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1530.61,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2081.63,"additional_payer_notes":"APC"}]}]},{"description":"Partial removal of penis","code_information":[{"code":"54120","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2614.94,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3486.59,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6729.12,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2614.94,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3556.32,"additional_payer_notes":"APC"}]}]},{"description":"Repair of circumcision","code_information":[{"code":"54163","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1550.71,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2067.62,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3990.5,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1550.71,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2108.97,"additional_payer_notes":"APC"}]}]},{"description":"Penis study","code_information":[{"code":"54240","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":160.18,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":213.57,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":412.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":160.18,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":217.84,"additional_payer_notes":"APC"}]}]},{"description":"Reconstruction of urethra","code_information":[{"code":"54322","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2614.94,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3486.59,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6729.12,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2614.94,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3556.32,"additional_payer_notes":"APC"}]}]},{"description":"Secondary urethral surgery","code_information":[{"code":"54348","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3977.55,"maximum":10235.57,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5303.4,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":10235.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3977.55,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5409.47,"additional_payer_notes":"APC"}]}]},{"description":"Insert multi-comp penis pros","code_information":[{"code":"54405","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8923.0,"maximum":43643.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20500.4,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":10765.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":8923.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":10765.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43643.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43643.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43643.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":39565.78,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15375.3,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":41120.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20910.41,"additional_payer_notes":"APC"}]}]},{"description":"Revision of penis","code_information":[{"code":"54420","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2614.94,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3486.59,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6729.12,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2614.94,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3556.32,"additional_payer_notes":"APC"}]}]},{"description":"Excise Lesion Testis","code_information":[{"code":"54512","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2614.94,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3486.59,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6729.12,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2614.94,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3556.32,"additional_payer_notes":"APC"}]}]},{"description":"Suspension of testis","code_information":[{"code":"54620","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2614.94,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3486.59,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6729.12,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2614.94,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3556.32,"additional_payer_notes":"APC"}]}]},{"description":"Laparoscope proc testis","code_information":[{"code":"54699","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4484.77,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5979.69,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":13249.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":10779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":13249.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11540.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4484.77,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6099.28,"additional_payer_notes":"APC"}]}]},{"description":"Fusion of spermatic ducts","code_information":[{"code":"54900","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1550.71,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2067.62,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3990.5,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1550.71,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2108.97,"additional_payer_notes":"APC"}]}]},{"description":"Removal of scrotum lesion","code_information":[{"code":"55120","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1550.71,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2067.62,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3990.5,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1550.71,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2108.97,"additional_payer_notes":"APC"}]}]},{"description":"Removal of hydrocele","code_information":[{"code":"55500","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2614.94,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3486.59,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6729.12,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2614.94,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3556.32,"additional_payer_notes":"APC"}]}]},{"description":"Incise sperm duct pouch","code_information":[{"code":"55605","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2959.0,"maximum":4106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0}]}]},{"description":"Removal of prostate","code_information":[{"code":"55801","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Extensive prostate surgery","code_information":[{"code":"55845","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Place rt device/marker pros","code_information":[{"code":"55876","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1026.79,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1369.06,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2642.28,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1026.79,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1396.44,"additional_payer_notes":"APC"}]}]},{"description":"Lysis of labial lesion(s)","code_information":[{"code":"56441","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2401.4,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3201.87,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6179.61,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2401.4,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3265.91,"additional_payer_notes":"APC"}]}]},{"description":"Extensive vulva surgery","code_information":[{"code":"56630","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3710.98,"maximum":9549.58,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4947.97,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":9549.58,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3710.98,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5046.93,"additional_payer_notes":"APC"}]}]},{"description":"Remove vagina gland lesion","code_information":[{"code":"56740","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2401.4,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3201.87,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6179.61,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2401.4,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3265.91,"additional_payer_notes":"APC"}]}]},{"description":"Drainage of pelvic fluid","code_information":[{"code":"57020","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3388.0,"maximum":9549.58,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4947.97,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":9549.58,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3710.98,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5046.93,"additional_payer_notes":"APC"}]}]},{"description":"Remove vagina tissue part","code_information":[{"code":"57107","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2401.4,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3201.87,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6179.61,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2401.4,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3265.91,"additional_payer_notes":"APC"}]}]},{"description":"Insert uteri tandem/ovoids","code_information":[{"code":"57155","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2959.0,"maximum":9549.58,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4947.97,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":9549.58,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3710.98,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5046.93,"additional_payer_notes":"APC"}]}]},{"description":"Repair of urethral lesion","code_information":[{"code":"57230","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2401.4,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3201.87,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6179.61,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2401.4,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3265.91,"additional_payer_notes":"APC"}]}]},{"description":"Suspension of vagina","code_information":[{"code":"57280","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0}]}]},{"description":"Immunofix e-phoresis serum","code_information":[{"code":"86334","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":16.76,"maximum":45.23,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22.34,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":45.23},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27.93},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27.93},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27.93},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":43.12,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16.76,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":39.1},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22.34},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22.79,"additional_payer_notes":"APC"}]}]},{"description":"Cell function assay w/stim","code_information":[{"code":"86352","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":101.9,"maximum":274.91,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":135.86,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":274.91},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":169.83},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":169.83},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":169.83},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":262.21,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":101.9,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":237.76},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":135.86},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":138.58,"additional_payer_notes":"APC"}]}]},{"description":"Mog-igg1 antb cba each","code_information":[{"code":"86362","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":9.04,"maximum":23.26,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.05,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":17.89},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15.06},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15.06},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15.06},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":23.26,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9.04,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21.09},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12.05},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.29,"additional_payer_notes":"APC"}]}]},{"description":"Nitroblue tetrazolium dye","code_information":[{"code":"86384","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":10.21,"maximum":26.27,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.61,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":23.04},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17.01},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17.01},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17.01},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":26.27,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10.21,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23.82},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13.61},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.88,"additional_payer_notes":"APC"}]}]},{"description":"Rheumatoid factor quant","code_information":[{"code":"86431","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4.25,"maximum":11.48,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5.67,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":11.48},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7.09},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7.09},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7.09},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":10.94,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4.25,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9.92},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5.67},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5.78,"additional_payer_notes":"APC"}]}]},{"description":"Antinomyces antibody","code_information":[{"code":"86602","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7.64,"maximum":19.65,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10.18,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":11.77},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12.73},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12.73},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12.73},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":19.65,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7.64,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17.82},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10.18},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10.38,"additional_payer_notes":"APC"}]}]},{"description":"Lyme disease antibody","code_information":[{"code":"86618","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":12.77,"maximum":34.46,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17.03,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":34.46},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21.29},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21.29},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21.29},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":32.87,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.77,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29.8},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17.03},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17.37,"additional_payer_notes":"APC"}]}]},{"description":"Q fever antibody","code_information":[{"code":"86638","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":9.09,"maximum":23.39,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.12,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":11.77},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15.15},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15.15},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15.15},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":23.39,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9.09,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21.21},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12.12},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.36,"additional_payer_notes":"APC"}]}]},{"description":"Encephaltis west eqne antbdy","code_information":[{"code":"86654","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":9.89,"maximum":25.46,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":11.77},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16.49},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16.49},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16.49},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":25.46,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9.89,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23.08},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13.19},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.45,"additional_payer_notes":"APC"}]}]},{"description":"Giardia lamblia antibody","code_information":[{"code":"86674","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":11.04,"maximum":29.78,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14.72,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":29.78},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18.4},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18.4},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18.4},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":28.41,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11.04,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25.76},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14.72},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15.01,"additional_payer_notes":"APC"}]}]},{"description":"Herpes simplex nes antbdy","code_information":[{"code":"86694","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":10.79,"maximum":29.12,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14.39,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":29.12},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17.99},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17.99},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17.99},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":27.77,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10.79,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25.18},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14.39},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14.68,"additional_payer_notes":"APC"}]}]},{"description":"Hep b core antibody igm","code_information":[{"code":"86705","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8.83,"maximum":23.82,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11.77,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":23.82},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14.71},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14.71},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14.71},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":22.72,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8.83,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20.6},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11.77},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.01,"additional_payer_notes":"APC"}]}]},{"description":"Leishmania antibody","code_information":[{"code":"86717","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":9.19,"maximum":23.64,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.25,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":11.77},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15.31},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15.31},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15.31},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":23.64,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9.19,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21.44},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12.25},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.5,"additional_payer_notes":"APC"}]}]},{"description":"Nocardia antibody","code_information":[{"code":"86744","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":11.77,"maximum":30.86,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15.99,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":11.77},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19.99},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19.99},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19.99},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":30.86,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11.99,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27.98},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15.99},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16.31,"additional_payer_notes":"APC"}]}]},{"description":"Rubeola antibody","code_information":[{"code":"86765","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":9.66,"maximum":26.06,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.88,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":26.06},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16.1},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16.1},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16.1},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":24.86,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9.66,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22.54},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12.88},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.14,"additional_payer_notes":"APC"}]}]},{"description":"Trichinella antibody","code_information":[{"code":"86784","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":9.42,"maximum":24.24,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.56,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":11.77},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15.7},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15.7},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15.7},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":24.24,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9.42,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21.98},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12.56},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.81,"additional_payer_notes":"APC"}]}]},{"description":"Hepatitis c ab test","code_information":[{"code":"86803","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":10.7,"maximum":28.88,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14.27,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":28.88},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17.84},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17.84},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17.84},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":27.54,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10.7,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24.97},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14.27},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14.56,"additional_payer_notes":"APC"}]}]},{"description":"Hla typing dr/dq","code_information":[{"code":"86816","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":22.63,"maximum":58.23,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":30.17,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":56.38},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":37.71},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":37.71},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":37.71},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":58.23,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22.63,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":52.8},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30.17},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":30.77,"additional_payer_notes":"APC"}]}]},{"description":"Hla class ii phenotype qual","code_information":[{"code":"86831","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":61.41,"maximum":158.03,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":81.88,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":140.03},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":102.35},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":102.35},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":102.35},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":158.03,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":61.41,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":143.29},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":81.88},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":83.52,"additional_payer_notes":"APC"}]}]},{"description":"Coombs test indirect titer","code_information":[{"code":"86886","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5.18,"maximum":325.23,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":168.51,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":10.48},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":6.48},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":6.48},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":6.48},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":325.23,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":126.39,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9.07},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5.18},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":171.88,"additional_payer_notes":"APC"}]}]},{"description":"Hemolysins/agglutinins","code_information":[{"code":"86941","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":9.08,"maximum":24.48,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.11,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":24.48},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15.14},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15.14},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15.14},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":23.37,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9.08,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21.19},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12.11},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.35,"additional_payer_notes":"APC"}]}]},{"description":"Culture Bacteria Anaerobic","code_information":[{"code":"87073","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7.24,"maximum":19.09,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9.66,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":19.09},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12.08},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12.08},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12.08},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":18.64,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7.24,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16.91},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9.66},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9.85,"additional_payer_notes":"APC"}]}]},{"description":"Skin fungi culture","code_information":[{"code":"87101","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5.78,"maximum":15.6,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7.71,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":15.6},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":9.64},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":9.64},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":9.64},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":14.88,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5.78,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13.49},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7.71},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7.86,"additional_payer_notes":"APC"}]}]},{"description":"Mycobacteric identification","code_information":[{"code":"87118","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":10.96,"maximum":28.2,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14.61,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":22.16},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18.26},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18.26},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18.26},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":28.2,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10.96,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25.57},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14.61},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14.9,"additional_payer_notes":"APC"}]}]},{"description":"Cul typ id bld pthgn 6+ trgt","code_information":[{"code":"87154","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":163.54,"maximum":420.86,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":218.06,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":323.92},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":272.58},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":272.58},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":272.58},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":420.86,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":163.54,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":381.61},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":218.06},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":222.42,"additional_payer_notes":"APC"}]}]},{"description":"Ova and parasites smears","code_information":[{"code":"87177","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6.68,"maximum":18.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8.9,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":18.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11.13},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11.13},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11.13},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":17.18,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6.68,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15.58},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8.9},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9.08,"additional_payer_notes":"APC"}]}]},{"description":"Bactericidal level serum","code_information":[{"code":"87197","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":11.26,"maximum":30.41,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15.02,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":30.41},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18.78},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18.78},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18.78},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":28.99,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11.26,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26.29},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15.02},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15.32,"additional_payer_notes":"APC"}]}]},{"description":"Virus inoculate eggs/animal","code_information":[{"code":"87250","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":14.67,"maximum":39.59,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19.56,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":39.59},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24.45},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24.45},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24.45},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":37.75,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14.67,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34.23},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19.56},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19.95,"additional_payer_notes":"APC"}]}]},{"description":"Giardia ag if","code_information":[{"code":"87269","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":10.21,"maximum":26.27,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.61,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":24.26},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17.01},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17.01},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17.01},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":26.27,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10.21,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23.82},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13.61},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.88,"additional_payer_notes":"APC"}]}]},{"description":"Legion pneumophilia ag if","code_information":[{"code":"87278","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":11.7,"maximum":30.11,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15.6,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":24.26},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19.5},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19.5},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19.5},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":30.11,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11.7,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27.3},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15.6},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15.91,"additional_payer_notes":"APC"}]}]},{"description":"Ag detection polyval if","code_information":[{"code":"87300","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8.98,"maximum":24.26,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11.98,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":24.26},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14.98},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14.98},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14.98},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":23.12,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8.98,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20.97},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11.98},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.22,"additional_payer_notes":"APC"}]}]},{"description":"Cytomegalovirus ag ia","code_information":[{"code":"87332","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8.98,"maximum":24.26,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11.98,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":24.26},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14.98},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14.98},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14.98},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":23.12,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8.98,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20.97},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11.98},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.22,"additional_payer_notes":"APC"}]}]},{"description":"Hepatitis be ag ia","code_information":[{"code":"87350","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8.65,"maximum":23.33,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11.53,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":23.33},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14.41},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14.41},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14.41},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":22.25,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8.65,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20.18},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11.53},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11.76,"additional_payer_notes":"APC"}]}]},{"description":"Rotavirus ag ia","code_information":[{"code":"87425","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8.98,"maximum":24.26,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11.98,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":24.26},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14.98},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14.98},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14.98},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":23.12,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8.98,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20.97},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11.98},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.22,"additional_payer_notes":"APC"}]}]},{"description":"Anaplsma phgcytophlm amp prb","code_information":[{"code":"87468","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":26.32,"maximum":67.72,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":35.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":51.96},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43.86},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43.86},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43.86},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":67.72,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26.32,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":61.41},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35.09},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":35.79,"additional_payer_notes":"APC"}]}]},{"description":"Construction of vagina","code_information":[{"code":"57291","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3388.0,"maximum":9549.58,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4947.97,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":9549.58,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3710.98,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5046.93,"additional_payer_notes":"APC"}]}]},{"description":"Repair urethrovaginal lesion","code_information":[{"code":"57310","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5501.01,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7334.68,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":14155.93,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5501.01,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7481.37,"additional_payer_notes":"APC"}]}]},{"description":"Exam of vagina w/scope","code_information":[{"code":"57420","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":226.06,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":301.41,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":581.72,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":226.06,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":307.44,"additional_payer_notes":"APC"}]}]},{"description":"Endocerv curettage w/scope","code_information":[{"code":"57456","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":226.06,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":301.41,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":581.72,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":226.06,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":307.44,"additional_payer_notes":"APC"}]}]},{"description":"Conization of cervix","code_information":[{"code":"57520","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2401.4,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3201.87,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6179.61,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2401.4,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3265.91,"additional_payer_notes":"APC"}]}]},{"description":"Remove cervix repair bowel","code_information":[{"code":"57556","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3710.98,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4947.97,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":9549.58,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3710.98,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5046.93,"additional_payer_notes":"APC"}]}]},{"description":"Myomectomy abdom method","code_information":[{"code":"58140","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0}]}]},{"description":"Removal of pelvis contents","code_information":[{"code":"58240","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Extensive hysterectomy","code_information":[{"code":"58285","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5257.0,"maximum":6462.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5257.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6462.0}]}]},{"description":"Artificial insemination","code_information":[{"code":"58322","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":149.98,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":199.97,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":385.94,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":149.98,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":203.97,"additional_payer_notes":"APC"}]}]},{"description":"Suspension of uterus","code_information":[{"code":"58400","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0}]}]},{"description":"Laparoscopic myomectomy","code_information":[{"code":"58545","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4484.77,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5979.69,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5257.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11540.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4484.77,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6099.28,"additional_payer_notes":"APC"}]}]},{"description":"Hysteroscopy biopsy","code_information":[{"code":"58558","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2401.4,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3201.87,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6179.61,"additional_payer_notes":"APC"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3824.0},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2401.4,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3265.91,"additional_payer_notes":"APC"}]}]},{"description":"Tlh w/t/o 250 g or less","code_information":[{"code":"58571","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":20292.15,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10514.07,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":20292.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7885.55,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10724.35,"additional_payer_notes":"APC"}]}]},{"description":"Occlude fallopian tube(s)","code_information":[{"code":"58615","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2401.4,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3201.87,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6179.61,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2401.4,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3265.91,"additional_payer_notes":"APC"}]}]},{"description":"Laparo proc oviduct-ovary","code_information":[{"code":"58679","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4484.77,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5979.69,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5257.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11540.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4484.77,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6099.28,"additional_payer_notes":"APC"}]}]},{"description":"Drainage of ovarian cyst(s)","code_information":[{"code":"58800","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2401.4,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3201.87,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6179.61,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2401.4,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3265.91,"additional_payer_notes":"APC"}]}]},{"description":"Removal of ovary(s)","code_information":[{"code":"58940","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0}]}]},{"description":"Resect Recur Gyn Mal w/Lym","code_information":[{"code":"58958","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Fetal cord puncture prenatal","code_information":[{"code":"59012","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":226.06,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":301.41,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":581.72,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":226.06,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":307.44,"additional_payer_notes":"APC"}]}]},{"description":"Umbilical cord occlud w/us","code_information":[{"code":"59072","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":226.06,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":301.41,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":581.72,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":226.06,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":307.44,"additional_payer_notes":"APC"}]}]},{"description":"Treat ectopic pregnancy","code_information":[{"code":"59140","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Repair of uterus","code_information":[{"code":"59350","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Care after delivery","code_information":[{"code":"59430","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5512.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0}]}]},{"description":"Attempted vbac delivery","code_information":[{"code":"59618","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Abortion","code_information":[{"code":"59841","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2401.4,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3201.87,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6179.61,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2401.4,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3265.91,"additional_payer_notes":"APC"}]}]},{"description":"Evacuate mole of uterus","code_information":[{"code":"59870","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2401.4,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3201.87,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6179.61,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2401.4,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3265.91,"additional_payer_notes":"APC"}]}]},{"description":"Partial thyroid excision","code_information":[{"code":"60210","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4484.77,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5979.69,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5257.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11540.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4484.77,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6099.28,"additional_payer_notes":"APC"}]}]},{"description":"Removal of thyroid","code_information":[{"code":"60270","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3579.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0}]}]},{"description":"Autotransplant parathyroid","code_information":[{"code":"60512","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Laparoscopy adrenalectomy","code_information":[{"code":"60650","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5257.0,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5257.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0}]}]},{"description":"Injection into brain canal","code_information":[{"code":"61055","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":227.71,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":303.61,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":585.96,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":227.71,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":309.68,"additional_payer_notes":"APC"}]}]},{"description":"Pierce skull for drainage","code_information":[{"code":"61151","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3388.0,"maximum":4106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0}]}]},{"description":"Open skull for exploration","code_information":[{"code":"61305","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6779.0,"maximum":8333.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0}]}]},{"description":"Decompressive craniotomy","code_information":[{"code":"61322","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6779.0,"maximum":8333.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0}]}]},{"description":"Incise skull for brain wound","code_information":[{"code":"61458","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6779.0,"maximum":8333.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0}]}]},{"description":"Breast reconstruction","code_information":[{"code":"19350","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2904.59,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3872.79,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7474.49,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2904.59,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3950.25,"additional_payer_notes":"APC"}]}]},{"description":"Mast mod rad","code_information":[{"code":"19307","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4925.89,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6567.85,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":7398.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6019.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":7398.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":12675.95,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4925.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6699.21,"additional_payer_notes":"APC"}]}]},{"description":"Place breast cath for rad","code_information":[{"code":"19297","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5512.0,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0}]}]},{"description":"Perq device breast ea imag","code_information":[{"code":"19282","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Biopsy of breast open","code_information":[{"code":"19101","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2904.59,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3872.79,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7474.49,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2904.59,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3950.25,"additional_payer_notes":"APC"}]}]},{"description":"Injection for breast x-ray","code_information":[{"code":"19030","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Mohs surg addl block","code_information":[{"code":"17315","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Destruction of skin lesions","code_information":[{"code":"17282","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":148.84,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":198.45,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":383.01,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":148.84,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":202.42,"additional_payer_notes":"APC"}]}]},{"description":"Destruction of skin lesions","code_information":[{"code":"17270","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":148.84,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":198.45,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":383.01,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":148.84,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":202.42,"additional_payer_notes":"APC"}]}]},{"description":"Destruct lesion 15 or more","code_information":[{"code":"17111","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":148.84,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":198.45,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":383.01,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":148.84,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":202.42,"additional_payer_notes":"APC"}]}]},{"description":"Prepare face/oral prosthesis","code_information":[{"code":"21083","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2459.51,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3279.35,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6329.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2459.51,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3344.94,"additional_payer_notes":"APC"}]}]},{"description":"Interdental fixation","code_information":[{"code":"21110","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1151.01,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1534.69,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2961.94,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1151.01,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1565.38,"additional_payer_notes":"APC"}]}]},{"description":"Reduction of forehead","code_information":[{"code":"21137","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2459.51,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3279.35,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6329.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2459.51,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3344.94,"additional_payer_notes":"APC"}]}]},{"description":"Lefort i-3/> piece w/ graft","code_information":[{"code":"21147","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Reconstruct orbit/forehead","code_information":[{"code":"21175","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Reconst lwr jaw w/o graft","code_information":[{"code":"21193","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Reduction of facial bones","code_information":[{"code":"21209","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Reconstruction of lower jaw","code_information":[{"code":"21244","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Revise eye sockets","code_information":[{"code":"21260","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Revision of eyelid","code_information":[{"code":"21282","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2459.51,"maximum":6329.15,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3279.35,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6329.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2459.51,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3344.94,"additional_payer_notes":"APC"}]}]},{"description":"Open tx nose & septal fx","code_information":[{"code":"21335","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2459.51,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3279.35,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6329.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2459.51,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3344.94,"additional_payer_notes":"APC"}]}]},{"description":"Closed tx nose/jaw fx","code_information":[{"code":"21345","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1151.01,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1534.69,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2961.94,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1151.01,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1565.38,"additional_payer_notes":"APC"}]}]},{"description":"Opn tx complx malar w/grft","code_information":[{"code":"21366","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Opn tx orbit fx w/o implant","code_information":[{"code":"21406","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Treat craniofacial fracture","code_information":[{"code":"21433","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Treat lower jaw fracture","code_information":[{"code":"21453","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Repair dislocated jaw","code_information":[{"code":"21490","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2459.51,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3279.35,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6329.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2459.51,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3344.94,"additional_payer_notes":"APC"}]}]},{"description":"Exc neck tum deep 5 cm/>","code_information":[{"code":"21554","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2154.81,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2873.08,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5545.05,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2154.81,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2930.54,"additional_payer_notes":"APC"}]}]},{"description":"Removal of rib and nerves","code_information":[{"code":"21616","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Revision of neck muscle","code_information":[{"code":"21725","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":525.32,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":700.42,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1351.81,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":525.32,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":714.43,"additional_payer_notes":"APC"}]}]},{"description":"Treat sternum fracture","code_information":[{"code":"21820","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":182.99,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":243.98,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":470.88,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":182.99,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":248.86,"additional_payer_notes":"APC"}]}]},{"description":"Exc back tum deep 5 cm/>","code_information":[{"code":"21933","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2154.81,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2873.08,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5545.05,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2154.81,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2930.54,"additional_payer_notes":"APC"}]}]},{"description":"Remove extra spine segment","code_information":[{"code":"22103","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Incis 1 vertebral seg cerv","code_information":[{"code":"22210","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Closed tx vert fx w/o manj","code_information":[{"code":"22310","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":182.99,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":243.98,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":470.88,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":182.99,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":248.86,"additional_payer_notes":"APC"}]}]},{"description":"Manipulation of spine","code_information":[{"code":"22505","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1192.86,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1590.48,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3069.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1192.86,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1622.29,"additional_payer_notes":"APC"}]}]},{"description":"Idet 1 or more levels","code_information":[{"code":"22527","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0}]}]},{"description":"Thorax spine fusion","code_information":[{"code":"22556","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":33471.73,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17342.86,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":33471.73,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13007.15,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":27583.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17689.72,"additional_payer_notes":"APC"}]}]},{"description":"Lumbar spine fusion","code_information":[{"code":"22612","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":33471.73,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17342.86,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":33471.73,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13007.15,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17689.72,"additional_payer_notes":"APC"}]}]},{"description":"Post fusion 13/> vert seg","code_information":[{"code":"22804","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6779.0,"maximum":33471.73,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17342.86,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":33471.73,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13007.15,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":27583.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17689.72,"additional_payer_notes":"APC"}]}]},{"description":"Insert spine fixation device","code_information":[{"code":"22841","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":4106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Reinsert spinal fixation","code_information":[{"code":"22849","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3388.0,"maximum":27583.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12698.86,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":24508.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9524.15,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":27583.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12952.84,"additional_payer_notes":"APC"}]}]},{"description":"Revise Lumbar Artif Disc","code_information":[{"code":"22862","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6779.0,"maximum":33471.73,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17342.86,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":33471.73,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13007.15,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":27583.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17689.72,"additional_payer_notes":"APC"}]}]},{"description":"Radical resect abd tumor<5cm","code_information":[{"code":"22904","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2154.81,"maximum":5545.05,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2873.08,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5545.05,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2154.81,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2930.54,"additional_payer_notes":"APC"}]}]},{"description":"Exploratory shoulder surgery","code_information":[{"code":"23040","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Resect shoulder tumor < 5 cm","code_information":[{"code":"23077","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2154.81,"maximum":5545.05,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2873.08,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5545.05,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2154.81,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2930.54,"additional_payer_notes":"APC"}]}]},{"description":"Removal of collar bone","code_information":[{"code":"23125","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Remove collar bone lesion","code_information":[{"code":"23170","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Resect clavicle tumor","code_information":[{"code":"23200","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Muscle transfer shoulder/arm","code_information":[{"code":"23395","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Repair of shoulder","code_information":[{"code":"23420","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Repair shoulder capsule","code_information":[{"code":"23466","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Reinforce shoulder bones","code_information":[{"code":"23491","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":24508.8,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12698.86,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":24508.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9524.15,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12952.84,"additional_payer_notes":"APC"}]}]},{"description":"Treat clavicle dislocation","code_information":[{"code":"23540","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":182.99,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":243.98,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":470.88,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":182.99,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":248.86,"additional_payer_notes":"APC"}]}]},{"description":"Treat humerus fracture","code_information":[{"code":"23605","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1192.86,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1590.48,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3069.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1192.86,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1622.29,"additional_payer_notes":"APC"}]}]},{"description":"Treat shoulder dislocation","code_information":[{"code":"23660","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Amputation of arm & girdle","code_information":[{"code":"23900","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":24508.8,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12698.86,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":24508.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9524.15,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12952.84,"additional_payer_notes":"APC"}]}]},{"description":"Release elbow joint","code_information":[{"code":"24006","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Resect arm/elbow tum 5 cm/>","code_information":[{"code":"24079","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2154.81,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2873.08,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5545.05,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2154.81,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2930.54,"additional_payer_notes":"APC"}]}]},{"description":"Remove elbow lesion","code_information":[{"code":"24120","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Partial removal of radius","code_information":[{"code":"24145","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":13851.98,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Removal of arm foreign body","code_information":[{"code":"24200","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1225.21,"maximum":4106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1633.61,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3152.87,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1225.21,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1666.28,"additional_payer_notes":"APC"}]}]},{"description":"Revision of arm muscles","code_information":[{"code":"24330","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Repr elbw med ligmnt w/tissu","code_information":[{"code":"24345","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":13851.98,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Replace elbow joint","code_information":[{"code":"24363","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8923.0,"maximum":33471.73,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17342.86,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":10765.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":8923.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":10765.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":33471.73,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13007.15,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":27583.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17689.72,"additional_payer_notes":"APC"}]}]},{"description":"Repair of humerus","code_information":[{"code":"24430","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":24508.8,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12698.86,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":24508.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9524.15,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12952.84,"additional_payer_notes":"APC"}]}]},{"description":"Treat humerus fracture","code_information":[{"code":"24516","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":24508.8,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12698.86,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":24508.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9524.15,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12952.84,"additional_payer_notes":"APC"}]}]},{"description":"Treat humerus fracture","code_information":[{"code":"24566","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1192.86,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1590.48,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3069.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1192.86,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1622.29,"additional_payer_notes":"APC"}]}]},{"description":"Treat elbow dislocation","code_information":[{"code":"24600","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":182.99,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":243.98,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":470.88,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":182.99,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":248.86,"additional_payer_notes":"APC"}]}]},{"description":"Treat radius fracture","code_information":[{"code":"24665","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Amputation of upper arm","code_information":[{"code":"24920","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":24508.8,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12698.86,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":24508.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9524.15,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12952.84,"additional_payer_notes":"APC"}]}]},{"description":"Incise flexor carpi radialis","code_information":[{"code":"25001","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Perq vertebral augmentation","code_information":[{"code":"22513","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Neck spine fusion","code_information":[{"code":"22548","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":27583.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12698.86,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":24508.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9524.15,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":27583.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12952.84,"additional_payer_notes":"APC"}]}]},{"description":"Spine & skull spinal fusion","code_information":[{"code":"22590","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":27583.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12698.86,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":24508.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9524.15,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":27583.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12952.84,"additional_payer_notes":"APC"}]}]},{"description":"Lumbar spine fusion combined","code_information":[{"code":"22633","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":51798.34,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26838.52,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43643.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43643.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43643.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":51798.34,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20128.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":41120.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27375.29,"additional_payer_notes":"APC"}]}]},{"description":"Kyphectomy 1-2 segments","code_information":[{"code":"22818","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6779.0,"maximum":33471.73,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17342.86,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":33471.73,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13007.15,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":27583.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17689.72,"additional_payer_notes":"APC"}]}]},{"description":"Insert spine fixation device","code_information":[{"code":"22845","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5512.0,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0}]}]},{"description":"Cerv artific diskectomy","code_information":[{"code":"22856","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8923.0,"maximum":33471.73,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17342.86,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":10765.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":8923.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":10765.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":33471.73,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13007.15,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17689.72,"additional_payer_notes":"APC"}]}]},{"description":"Exc abdl tum deep < 5 cm","code_information":[{"code":"22900","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2154.81,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2873.08,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5545.05,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2154.81,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2930.54,"additional_payer_notes":"APC"}]}]},{"description":"Release shoulder joint","code_information":[{"code":"23020","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Exc shoulder les sc 3 cm/>","code_information":[{"code":"23071","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1225.21,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1633.61,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3152.87,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1225.21,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1666.28,"additional_payer_notes":"APC"}]}]},{"description":"Remove shoulder joint lining","code_information":[{"code":"23105","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":13851.98,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Removal of bone lesion","code_information":[{"code":"23146","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":13851.98,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Remove shoulder blade lesion","code_information":[{"code":"23182","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":13851.98,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Remove shoulder fb deep","code_information":[{"code":"23333","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2154.81,"maximum":5545.05,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2873.08,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5545.05,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2154.81,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2930.54,"additional_payer_notes":"APC"}]}]},{"description":"Incise tendon(s) & muscle(s)","code_information":[{"code":"23406","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":13851.98,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Repair shoulder capsule","code_information":[{"code":"23455","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Revis reconst shoulder joint","code_information":[{"code":"23474","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":24508.8,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12698.86,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":24508.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9524.15,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12952.84,"additional_payer_notes":"APC"}]}]},{"description":"Treat clavicle dislocation","code_information":[{"code":"23520","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1192.86,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1590.48,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3069.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1192.86,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1622.29,"additional_payer_notes":"APC"}]}]},{"description":"Treat shoulder blade fx","code_information":[{"code":"23570","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":182.99,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":243.98,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":470.88,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":182.99,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":248.86,"additional_payer_notes":"APC"}]}]},{"description":"Treat humerus fracture","code_information":[{"code":"23625","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1192.86,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1590.48,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3069.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1192.86,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1622.29,"additional_payer_notes":"APC"}]}]},{"description":"Treat dislocation/fracture","code_information":[{"code":"23680","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":24508.8,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12698.86,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":24508.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9524.15,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12952.84,"additional_payer_notes":"APC"}]}]},{"description":"Drainage of arm lesion","code_information":[{"code":"23930","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2154.81,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2873.08,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5545.05,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2154.81,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2930.54,"additional_payer_notes":"APC"}]}]},{"description":"Ex arm/elbow tum deep 5 cm/>","code_information":[{"code":"24073","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2154.81,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2873.08,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5545.05,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2154.81,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2930.54,"additional_payer_notes":"APC"}]}]},{"description":"Removal of elbow bursa","code_information":[{"code":"24105","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Removal of arm bone lesion","code_information":[{"code":"24134","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":13851.98,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Resect radius tumor","code_information":[{"code":"24152","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Muscle/tendon transfer","code_information":[{"code":"24301","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":13851.98,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Repair arm tendon/muscle","code_information":[{"code":"24341","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5699.0},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Repair elbow deb/attch open","code_information":[{"code":"24359","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Revise reconst elbow joint","code_information":[{"code":"24371","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8923.0,"maximum":33471.73,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17342.86,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":10765.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":8923.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":10765.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":33471.73,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13007.15,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":27583.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17689.72,"additional_payer_notes":"APC"}]}]},{"description":"Reinforce humerus","code_information":[{"code":"24498","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":24508.8,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12698.86,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":24508.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9524.15,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12952.84,"additional_payer_notes":"APC"}]}]},{"description":"Treat humerus fracture","code_information":[{"code":"24545","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":24508.8,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12698.86,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":24508.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9524.15,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12952.84,"additional_payer_notes":"APC"}]}]},{"description":"Treat humerus fracture","code_information":[{"code":"24579","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":24508.8,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12698.86,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":24508.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9524.15,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12952.84,"additional_payer_notes":"APC"}]}]},{"description":"Treat elbow fracture","code_information":[{"code":"24635","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Treat ulnar fracture","code_information":[{"code":"24685","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Revision of amputation","code_information":[{"code":"24935","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Radiation treatment delivery","code_information":[{"code":"G6014","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":879.96,"maximum":911.44,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":911.44},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":879.96},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":911.44}]}]},{"description":"Radiation treatment delivery","code_information":[{"code":"G6006","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":479.55,"maximum":496.69,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":496.69},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":479.55},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":496.69}]}]},{"description":"Tomosynthesis, mammo","code_information":[{"code":"G0279","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":84.36,"maximum":87.37,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":87.37},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":84.36},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":87.37}]},{"setting":"outpatient","billing_class":"facility","modifier_code":["TC"],"minimum":9.12,"maximum":23.47,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.16,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":23.47,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9.12,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.4,"additional_payer_notes":"APC"}]}]},{"description":"Liver elastography","code_information":[{"code":"91200","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":50.62,"maximum":245.63,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":127.27,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":52.42},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":50.62},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":52.42},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":245.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":95.45,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":129.82,"additional_payer_notes":"APC"}]}]},{"description":"Nuclear rx iv admin","code_information":[{"code":"79101","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":159.92,"maximum":445.43,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":230.79,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":165.65},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":159.92},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":165.65},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":445.43,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":173.1,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":235.41,"additional_payer_notes":"APC"}]}]},{"description":"Pet image w/ct lmtd","code_information":[{"code":"78814","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1060.78,"maximum":2729.74,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1414.38,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":2639.09},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2599.14},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":2639.09},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2729.74,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1060.78,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1442.66,"additional_payer_notes":"APC"}]}]},{"description":"Tumor imaging mult areas","code_information":[{"code":"78801","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":296.56,"maximum":792.28,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":395.42,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":792.28},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":764.93},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":792.28},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":763.16,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":296.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":403.33,"additional_payer_notes":"APC"}]}]},{"description":"K flow/funct image w/o drug","code_information":[{"code":"78707","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":402.79,"maximum":1036.52,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":537.06,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":665.52},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":642.53},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":665.52},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1036.52,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":402.79,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":547.8,"additional_payer_notes":"APC"}]}]},{"description":"Brain flow imaging only","code_information":[{"code":"78610","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":402.79,"maximum":1036.52,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":537.06,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":570.75},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":551.05},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":570.75},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1036.52,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":402.79,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":547.8,"additional_payer_notes":"APC"}]}]},{"description":"Lung perfusion differential","code_information":[{"code":"78597","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":296.56,"maximum":763.16,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":395.42,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":596.62},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":575.99},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":596.62},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":763.16,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":296.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":403.33,"additional_payer_notes":"APC"}]}]},{"description":"Heart first pass multiple","code_information":[{"code":"78483","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":402.79,"maximum":1036.52,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":537.06,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":611.38},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":590.25},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":611.38},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1036.52,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":402.79,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":547.8,"additional_payer_notes":"APC"}]}]},{"description":"Ven thrombosis images bilat","code_information":[{"code":"78458","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":296.56,"maximum":763.16,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":395.42,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":463.71},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":447.69},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":463.71},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":763.16,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":296.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":403.33,"additional_payer_notes":"APC"}]}]},{"description":"Aqmbf pet rest & rx stress","code_information":[{"code":"78434","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":634.81,"maximum":650.97,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":650.97},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":634.81},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":650.97}]}]},{"description":"Bone mineral dual photon","code_information":[{"code":"78351","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":51.79,"maximum":53.65,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":53.65},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":51.79},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":53.65}]}]},{"description":"GI protein loss exam","code_information":[{"code":"78282","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":162.42,"maximum":763.16,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":395.42,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":164.92},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":162.42},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":164.92},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":763.16,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":296.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":403.33,"additional_payer_notes":"APC"}]}]},{"description":"Salivary gland function exam","code_information":[{"code":"78232","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":271.81,"maximum":763.16,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":395.42,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":281.54},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":271.81},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":281.54},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":763.16,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":296.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":403.33,"additional_payer_notes":"APC"}]}]},{"description":"Liver imaging","code_information":[{"code":"78201","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":402.79,"maximum":1036.52,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":537.06,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":595.38},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":574.81},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":595.38},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1036.52,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":402.79,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":547.8,"additional_payer_notes":"APC"}]}]},{"description":"Red cell mass single","code_information":[{"code":"78120","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":282.53,"maximum":763.16,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":395.42,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":292.63},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":282.53},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":292.63},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":763.16,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":296.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":403.33,"additional_payer_notes":"APC"}]}]},{"description":"Parathyrd planar w/wo subtrj","code_information":[{"code":"78071","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":296.56,"maximum":1073.6,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":395.42,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":1073.6},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1036.53},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":1073.6},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":763.16,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":296.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":403.33,"additional_payer_notes":"APC"}]}]},{"description":"Thyroid uptake measurement","code_information":[{"code":"78012","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":240.22,"maximum":763.16,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":395.42,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":248.84},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":240.22},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":248.84},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":763.16,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":296.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":403.33,"additional_payer_notes":"APC"}]}]},{"description":"Hdr rdncl skn surf brachytx","code_information":[{"code":"77767","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":286.12,"maximum":736.29,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":381.5,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":589.21},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":568.88},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":589.21},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":736.29,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":286.12,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":389.13,"additional_payer_notes":"APC"}]}]},{"description":"Hyperthermia treatment","code_information":[{"code":"77605","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":516.67,"maximum":2371.98,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":688.89,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":2371.98},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2290.08},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":2371.98},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1329.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":516.67,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":702.67,"additional_payer_notes":"APC"}]}]},{"description":"SBRT Management","code_information":[{"code":"77435","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2138.13,"maximum":2214.61,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":2214.61},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2138.13},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":2214.61}]}]},{"description":"Radiation treatment delivery","code_information":[{"code":"77402","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":75.69,"maximum":497.91,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":100.92,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":497.91},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":480.73},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":497.91},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":194.77,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":75.69,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":102.94,"additional_payer_notes":"APC"}]}]},{"description":"Radiation physics consult","code_information":[{"code":"77370","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":99.71,"maximum":416.11,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":132.94,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":416.11},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":401.73},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":416.11},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":256.58,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":99.71,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":135.6,"additional_payer_notes":"APC"}]}]},{"description":"Brachytx isodose complex","code_information":[{"code":"77318","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":277.76,"maximum":714.78,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":370.35,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":707.08},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":682.69},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":707.08},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":714.78,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":277.76,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":377.76,"additional_payer_notes":"APC"}]}]},{"description":"Respirator motion mgmt simul","code_information":[{"code":"77293","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1213.35,"maximum":1256.75,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":1256.75},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1213.35},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":1256.75}]}]},{"description":"Tbs techl calculation only","code_information":[{"code":"77091","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":64.56,"maximum":166.13,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":86.08,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":101.92},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":100.37},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":101.92},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":166.13,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":64.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":87.8,"additional_payer_notes":"APC"}]}]},{"description":"Ct bone density axial","code_information":[{"code":"77078","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":64.56,"maximum":347.79,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":86.08,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":347.79},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":335.77},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":347.79},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":166.13,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":64.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":87.8,"additional_payer_notes":"APC"}]}]},{"description":"Breast tomosynthesis bi","code_information":[{"code":"77063","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":85.05,"maximum":88.11,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":88.11},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":85.05},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":88.11}]},{"setting":"outpatient","billing_class":"facility","modifier_code":["TC"],"minimum":16.8,"maximum":43.23,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22.4,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":43.23,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16.8,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22.85,"additional_payer_notes":"APC"}]}]},{"description":"Mri breast c- unilateral","code_information":[{"code":"77046","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":177.0,"maximum":610.88,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":236.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":610.88},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":595.7},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":610.88},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":455.49,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":177.0,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":240.72,"additional_payer_notes":"APC"}]}]},{"description":"Needle localization by xray","code_information":[{"code":"77002","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":215.78,"maximum":223.49,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":223.49},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":215.78},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":223.49}]}]},{"description":"Use 1st target lesion","code_information":[{"code":"76982","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":77.56,"maximum":229.81,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":103.41,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":229.81},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":224.11},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":229.81},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":199.58,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":77.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":105.48,"additional_payer_notes":"APC"}]}]},{"description":"Echo guide for amniocentesis","code_information":[{"code":"76946","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":43.47,"maximum":45.03,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":45.03},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":43.47},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":45.03}]}]},{"description":"Us exam infant hips static","code_information":[{"code":"76886","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":64.56,"maximum":261.62,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":86.08,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":261.62},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":252.6},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":261.62},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":166.13,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":64.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":87.8,"additional_payer_notes":"APC"}]}]},{"description":"Us exam pelvic limited","code_information":[{"code":"76857","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":75.56,"maximum":199.58,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":103.41,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":78.26},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":75.56},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":78.26},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":199.58,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":77.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":105.48,"additional_payer_notes":"APC"}]}]},{"description":"Removal neck/armpit lesion","code_information":[{"code":"38555","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4925.89,"maximum":12675.95,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6567.85,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":7398.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6019.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":7398.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":12675.95,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4925.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6699.21,"additional_payer_notes":"APC"}]}]},{"description":"Removal of lymph nodes neck","code_information":[{"code":"38720","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4925.89,"maximum":12675.95,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6567.85,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":12675.95,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4925.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6699.21,"additional_payer_notes":"APC"}]}]},{"description":"Remove pelvis lymph nodes","code_information":[{"code":"38770","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5257.0,"maximum":6462.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5257.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6462.0}]}]},{"description":"Exploration of chest","code_information":[{"code":"39010","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5257.0,"maximum":6462.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5257.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6462.0}]}]},{"description":"Repair of diaphragm hernia","code_information":[{"code":"39540","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5257.0,"maximum":6462.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5257.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6462.0}]}]},{"description":"Partial excision of lip","code_information":[{"code":"40510","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2459.51,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3279.35,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6329.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2459.51,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3344.94,"additional_payer_notes":"APC"}]}]},{"description":"Repair cleft lip/nasal","code_information":[{"code":"40700","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Removal foreign body mouth","code_information":[{"code":"40804","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":672.83,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":897.11,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1731.42,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":672.83,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":915.05,"additional_payer_notes":"APC"}]}]},{"description":"Excise oral mucosa for graft","code_information":[{"code":"40818","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":400.09,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":533.45,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1029.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":400.09,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":544.12,"additional_payer_notes":"APC"}]}]},{"description":"Reconstruction of mouth","code_information":[{"code":"40844","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Drainage of mouth lesion","code_information":[{"code":"41009","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":400.09,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":533.45,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1029.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":400.09,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":544.12,"additional_payer_notes":"APC"}]}]},{"description":"Biopsy of tongue","code_information":[{"code":"41105","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2459.51,"maximum":6329.15,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3279.35,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6329.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2459.51,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3344.94,"additional_payer_notes":"APC"}]}]},{"description":"Partial removal of tongue","code_information":[{"code":"41120","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Repair tongue laceration","code_information":[{"code":"41250","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":331.39,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":441.86,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":852.79,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":331.39,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":450.7,"additional_payer_notes":"APC"}]}]},{"description":"Drainage of gum lesion","code_information":[{"code":"41800","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":98.7,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":131.6,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":253.99,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":98.7,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":134.23,"additional_payer_notes":"APC"}]}]},{"description":"Excision of gum lesion","code_information":[{"code":"41826","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2459.51,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3279.35,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6329.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2459.51,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3344.94,"additional_payer_notes":"APC"}]}]},{"description":"Dental surgery procedure","code_information":[{"code":"41899","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":175.7,"maximum":13249.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":234.27,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":13249.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":10779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":13249.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":452.14,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":175.7,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":238.96,"additional_payer_notes":"APC"}]}]},{"description":"Repair palate pharynx/uvula","code_information":[{"code":"42145","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":11300.84,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Reconstruct cleft palate","code_information":[{"code":"42220","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Palate/uvula surgery","code_information":[{"code":"42299","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":175.7,"maximum":13249.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":234.27,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":13249.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":10779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":13249.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":452.14,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":175.7,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":238.96,"additional_payer_notes":"APC"}]}]},{"description":"Biopsy of salivary gland","code_information":[{"code":"42400","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":525.32,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":700.42,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1351.81,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":525.32,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":714.43,"additional_payer_notes":"APC"}]}]},{"description":"Excise parotid gland/lesion","code_information":[{"code":"42426","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0}]}]},{"description":"Injection for salivary x-ray","code_information":[{"code":"42550","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Drainage of throat abscess","code_information":[{"code":"42725","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Remove tonsils and adenoids","code_information":[{"code":"42820","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4226.0,"maximum":11300.84,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":4226.0},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Extensive surgery of throat","code_information":[{"code":"42842","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":11300.84,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Repair throat wound","code_information":[{"code":"42900","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1151.01,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1534.69,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2961.94,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1151.01,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1565.38,"additional_payer_notes":"APC"}]}]},{"description":"Control nose/throat bleeding","code_information":[{"code":"42971","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Removal of esophagus","code_information":[{"code":"43107","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Partial removal of esophagus","code_information":[{"code":"43122","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Esophagoscp rig trnso biopsy","code_information":[{"code":"43193","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1423.51,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1898.01,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3663.16,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1423.51,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1935.97,"additional_payer_notes":"APC"}]}]},{"description":"Esophagoscopy flex biopsy","code_information":[{"code":"43202","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1423.51,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1898.01,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3663.16,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1423.51,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1935.97,"additional_payer_notes":"APC"}]}]},{"description":"Esophagosc dilate balloon 30","code_information":[{"code":"43214","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1423.51,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1898.01,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3663.16,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1423.51,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1935.97,"additional_payer_notes":"APC"}]}]},{"description":"Esophagoscop ultrasound exam","code_information":[{"code":"43231","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1423.51,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1898.01,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3663.16,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1423.51,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1935.97,"additional_payer_notes":"APC"}]}]},{"description":"Egd w/transmural drain cyst","code_information":[{"code":"43240","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":11589.23,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6004.78,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11589.23,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4503.59,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6124.88,"additional_payer_notes":"APC"}]}]},{"description":"Egd guide wire insertion","code_information":[{"code":"43248","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":672.83,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":897.11,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1731.42,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":672.83,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":915.05,"additional_payer_notes":"APC"}]}]},{"description":"Umbilical artery echo","code_information":[{"code":"76820","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":73.17,"maximum":199.58,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":103.41,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":75.8},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":73.17},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":75.8},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":199.58,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":77.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":105.48,"additional_payer_notes":"APC"}]}]},{"description":"Ob us detailed addl fetus","code_information":[{"code":"76812","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":384.48,"maximum":398.23,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":398.23},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":384.48},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":398.23}]}]},{"description":"Us exam abdo back wall lim","code_information":[{"code":"76775","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":77.56,"maximum":199.58,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":103.41,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":100.43},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":96.95},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":100.43},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":199.58,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":77.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":105.48,"additional_payer_notes":"APC"}]}]},{"description":"Echo exam of eye","code_information":[{"code":"76529","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":64.56,"maximum":166.13,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":86.08,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":161.95},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":156.35},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":161.95},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":166.13,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":64.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":87.8,"additional_payer_notes":"APC"}]}]},{"description":"Echo exam of head","code_information":[{"code":"76506","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":77.56,"maximum":297.32,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":103.41,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":297.32},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":287.06},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":297.32},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":199.58,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":77.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":105.48,"additional_payer_notes":"APC"}]}]},{"description":"3d render w/intrp postproces","code_information":[{"code":"76376","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":43.47,"maximum":45.03,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":45.03},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":43.47},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":45.03}]}]},{"description":"Mr safety implant elec prepj","code_information":[{"code":"76018","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":70.53,"maximum":355.65,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":94.04,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":355.65},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":326.01},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":355.65},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":181.49,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":70.53,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":95.92,"additional_payer_notes":"APC"}]}]},{"description":"Xray control catheter change","code_information":[{"code":"75984","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":237.15,"maximum":245.63,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":245.63},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":237.15},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":245.63}]}]},{"description":"Follow-up angiography","code_information":[{"code":"75898","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":152.28,"maximum":6027.57,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3123.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":154.62},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":152.28},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":154.62},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6027.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2342.32,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3185.56,"additional_payer_notes":"APC"}]}]},{"description":"Vein x-ray skull epidural","code_information":[{"code":"75872","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":289.41,"maximum":1197.51,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":620.47,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":299.78},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":289.41},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":299.78},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1197.51,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":465.35,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":632.88,"additional_payer_notes":"APC"}]}]},{"description":"Vein x-ray trunk","code_information":[{"code":"75825","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":266.85,"maximum":6027.57,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3123.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":276.41},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":266.85},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":276.41},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6027.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2342.32,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3185.56,"additional_payer_notes":"APC"}]}]},{"description":"Lymph vessel x-ray arm/leg","code_information":[{"code":"75801","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":465.35,"maximum":1197.51,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":620.47,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":723.58},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":712.62},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":723.58},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1197.51,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":465.35,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":632.88,"additional_payer_notes":"APC"}]}]},{"description":"Artery x-rays adrenal gland","code_information":[{"code":"75731","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":382.8,"maximum":6027.57,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3123.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":396.51},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":382.8},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":396.51},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6027.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2342.32,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3185.56,"additional_payer_notes":"APC"}]}]},{"description":"Contrast exam thoracic aorta","code_information":[{"code":"75605","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":276.36,"maximum":10622.5,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5503.89,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":286.25},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":276.36},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":286.25},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":10622.5,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4127.91,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5613.96,"additional_payer_notes":"APC"}]}]},{"description":"Card mri w/stress img & dye","code_information":[{"code":"75563","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":581.54,"maximum":1496.49,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":775.38,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":1219.83},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1177.73},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":1219.83},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1496.49,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":581.54,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":790.89,"additional_payer_notes":"APC"}]}]},{"description":"Mri fetal sngl/1st gestation","code_information":[{"code":"74712","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":177.0,"maximum":1136.15,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":236.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":1136.15},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1096.9},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":1136.15},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":455.49,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":177.0,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":240.72,"additional_payer_notes":"APC"}]}]},{"description":"Contrst x-ray urinary tract","code_information":[{"code":"74425","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":258.81,"maximum":1204.35,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":345.07,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":1204.35},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1162.75},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":1204.35},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":665.99,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":258.81,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":351.98,"additional_payer_notes":"APC"}]}]},{"description":"X-ray guide for GI tube","code_information":[{"code":"74340","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":268.66,"maximum":278.26,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":278.26},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":268.66},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":278.26}]}]},{"description":"Contrast x-ray exam of colon","code_information":[{"code":"74280","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":130.12,"maximum":559.47,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":173.49,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":559.47},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":540.13},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":559.47},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":334.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":130.12,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":176.96,"additional_payer_notes":"APC"}]}]},{"description":"Contrst x-ray uppr gi tract","code_information":[{"code":"74246","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":130.12,"maximum":334.84,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":173.49,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":317.01},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":306.06},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":317.01},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":334.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":130.12,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":176.96,"additional_payer_notes":"APC"}]}]},{"description":"Mri angio abdom w orw/o dye","code_information":[{"code":"74185","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1039.88,"maximum":1077.07,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":1077.07},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1039.88},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":1077.07}]}]},{"description":"Ct angio abd&pelv w/o&w/dye","code_information":[{"code":"74174","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":258.81,"maximum":956.48,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":345.07,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":956.48},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":923.44},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":956.48},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":665.99,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":258.81,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":351.98,"additional_payer_notes":"APC"}]}]},{"description":"Mr ang lwr ext w or w/o dye","code_information":[{"code":"73725","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1032.75,"maximum":1069.68,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":1069.68},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1032.75},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":1069.68}]}]},{"description":"Ct lwr extremity w/o&w/dye","code_information":[{"code":"73702","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":130.12,"maximum":735.44,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":173.49,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":735.44},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":710.04},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":735.44},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":334.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":130.12,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":176.96,"additional_payer_notes":"APC"}]}]},{"description":"X-ray exam of ankle","code_information":[{"code":"73610","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":64.56,"maximum":166.13,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":86.08,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":77.03},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":74.37},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":77.03},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":166.13,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":64.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":87.8,"additional_payer_notes":"APC"}]}]},{"description":"X-ray exam of knee 1 or 2","code_information":[{"code":"73560","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":64.56,"maximum":166.13,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":86.08,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":77.03},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":74.37},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":77.03},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":166.13,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":64.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":87.8,"additional_payer_notes":"APC"}]}]},{"description":"X-ray exam hip uni 2-3 views","code_information":[{"code":"73502","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":64.56,"maximum":166.13,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":86.08,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":102.89},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":99.32},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":102.89},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":166.13,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":64.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":87.8,"additional_payer_notes":"APC"}]}]},{"description":"Mri Upper Extremity W/O Dye","code_information":[{"code":"73218","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":177.0,"maximum":1021.69,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":236.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":1021.69},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":986.41},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":1021.69},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":455.49,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":177.0,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":240.72,"additional_payer_notes":"APC"}]}]},{"description":"Contrast x-ray of wrist","code_information":[{"code":"73115","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":258.81,"maximum":665.99,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":345.07,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":269.03},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":259.73},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":269.03},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":665.99,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":258.81,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":351.98,"additional_payer_notes":"APC"}]}]},{"description":"X-ray exam of humerus","code_information":[{"code":"73060","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":64.56,"maximum":166.13,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":86.08,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":69.65},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":67.24},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":69.65},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":166.13,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":64.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":87.8,"additional_payer_notes":"APC"}]}]},{"description":"Discography cerv/thor spine","code_information":[{"code":"72285","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":176.56,"maximum":3727.72,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1931.46,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":182.88},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":176.56},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":182.88},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3727.72,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1448.59,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1970.09,"additional_payer_notes":"APC"}]}]},{"description":"Mr angio pelvis w/o & w/dye","code_information":[{"code":"72198","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1031.56,"maximum":1068.46,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":1068.46},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1031.56},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":1068.46}]}]},{"description":"X-ray exam of pelvis","code_information":[{"code":"72190","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":77.56,"maximum":199.58,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":103.41,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":93.03},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":89.81},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":93.03},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":199.58,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":77.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":105.48,"additional_payer_notes":"APC"}]}]},{"description":"Mri chest spine w/dye","code_information":[{"code":"72147","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":258.81,"maximum":796.48,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":345.07,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":796.48},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":768.98},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":796.48},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":665.99,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":258.81,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":351.98,"additional_payer_notes":"APC"}]}]},{"description":"Ct chest spine w/dye","code_information":[{"code":"72129","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":130.12,"maximum":577.92,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":173.49,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":577.92},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":557.96},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":577.92},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":334.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":130.12,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":176.96,"additional_payer_notes":"APC"}]}]},{"description":"X-ray exam l-s spine 2/3 vws","code_information":[{"code":"72100","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":77.56,"maximum":199.58,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":103.41,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":80.72},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":77.94},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":80.72},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":199.58,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":77.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":105.48,"additional_payer_notes":"APC"}]}]},{"description":"Implt brain chemotx add-on","code_information":[{"code":"61517","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3388.0,"maximum":4106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0}]}]},{"description":"Removal of brain lesion","code_information":[{"code":"61530","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6779.0,"maximum":8333.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0}]}]},{"description":"Removal of brain tissue","code_information":[{"code":"61539","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6779.0,"maximum":8333.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0}]}]},{"description":"Release of skull seams","code_information":[{"code":"61550","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6779.0,"maximum":8333.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0}]}]},{"description":"Removal of brain tissue","code_information":[{"code":"61566","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6779.0,"maximum":8333.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0}]}]},{"description":"Craniofacial approach skull","code_information":[{"code":"61582","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6779.0,"maximum":8333.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0}]}]},{"description":"Transtemporal approach/skull","code_information":[{"code":"61595","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6779.0,"maximum":8333.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0}]}]},{"description":"Resect/excise cranial lesion","code_information":[{"code":"61607","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6779.0,"maximum":8333.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0}]}]},{"description":"Endovasc tempory vessel occl","code_information":[{"code":"61623","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":27583.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11418.47,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":22037.64,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8563.85,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":27583.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11646.84,"additional_payer_notes":"APC"}]}]},{"description":"Perq art m-thrombect &/nfs","code_information":[{"code":"61645","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6019.0,"maximum":7398.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":7398.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6019.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":7398.0}]}]},{"description":"Intracranial vessel surgery","code_information":[{"code":"61692","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6779.0,"maximum":8333.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0}]}]},{"description":"Revise circulation to head","code_information":[{"code":"61710","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6779.0,"maximum":8333.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0}]}]},{"description":"Scan proc cranial intra","code_information":[{"code":"61781","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Srs cran les complex addl","code_information":[{"code":"61799","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3579.0,"maximum":13249.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":13249.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":10779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":13249.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0}]}]},{"description":"Revise/remove neuroelectrode","code_information":[{"code":"61880","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2593.52,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3458.03,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6674.0,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2593.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3527.19,"additional_payer_notes":"APC"}]}]},{"description":"Reduction of skull defect","code_information":[{"code":"62115","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6779.0,"maximum":8333.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0}]}]},{"description":"Repair of skull & brain","code_information":[{"code":"62145","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6779.0,"maximum":8333.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0}]}]},{"description":"Remove pituit tumor w/scope","code_information":[{"code":"62165","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6779.0,"maximum":8333.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0}]}]},{"description":"Establish brain cavity shunt","code_information":[{"code":"62223","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Interdiscal perq aspir dx","code_information":[{"code":"62267","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":525.32,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":700.42,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1351.81,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":525.32,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":714.43,"additional_payer_notes":"APC"}]}]},{"description":"Treat spinal canal lesion","code_information":[{"code":"62282","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":656.13,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":874.84,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1688.44,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":656.13,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":892.34,"additional_payer_notes":"APC"}]}]},{"description":"Myelography lumbar injection","code_information":[{"code":"62303","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":581.54,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":775.38,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1496.49,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":581.54,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":790.89,"additional_payer_notes":"APC"}]}]},{"description":"Implant spine infusion pump","code_information":[{"code":"62362","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8923.0,"maximum":44873.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17827.56,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":10765.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":8923.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":10765.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":44873.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":44873.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":44873.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":34407.2,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13370.67,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":43285.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18184.11,"additional_payer_notes":"APC"}]}]},{"description":"Remove spine lamina 1/2 lmbr","code_information":[{"code":"63005","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Spinal disk surgery add-on","code_information":[{"code":"63035","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Remove spinal lamina add-on","code_information":[{"code":"63048","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Neck spine disk surgery","code_information":[{"code":"63075","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Remov vertbr dcmprn thrclmbr","code_information":[{"code":"63087","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6779.0,"maximum":8333.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0}]}]},{"description":"Drainage of spinal cyst","code_information":[{"code":"63172","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6779.0,"maximum":8333.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0}]}]},{"description":"Revise spinal cord vsls thrc","code_information":[{"code":"63251","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6779.0,"maximum":8333.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0}]}]},{"description":"Excise intrspinl lesion lmbr","code_information":[{"code":"63272","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6779.0,"maximum":27583.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":27583.0}]}]},{"description":"Bx/exc idrl spine lesn lmbr","code_information":[{"code":"63282","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6779.0,"maximum":27583.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":27583.0}]}]},{"description":"Remove vert xdrl body thrc","code_information":[{"code":"63301","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6779.0,"maximum":8333.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0}]}]},{"description":"Remove spinal cord lesion","code_information":[{"code":"63600","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1448.59,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1931.46,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3727.72,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1448.59,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1970.09,"additional_payer_notes":"APC"}]}]},{"description":"Revise spine eltrd perq aray","code_information":[{"code":"63663","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4727.69,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6303.59,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":12165.93,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4727.69,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6429.66,"additional_payer_notes":"APC"}]}]},{"description":"Repair spinal fluid leakage","code_information":[{"code":"63707","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Candida dna amp probe","code_information":[{"code":"87481","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":26.32,"maximum":71.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":35.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":71.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43.86},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43.86},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43.86},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":67.72,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26.32,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":61.41},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35.09},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":35.79,"additional_payer_notes":"APC"}]}]},{"description":"Chylmd trach dna amp probe","code_information":[{"code":"87491","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":26.32,"maximum":71.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":35.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":71.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43.86},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43.86},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43.86},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":67.72,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26.32,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":61.41},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35.09},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":35.79,"additional_payer_notes":"APC"}]}]},{"description":"Influenza dna amp prob 1+","code_information":[{"code":"87501","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":38.48,"maximum":103.84,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":51.31,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":103.84},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":64.14},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":64.14},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":64.14},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":99.03,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":38.48,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":89.79},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":51.31},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":52.34,"additional_payer_notes":"APC"}]}]},{"description":"Gardner vag dna quant","code_information":[{"code":"87512","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":31.32,"maximum":84.49,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":41.76,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":84.49},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":52.2},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":52.2},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":52.2},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":80.6,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":31.32,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":73.08},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":41.76},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":42.6,"additional_payer_notes":"APC"}]}]},{"description":"Hepatitis g dna dir probe","code_information":[{"code":"87525","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":22.35,"maximum":57.51,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":29.8,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":40.58},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":37.25},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":37.25},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":37.25},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":57.51,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22.35,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":52.15},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29.8},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":30.4,"additional_payer_notes":"APC"}]}]},{"description":"Hhv-6 dna quant","code_information":[{"code":"87533","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":31.32,"maximum":84.49,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":41.76,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":84.49},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":52.2},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":52.2},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":52.2},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":80.6,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":31.32,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":73.08},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":41.76},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":42.6,"additional_payer_notes":"APC"}]}]},{"description":"Legion pneumo dna amp prob","code_information":[{"code":"87541","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":26.32,"maximum":71.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":35.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":71.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43.86},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43.86},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43.86},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":67.72,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26.32,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":61.41},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35.09},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":35.79,"additional_payer_notes":"APC"}]}]},{"description":"M.avium-intra dna dir prob","code_information":[{"code":"87560","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":20.47,"maximum":52.67,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27.29,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":40.58},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":34.11},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":34.11},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":34.11},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":52.67,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20.47,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":47.76},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27.29},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27.84,"additional_payer_notes":"APC"}]}]},{"description":"N.gonorrhoeae dna dir prob","code_information":[{"code":"87590","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":20.16,"maximum":51.88,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26.88,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":40.58},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":33.6},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":33.6},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":33.6},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":51.88,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20.16,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":47.04},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26.88},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27.42,"additional_payer_notes":"APC"}]}]},{"description":"Hpv sep hi-rsk typ&pool rslt","code_information":[{"code":"87626","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":52.65,"maximum":135.49,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":70.2,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":101.09},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":87.75},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":87.75},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":87.75},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":135.49,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":52.65,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":122.85},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":70.2},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":71.6,"additional_payer_notes":"APC"}]}]},{"description":"Staph a dna amp probe","code_information":[{"code":"87640","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":26.32,"maximum":71.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":35.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":71.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43.86},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43.86},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43.86},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":67.72,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26.32,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":61.41},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35.09},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":35.79,"additional_payer_notes":"APC"}]}]},{"description":"Zika virus dna/rna amp probe","code_information":[{"code":"87662","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":38.48,"maximum":99.03,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":51.31,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":94.1},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":64.14},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":64.14},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":64.14},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":99.03,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":38.48,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":89.79},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":51.31},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":52.34,"additional_payer_notes":"APC"}]}]},{"description":"Influenza assay w/optic","code_information":[{"code":"87804","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":12.41,"maximum":31.94,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16.55,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":24.26},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20.69},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20.69},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20.69},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":31.94,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.41,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28.96},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16.55},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16.88,"additional_payer_notes":"APC"}]}]},{"description":"Strep a assay w/optic","code_information":[{"code":"87880","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":12.4,"maximum":31.9,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16.53,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":24.26},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20.66},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20.66},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20.66},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":31.9,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.4,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28.93},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16.53},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16.86,"additional_payer_notes":"APC"}]}]},{"description":"Genotype dna/rna hiv","code_information":[{"code":"87906","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":96.55,"maximum":260.47,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":128.73,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":260.47},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":160.91},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":160.91},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":160.91},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":248.45,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":96.55,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":225.28},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":128.73},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":131.3,"additional_payer_notes":"APC"}]}]},{"description":"Cytopath c/v automated","code_information":[{"code":"88147","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":21.4,"maximum":97.58,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":50.56,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":21.4},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":63.2},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":63.2},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":63.2},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":97.58,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":37.92,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":88.48},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":50.56},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":51.57,"additional_payer_notes":"APC"}]}]},{"description":"Cytopath tbs c/v auto redo","code_information":[{"code":"88166","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":13.9,"maximum":35.78,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18.54,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":21.4},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22.74},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22.74},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22.74},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":35.78,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.9,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31.83},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15.12},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18.91,"additional_payer_notes":"APC"}]}]},{"description":"Tissue culture tumor","code_information":[{"code":"88239","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":100.79,"maximum":284.71,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":147.52,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":100.79},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":184.4},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":184.4},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":184.4},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":284.71,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":110.64,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":258.16},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":147.52},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":150.47,"additional_payer_notes":"APC"}]}]},{"description":"Chromosome analysis 45","code_information":[{"code":"88263","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":112.72,"maximum":304.12,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":150.29,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":304.12},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":187.86},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":187.86},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":187.86},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":290.06,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":112.72,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":263.01},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":150.29},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":153.3,"additional_payer_notes":"APC"}]}]},{"description":"Cytogenetics 100-300","code_information":[{"code":"88275","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":38.39,"maximum":98.8,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":51.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":81.25},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":63.99},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":63.99},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":63.99},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":98.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":38.39,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":89.58},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":51.19},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":52.21,"additional_payer_notes":"APC"}]}]},{"description":"Hgb quant transcutaneous","code_information":[{"code":"88738","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3.76,"maximum":10.15,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5.02,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":10.15},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":6.28},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":6.28},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":6.28},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":9.69,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3.76,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8.79},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5.02},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5.12,"additional_payer_notes":"APC"}]}]},{"description":"Exam feces for meat fibers","code_information":[{"code":"89160","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3.64,"maximum":9.36,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4.85,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7.45},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":6.06},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":6.06},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":6.06},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":9.36,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3.64,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8.49},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":4.85},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4.95,"additional_payer_notes":"APC"}]}]},{"description":"Sperm evaluation test","code_information":[{"code":"89329","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":14.69,"maximum":37.81,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19.59,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":25.8},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24.49},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24.49},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24.49},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":37.81,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14.69,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34.28},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19.59},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19.98,"additional_payer_notes":"APC"}]}]},{"description":"Scr c/v cyto,thinlayer,rescr","code_information":[{"code":"G0145","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":19.87,"maximum":53.35,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26.49,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":53.35},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":33.11},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":33.11},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":33.11},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":51.13,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19.87,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":46.36},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26.49},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27.02,"additional_payer_notes":"APC"}]}]},{"description":"ELISA HIV-1/HIV-2 screen","code_information":[{"code":"G0433","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":13.72,"maximum":35.3,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18.29,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":27.74},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22.86},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22.86},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22.86},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":35.3,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.72,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32.01},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18.29},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18.66,"additional_payer_notes":"APC"}]}]},{"description":"Drug test def 15-21 classes","code_information":[{"code":"G0482","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":149.06,"maximum":383.57,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":198.74,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":246.62},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":248.43},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":248.43},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":248.43},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":383.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":149.06,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":347.8},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":198.74},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":202.71,"additional_payer_notes":"APC"}]}]},{"description":"Blood thymol turbidity","code_information":[{"code":"P2033","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3.71,"maximum":9.55,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4.95,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":9.07},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":6.19},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":6.19},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":6.19},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":9.55,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3.71,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8.66},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":4.95},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5.05,"additional_payer_notes":"APC"}]}]},{"description":"Fern test","code_information":[{"code":"Q0114","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7.3,"maximum":18.8,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9.74,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":14.47},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12.18},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12.18},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12.18},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":18.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7.3,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17.05},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9.74},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9.93,"additional_payer_notes":"APC"}]}]},{"description":"Prosth Retina Receive&Gen","code_information":[{"code":"0100T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":51942.0,"maximum":54996.0,"payers_information":[{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":54996.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":54996.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":54996.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":51942.0}]}]},{"description":"Post vert arthrplst 1 lumbar","code_information":[{"code":"0202T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":9524.15,"maximum":24508.8,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12698.86,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":24508.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9524.15,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12952.84,"additional_payer_notes":"APC"}]}]},{"description":"Plmt post facet implt cerv","code_information":[{"code":"0219T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":9524.15,"maximum":24508.8,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12698.86,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":24508.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9524.15,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12952.84,"additional_payer_notes":"APC"}]}]},{"description":"Trluml perip athrc iliac art","code_information":[{"code":"0238T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":13599.0,"maximum":34994.75,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18131.99,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":34994.75,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13599.0,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":27583.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18494.63,"additional_payer_notes":"APC"}]}]},{"description":"Rev/remvl crtd sns dev total","code_information":[{"code":"0269T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":17314.0,"maximum":18364.0,"payers_information":[{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0}]}]},{"description":"Trnscth renal symp denrv unl","code_information":[{"code":"0338T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4222.18,"maximum":10865.09,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5629.58,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":10865.09,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4222.18,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5742.17,"additional_payer_notes":"APC"}]}]},{"description":"Insj/rplc cardiac modulj sys","code_information":[{"code":"0408T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":23285.27,"maximum":59920.75,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":31047.02,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":54996.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":54996.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":54996.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":59920.75,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23285.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":51942.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":31667.96,"additional_payer_notes":"APC"}]}]},{"description":"Explore/treat wrist joint","code_information":[{"code":"25040","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Resect forarm/wrist tum 3cm>","code_information":[{"code":"25078","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2154.81,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2873.08,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5545.05,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2154.81,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2930.54,"additional_payer_notes":"APC"}]}]},{"description":"Remove wrist tendon lesion","code_information":[{"code":"25111","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1192.86,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1590.48,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3069.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1192.86,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1622.29,"additional_payer_notes":"APC"}]}]},{"description":"Remove/graft forearm lesion","code_information":[{"code":"25126","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Removal of wrist bone","code_information":[{"code":"25210","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Manipulate wrist w/anesthes","code_information":[{"code":"25259","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1192.86,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1590.48,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3069.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1192.86,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1622.29,"additional_payer_notes":"APC"}]}]},{"description":"Revise wrist/forearm tendon","code_information":[{"code":"25280","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Revise palsy hand tendon(s)","code_information":[{"code":"25316","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Revise radius & ulna","code_information":[{"code":"25365","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":24508.8,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12698.86,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":24508.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9524.15,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12952.84,"additional_payer_notes":"APC"}]}]},{"description":"Repair radius or ulna","code_information":[{"code":"25400","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Repair/graft wrist bone","code_information":[{"code":"25440","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Remove wrist joint implant","code_information":[{"code":"25449","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Treat fracture of radius","code_information":[{"code":"25515","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Treat fracture radius & ulna","code_information":[{"code":"25565","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1192.86,"maximum":4106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1590.48,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3069.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1192.86,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1622.29,"additional_payer_notes":"APC"}]}]},{"description":"Treat Fx Radial 3+ Frag","code_information":[{"code":"25609","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Pin ulnar styloid fracture","code_information":[{"code":"25651","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Treat wrist fracture","code_information":[{"code":"25685","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":13851.98,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Fusion radioulnar jnt/ulna","code_information":[{"code":"25830","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Amputation follow-up surgery","code_information":[{"code":"25924","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Drainage of palm bursa","code_information":[{"code":"26025","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":6246.19,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Incision of finger tendon","code_information":[{"code":"26060","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1192.86,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1590.48,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3069.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1192.86,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1622.29,"additional_payer_notes":"APC"}]}]},{"description":"Exc hand tum deep 1.5 cm/>","code_information":[{"code":"26113","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1225.21,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1633.61,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3152.87,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1225.21,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1666.28,"additional_payer_notes":"APC"}]}]},{"description":"Remove wrist joint lining","code_information":[{"code":"26130","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":6246.19,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Remove hand bone lesion","code_information":[{"code":"26200","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1192.86,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1590.48,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3069.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1192.86,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1622.29,"additional_payer_notes":"APC"}]}]},{"description":"Resect prox finger tumor","code_information":[{"code":"26260","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":6246.19,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Repair finger/hand tendon","code_information":[{"code":"26357","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Repair/graft hand tendon","code_information":[{"code":"26412","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Repair finger tendon","code_information":[{"code":"26433","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":6246.19,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Incision of finger tendon","code_information":[{"code":"26455","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1192.86,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1590.48,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3069.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1192.86,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1622.29,"additional_payer_notes":"APC"}]}]},{"description":"Transplant hand tendon","code_information":[{"code":"26480","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Finger tendon transfer","code_information":[{"code":"26497","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Fusion of knuckle joints","code_information":[{"code":"26517","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Repair hand joint","code_information":[{"code":"26540","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":6246.19,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Single transfer toe-hand","code_information":[{"code":"26553","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Correct finger deformity","code_information":[{"code":"26567","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Treat metacarpal fracture","code_information":[{"code":"26600","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":182.99,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":243.98,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":470.88,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":182.99,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":248.86,"additional_payer_notes":"APC"}]}]},{"description":"Decompress forearm 2 spaces","code_information":[{"code":"25025","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1192.86,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1590.48,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3069.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1192.86,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1622.29,"additional_payer_notes":"APC"}]}]},{"description":"Exc forearm tum deep 3 cm/>","code_information":[{"code":"25073","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2154.81,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2873.08,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5545.05,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2154.81,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2930.54,"additional_payer_notes":"APC"}]}]},{"description":"Remove wrist joint lining","code_information":[{"code":"25105","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Excise wrist tendon sheath","code_information":[{"code":"25118","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1192.86,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1590.48,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3069.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1192.86,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1622.29,"additional_payer_notes":"APC"}]}]},{"description":"Remove forearm bone lesion","code_information":[{"code":"25145","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Injection for wrist x-ray","code_information":[{"code":"25246","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Repair forearm tendon/muscle","code_information":[{"code":"25270","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Fusion of tendons at wrist","code_information":[{"code":"25301","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Reconstruct ulna/radioulnar","code_information":[{"code":"25337","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Lengthen radius or ulna","code_information":[{"code":"25391","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":24508.8,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12698.86,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":24508.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9524.15,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12952.84,"additional_payer_notes":"APC"}]}]},{"description":"Repair/graft radius or ulna","code_information":[{"code":"25425","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Reconstruct wrist joint","code_information":[{"code":"25444","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":24508.8,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12698.86,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":24508.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9524.15,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12952.84,"additional_payer_notes":"APC"}]}]},{"description":"Reinforce ulna","code_information":[{"code":"25491","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":24508.8,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12698.86,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":24508.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9524.15,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12952.84,"additional_payer_notes":"APC"}]}]},{"description":"Treat fracture of ulna","code_information":[{"code":"25530","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":182.99,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":243.98,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":470.88,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":182.99,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":248.86,"additional_payer_notes":"APC"}]}]},{"description":"Treat fracture radius/ulna","code_information":[{"code":"25605","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1192.86,"maximum":4106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1590.48,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3069.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1192.86,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1622.29,"additional_payer_notes":"APC"}]}]},{"description":"Treat wrist bone fracture","code_information":[{"code":"25630","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":182.99,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":243.98,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":470.88,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":182.99,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":248.86,"additional_payer_notes":"APC"}]}]},{"description":"Pin radioulnar dislocation","code_information":[{"code":"25671","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Fusion/graft of wrist joint","code_information":[{"code":"25805","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Amputation follow-up surgery","code_information":[{"code":"25909","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":13851.98,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Forearm or wrist surgery","code_information":[{"code":"25999","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":182.99,"maximum":13249.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":243.98,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":13249.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":10779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":13249.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":470.88,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":182.99,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":248.86,"additional_payer_notes":"APC"}]}]},{"description":"Decompress fingers/hand","code_information":[{"code":"26037","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":6246.19,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Biopsy hand joint lining","code_information":[{"code":"26100","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":6246.19,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Rad resect hand tumor 3 cm/>","code_information":[{"code":"26118","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2154.81,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2873.08,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5545.05,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2154.81,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2930.54,"additional_payer_notes":"APC"}]}]},{"description":"Remove tendon sheath lesion","code_information":[{"code":"26160","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1192.86,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1590.48,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3069.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1192.86,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1622.29,"additional_payer_notes":"APC"}]}]},{"description":"Partial removal of hand bone","code_information":[{"code":"26230","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":6246.19,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Manipulat palm cord post inj","code_information":[{"code":"26341","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":182.99,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":243.98,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":470.88,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":182.99,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":248.86,"additional_payer_notes":"APC"}]}]},{"description":"Repair finger/hand tendon","code_information":[{"code":"26373","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Repair/graft finger tendon","code_information":[{"code":"26420","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Release palm & finger tendon","code_information":[{"code":"26442","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Tendon lengthening","code_information":[{"code":"26476","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":6246.19,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Revise thumb tendon","code_information":[{"code":"26490","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Hand tendon reconstruction","code_information":[{"code":"26502","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Revise knuckle joint","code_information":[{"code":"26530","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Repair nonunion hand","code_information":[{"code":"26546","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":13851.98,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Repair of web finger","code_information":[{"code":"26560","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1192.86,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1590.48,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3069.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1192.86,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1622.29,"additional_payer_notes":"APC"}]}]},{"description":"Repair finger deformity","code_information":[{"code":"26590","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1192.86,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1590.48,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3069.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1192.86,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1622.29,"additional_payer_notes":"APC"}]}]},{"description":"Treat thumb fracture","code_information":[{"code":"26665","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Pin knuckle dislocation","code_information":[{"code":"26706","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":6246.19,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Treat finger fracture each","code_information":[{"code":"26746","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Treat finger dislocation","code_information":[{"code":"26785","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Fusion of finger joint","code_information":[{"code":"26860","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Drainage of pelvis lesion","code_information":[{"code":"26990","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Incision of hip/thigh fascia","code_information":[{"code":"27025","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Exc hip pelvis les sc 3 cm/>","code_information":[{"code":"27043","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2154.81,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2873.08,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5545.05,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2154.81,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2930.54,"additional_payer_notes":"APC"}]}]},{"description":"Buttock fasciotomy w/dbrdmt","code_information":[{"code":"27057","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1192.86,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1590.48,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3069.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1192.86,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1622.29,"additional_payer_notes":"APC"}]}]},{"description":"Part removal hip bone deep","code_information":[{"code":"27071","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Removal of hip prosthesis","code_information":[{"code":"27090","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":13851.98,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Transfer of spinal muscle","code_information":[{"code":"27105","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Revise hip joint replacement","code_information":[{"code":"27134","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6779.0,"maximum":27583.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12698.86,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":24508.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9524.15,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":27583.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12952.84,"additional_payer_notes":"APC"}]}]},{"description":"Revision of pelvis","code_information":[{"code":"27158","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Revise head/neck of femur","code_information":[{"code":"27179","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Treat pelvic ring fracture","code_information":[{"code":"27217","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3579.0,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0}]}]},{"description":"Treat thigh fracture","code_information":[{"code":"27232","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1192.86,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1590.48,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3069.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1192.86,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1622.29,"additional_payer_notes":"APC"}]}]},{"description":"Treat thigh fracture","code_information":[{"code":"27248","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Treat hip dislocation","code_information":[{"code":"27259","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Fusion of sacroiliac joint","code_information":[{"code":"27280","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":33471.73,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17342.86,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":33471.73,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13007.15,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":27583.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17689.72,"additional_payer_notes":"APC"}]}]},{"description":"Drainage of bone lesion","code_information":[{"code":"27303","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Neurectomy popliteal","code_information":[{"code":"27326","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1448.59,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1931.46,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3727.72,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1448.59,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1970.09,"additional_payer_notes":"APC"}]}]},{"description":"Remove knee joint lining","code_information":[{"code":"27334","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Remove femur lesion","code_information":[{"code":"27355","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Repair of kneecap tendon","code_information":[{"code":"27380","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":13851.98,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Lengthening of thigh tendons","code_information":[{"code":"27394","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":13851.98,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Repair of knee ligaments","code_information":[{"code":"27409","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Lat retinacular release open","code_information":[{"code":"27425","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Revision of knee joint","code_information":[{"code":"27440","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":24508.8,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12698.86,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":24508.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9524.15,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12952.84,"additional_payer_notes":"APC"}]}]},{"description":"Incision of thigh","code_information":[{"code":"27450","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Repair/graft of thigh","code_information":[{"code":"27472","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Reinforce thigh","code_information":[{"code":"27495","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Treatment of thigh fracture","code_information":[{"code":"27503","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1192.86,"maximum":4106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1590.48,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3069.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1192.86,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1622.29,"additional_payer_notes":"APC"}]}]},{"description":"Treatment of thigh fracture","code_information":[{"code":"27514","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":24508.8,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12698.86,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":24508.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9524.15,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12952.84,"additional_payer_notes":"APC"}]}]},{"description":"Treat knee fracture","code_information":[{"code":"27535","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Treat knee dislocation","code_information":[{"code":"27558","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Egd w/thrml txmnt gerd","code_information":[{"code":"43257","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2860.11,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3813.48,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7360.02,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2860.11,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3889.75,"additional_payer_notes":"APC"}]}]},{"description":"Egd endoscopic stent place","code_information":[{"code":"43266","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":11589.23,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6004.78,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11589.23,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4503.59,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6124.88,"additional_payer_notes":"APC"}]}]},{"description":"Lap myotomy heller","code_information":[{"code":"43279","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0}]}]},{"description":"Repair of esophagus","code_information":[{"code":"43310","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Esophagomyotomy abdominal","code_information":[{"code":"43330","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Esoph lengthening","code_information":[{"code":"43338","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5257.0,"maximum":6462.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5257.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6462.0}]}]},{"description":"Ligate/staple esophagus","code_information":[{"code":"43405","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Free jejunum flap microvasc","code_information":[{"code":"43496","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Excision of stomach lesion","code_information":[{"code":"43610","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Removal of stomach partial","code_information":[{"code":"43634","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Laparoscopy vagus nerve","code_information":[{"code":"43651","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4484.77,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5979.69,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5257.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11540.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4484.77,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6099.28,"additional_payer_notes":"APC"}]}]},{"description":"Dx duod intub w/asp spec","code_information":[{"code":"43756","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":672.83,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":897.11,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1731.42,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":672.83,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":915.05,"additional_payer_notes":"APC"}]}]},{"description":"Lap sleeve gastrectomy","code_information":[{"code":"43775","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5257.0,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5257.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0}]}]},{"description":"Repair of stomach lesion","code_information":[{"code":"43840","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2860.11,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3813.48,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7360.02,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2860.11,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3889.75,"additional_payer_notes":"APC"}]}]},{"description":"Revise stomach-bowel fusion","code_information":[{"code":"43865","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Stomach surgery procedure","code_information":[{"code":"43999","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":672.83,"maximum":13249.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":897.11,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":13249.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":10779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":13249.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1731.42,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":672.83,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":915.05,"additional_payer_notes":"APC"}]}]},{"description":"Correct malrotation of bowel","code_information":[{"code":"44055","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Enterectomy w/taper cong","code_information":[{"code":"44127","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Mobilization of colon","code_information":[{"code":"44139","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Removal of colon","code_information":[{"code":"44150","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Lap jejunostomy","code_information":[{"code":"44186","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4484.77,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5979.69,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5257.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11540.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4484.77,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6099.28,"additional_payer_notes":"APC"}]}]},{"description":"L colectomy/coloproctostomy","code_information":[{"code":"44207","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5257.0,"maximum":6462.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5257.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6462.0}]}]},{"description":"Open bowel to skin","code_information":[{"code":"44300","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1423.51,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1898.01,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3663.16,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1423.51,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1935.97,"additional_payer_notes":"APC"}]}]},{"description":"Revision of colostomy","code_information":[{"code":"44345","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2628.85,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3505.13,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6764.9,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2628.85,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3575.23,"additional_payer_notes":"APC"}]}]},{"description":"Small bowel endoscopy","code_information":[{"code":"44369","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1423.51,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1898.01,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3663.16,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1423.51,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1935.97,"additional_payer_notes":"APC"}]}]},{"description":"Small bowel endoscopy br/wa","code_information":[{"code":"44380","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":672.83,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":897.11,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1731.42,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":672.83,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":915.05,"additional_payer_notes":"APC"}]}]},{"description":"Colonoscopy for foreign body","code_information":[{"code":"44390","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":689.87,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":919.83,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1775.27,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":689.87,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":938.23,"additional_payer_notes":"APC"}]}]},{"description":"Colonoscopy w/dilation","code_information":[{"code":"44405","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":887.71,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1183.61,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2284.37,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":887.71,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1207.28,"additional_payer_notes":"APC"}]}]},{"description":"Repair of bowel lesion","code_information":[{"code":"44605","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Repair bowel-bladder fistula","code_information":[{"code":"44661","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Unlisted px small intestine","code_information":[{"code":"44799","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":672.83,"maximum":13249.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":897.11,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":13249.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":10779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":13249.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1731.42,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":672.83,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":915.05,"additional_payer_notes":"APC"}]}]},{"description":"Appendectomy","code_information":[{"code":"44960","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Removal of rectum","code_information":[{"code":"45110","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Removal of rectum and colon","code_information":[{"code":"45121","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Exc rect tum transanal part","code_information":[{"code":"45171","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2059.07,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2745.43,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5298.68,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2059.07,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2800.34,"additional_payer_notes":"APC"}]}]},{"description":"Proctosigmoidoscopy removal","code_information":[{"code":"45309","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":887.71,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1183.61,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2284.37,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":887.71,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1207.28,"additional_payer_notes":"APC"}]}]},{"description":"Middle cerebral artery echo","code_information":[{"code":"76821","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":77.56,"maximum":199.58,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":103.41,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":197.64},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":190.83},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":197.64},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":199.58,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":77.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":105.48,"additional_payer_notes":"APC"}]}]},{"description":"Ob us nuchal meas 1 gest","code_information":[{"code":"76813","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":77.56,"maximum":209.96,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":103.41,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":209.96},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":202.71},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":209.96},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":199.58,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":77.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":105.48,"additional_payer_notes":"APC"}]}]},{"description":"Us exam k transpl w/doppler","code_information":[{"code":"76776","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":77.56,"maximum":411.77,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":103.41,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":411.77},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":397.56},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":411.77},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":199.58,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":77.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":105.48,"additional_payer_notes":"APC"}]}]},{"description":"Us exam of head and neck","code_information":[{"code":"76536","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":77.56,"maximum":304.72,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":103.41,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":304.72},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":294.18},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":304.72},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":199.58,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":77.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":105.48,"additional_payer_notes":"APC"}]}]},{"description":"Ophth us b & quant a","code_information":[{"code":"76510","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":98.7,"maximum":282.56,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":131.6,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":282.56},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":272.79},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":282.56},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":253.99,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":98.7,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":134.23,"additional_payer_notes":"APC"}]}]},{"description":"3d render w/intrp postproces","code_information":[{"code":"76377","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":81.49,"maximum":84.41,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":84.41},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":81.49},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":84.41}]}]},{"description":"Mr safety implt pos&/immoblj","code_information":[{"code":"76019","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":43.76,"maximum":461.61,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":58.35,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":461.61},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":423.15},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":461.61},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":112.62,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":43.76,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":59.52,"additional_payer_notes":"APC"}]}]},{"description":"Abscess drainage under x-ray","code_information":[{"code":"75989","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":206.25,"maximum":213.64,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":213.64},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":206.25},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":213.64}]}]},{"description":"Remove cva device obstruct","code_information":[{"code":"75901","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":510.42,"maximum":528.68,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":528.68},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":510.42},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":528.68}]}]},{"description":"Vein x-ray eye socket","code_information":[{"code":"75880","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":355.98,"maximum":1197.51,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":620.47,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":368.71},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":355.98},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":368.71},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1197.51,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":465.35,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":632.88,"additional_payer_notes":"APC"}]}]},{"description":"Vein x-ray chest","code_information":[{"code":"75827","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":273.99,"maximum":3005.03,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1557.01,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":283.8},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":273.99},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":283.8},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3005.03,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1167.76,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1588.15,"additional_payer_notes":"APC"}]}]},{"description":"Lymph vessel x-ray arms/legs","code_information":[{"code":"75803","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":684.2,"maximum":3005.03,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1557.01,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":694.7},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":684.2},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":694.7},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3005.03,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1167.76,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1588.15,"additional_payer_notes":"APC"}]}]},{"description":"Artery x-rays adrenals","code_information":[{"code":"75733","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":400.15,"maximum":6027.57,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3123.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":414.47},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":400.15},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":414.47},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6027.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2342.32,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3185.56,"additional_payer_notes":"APC"}]}]},{"description":"Contrast exam abdominl aorta","code_information":[{"code":"75625","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":273.99,"maximum":6027.57,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3123.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":283.8},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":273.99},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":283.8},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6027.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2342.32,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3185.56,"additional_payer_notes":"APC"}]}]},{"description":"Card mri veloc flow mapping","code_information":[{"code":"75565","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":141.39,"maximum":146.45,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":146.45},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":141.39},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":146.45}]}]},{"description":"Mri fetal ea addl gestation","code_information":[{"code":"74713","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":470.04,"maximum":486.84,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":486.84},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":470.04},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":486.84}]}]},{"description":"Contrast x-ray bladder","code_information":[{"code":"74430","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":70.8,"maximum":665.99,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":345.07,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":73.35},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":70.8},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":73.35},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":665.99,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":258.81,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":351.98,"additional_payer_notes":"APC"}]}]},{"description":"X-ray guide intestinal tube","code_information":[{"code":"74355","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":345.63,"maximum":358.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":358.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":345.63},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":358.0}]}]},{"description":"Contrast x-ray exam of colon","code_information":[{"code":"74283","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":130.12,"maximum":351.47,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":173.49,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":351.47},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":339.33},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":351.47},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":334.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":130.12,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":176.96,"additional_payer_notes":"APC"}]}]},{"description":"X-ray sm int f-thru std","code_information":[{"code":"74248","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":155.12,"maximum":160.67,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":160.67},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":155.12},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":160.67}]}]},{"description":"X-ray exam of peritoneum","code_information":[{"code":"74190","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":116.54,"maximum":1043.1,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":540.46,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":118.33},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":116.54},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":118.33},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1043.1,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":405.35,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":551.27,"additional_payer_notes":"APC"}]}]},{"description":"Ct angio abdom w/o & w/dye","code_information":[{"code":"74175","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":130.12,"maximum":741.09,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":173.49,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":741.09},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":715.5},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":741.09},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":334.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":130.12,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":176.96,"additional_payer_notes":"APC"}]}]},{"description":"X-ray exam abdomen 1 view","code_information":[{"code":"74018","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":59.99,"maximum":166.13,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":86.08,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":62.1},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":59.99},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":62.1},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":166.13,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":64.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":87.8,"additional_payer_notes":"APC"}]}]},{"description":"Ct angio lwr extr w/o&w/dye","code_information":[{"code":"73706","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":130.12,"maximum":882.12,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":173.49,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":882.12},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":851.67},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":882.12},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":334.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":130.12,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":176.96,"additional_payer_notes":"APC"}]}]},{"description":"Contrast x-ray of ankle","code_information":[{"code":"73615","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":253.79,"maximum":665.99,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":345.07,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":262.87},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":253.79},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":262.87},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":665.99,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":258.81,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":351.98,"additional_payer_notes":"APC"}]}]},{"description":"X-ray exam of knee 3","code_information":[{"code":"73562","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":64.56,"maximum":166.13,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":86.08,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":89.34},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":86.25},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":89.34},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":166.13,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":64.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":87.8,"additional_payer_notes":"APC"}]}]},{"description":"X-ray exam hip uni 4/> views","code_information":[{"code":"73503","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":77.56,"maximum":199.58,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":103.41,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":127.47},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":123.08},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":127.47},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":199.58,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":77.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":105.48,"additional_payer_notes":"APC"}]}]},{"description":"Mri Upper Extremity W/Dye","code_information":[{"code":"73219","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":258.81,"maximum":1110.31,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":345.07,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":1110.31},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1071.95},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":1110.31},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":665.99,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":258.81,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":351.98,"additional_payer_notes":"APC"}]}]},{"description":"X-ray exam of hand","code_information":[{"code":"73120","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":57.74,"maximum":199.58,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":103.41,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":59.8},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":57.74},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":59.8},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":199.58,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":77.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":105.48,"additional_payer_notes":"APC"}]}]},{"description":"X-ray exam of elbow","code_information":[{"code":"73070","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":63.69,"maximum":166.13,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":86.08,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":65.95},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":63.69},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":65.95},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":166.13,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":64.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":87.8,"additional_payer_notes":"APC"}]}]},{"description":"X-ray of lower spine disk","code_information":[{"code":"72295","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":183.68,"maximum":3727.72,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1931.46,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":190.24},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":183.68},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":190.24},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3727.72,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1448.59,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1970.09,"additional_payer_notes":"APC"}]}]},{"description":"X-ray exam si joints","code_information":[{"code":"72200","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":64.88,"maximum":199.58,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":103.41,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":67.2},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":64.88},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":67.2},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":199.58,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":77.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":105.48,"additional_payer_notes":"APC"}]}]},{"description":"Ct angiograph pelv w/o&w/dye","code_information":[{"code":"72191","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":130.12,"maximum":737.42,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":173.49,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":737.42},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":711.93},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":737.42},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":334.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":130.12,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":176.96,"additional_payer_notes":"APC"}]}]},{"description":"Mri lumbar spine w/o dye","code_information":[{"code":"72148","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":177.0,"maximum":507.77,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":236.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":507.77},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":490.24},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":507.77},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":455.49,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":177.0,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":240.72,"additional_payer_notes":"APC"}]}]},{"description":"Ct chest spine w/o & w/dye","code_information":[{"code":"72130","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":130.12,"maximum":718.21,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":173.49,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":718.21},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":693.42},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":718.21},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":334.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":130.12,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":176.96,"additional_payer_notes":"APC"}]}]},{"description":"X-ray exam l-2 spine 4/>vws","code_information":[{"code":"72110","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":77.56,"maximum":199.58,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":103.41,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":112.73},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":108.83},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":112.73},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":199.58,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":77.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":105.48,"additional_payer_notes":"APC"}]}]},{"description":"X-ray exam thorac spine 2vws","code_information":[{"code":"72070","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":74.37,"maximum":199.58,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":103.41,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":77.03},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":74.37},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":77.03},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":199.58,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":77.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":105.48,"additional_payer_notes":"APC"}]}]},{"description":"Mri chest w/o dye","code_information":[{"code":"71550","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":177.0,"maximum":1173.06,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":236.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":1173.06},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1132.57},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":1173.06},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":455.49,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":177.0,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":240.72,"additional_payer_notes":"APC"}]}]},{"description":"X-ray exam ribs/chest4/> vws","code_information":[{"code":"71111","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":77.56,"maximum":199.58,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":103.41,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":106.57},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":102.88},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":106.57},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":199.58,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":77.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":105.48,"additional_payer_notes":"APC"}]}]},{"description":"Mri brain w/o & w/dye","code_information":[{"code":"70559","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":130.12,"maximum":4517.04,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":173.49,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4517.04},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4448.67},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4517.04},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":334.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":130.12,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":176.96,"additional_payer_notes":"APC"}]}]},{"description":"Mr angiograph neck w/o&w/dye","code_information":[{"code":"70549","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":258.81,"maximum":1762.57,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":345.07,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":1762.57},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1701.71},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":1762.57},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":665.99,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":258.81,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":351.98,"additional_payer_notes":"APC"}]}]},{"description":"Mri orbit/face/neck w/o dye","code_information":[{"code":"70540","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":177.0,"maximum":1002.01,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":236.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":1002.01},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":967.41},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":1002.01},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":455.49,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":177.0,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":240.72,"additional_payer_notes":"APC"}]}]},{"description":"Ct maxillofacial w/o dye","code_information":[{"code":"70486","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":77.56,"maximum":333.03,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":103.41,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":333.03},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":321.52},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":333.03},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":199.58,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":77.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":105.48,"additional_payer_notes":"APC"}]}]},{"description":"X-ray exam of salivary gland","code_information":[{"code":"70380","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":64.56,"maximum":166.13,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":86.08,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":91.8},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":88.63},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":91.8},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":166.13,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":64.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":87.8,"additional_payer_notes":"APC"}]}]},{"description":"X-ray exam of jaw joints","code_information":[{"code":"70330","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":64.56,"maximum":166.13,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":86.08,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":117.63},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":113.59},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":117.63},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":166.13,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":64.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":87.8,"additional_payer_notes":"APC"}]}]},{"description":"X-ray exam of sinuses","code_information":[{"code":"70220","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":64.56,"maximum":166.13,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":86.08,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":84.41},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":81.49},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":84.41},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":166.13,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":64.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":87.8,"additional_payer_notes":"APC"}]}]},{"description":"X-ray exam of middle ear","code_information":[{"code":"70134","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":111.2,"maximum":1043.1,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":540.46,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":115.18},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":111.2},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":115.18},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1043.1,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":405.35,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":551.27,"additional_payer_notes":"APC"}]}]},{"description":"Quan mri alys brn w/dx mri","code_information":[{"code":"0866T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":177.0,"maximum":653.39,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":236.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":653.39},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":598.94},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":653.39},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":455.49,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":177.0,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":240.72,"additional_payer_notes":"APC"}]}]},{"description":"Molec fluor img sus nev 1st","code_information":[{"code":"0700T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":106.8,"maximum":115.39,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":115.39},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":106.8},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":115.39}]}]},{"description":"Ct breast w/3d bi c-/c+","code_information":[{"code":"0638T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":258.81,"maximum":665.99,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":345.07,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":524.67},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":508.26},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":524.67},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":665.99,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":258.81,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":351.98,"additional_payer_notes":"APC"}]}]},{"description":"Mrs disc pain transmis data","code_information":[{"code":"0610T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":600.2,"maximum":609.43,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":609.43},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":600.2},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":609.43}]}]},{"description":"Antmc guide 3d print 1st gd","code_information":[{"code":"0561T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":98.7,"maximum":253.99,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":131.6,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":253.06},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":249.24},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":253.06},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":253.99,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":98.7,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":134.23,"additional_payer_notes":"APC"}]}]},{"description":"Insj wcs lv compl sys","code_information":[{"code":"0515T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1666.16,"maximum":54996.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22001.33,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":1719.96},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1666.16},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":1719.96},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":54996.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":54996.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":54996.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":42462.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16501.0,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":51942.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22441.36,"additional_payer_notes":"APC"}]}]},{"description":"Intraop oct breast cavity","code_information":[{"code":"0353T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1188.45,"maximum":1206.72,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":1206.72},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1188.45},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":1206.72}]}]},{"description":"Tear film img uni/bi w/i&r","code_information":[{"code":"0330T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":27.71,"maximum":118.21,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":36.94,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":118.21},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":116.43},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":118.21},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":71.3,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27.71,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":37.68,"additional_payer_notes":"APC"}]}]},{"description":"Drainage of pilonidal cyst","code_information":[{"code":"10080","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":525.32,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":700.42,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1351.81,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":525.32,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":714.43,"additional_payer_notes":"APC"}]}]},{"description":"Debride infected skin add-on","code_information":[{"code":"11001","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Deb subq tissue 20 sq cm/<","code_information":[{"code":"11042","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":301.57,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":402.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":776.03,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":301.57,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":410.13,"additional_payer_notes":"APC"}]}]},{"description":"Trim skin lesions over 4","code_information":[{"code":"11057","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":148.84,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":198.45,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":383.01,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":148.84,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":202.42,"additional_payer_notes":"APC"}]}]},{"description":"Shave skin lesion 0.6-1.0 cm","code_information":[{"code":"11306","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":148.84,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":198.45,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":383.01,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":148.84,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":202.42,"additional_payer_notes":"APC"}]}]},{"description":"Exc tr-ext b9+marg 0.6-1 cm","code_information":[{"code":"11401","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":301.57,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":402.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":776.03,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":301.57,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":410.13,"additional_payer_notes":"APC"}]}]},{"description":"Exc h-f-nk-sp b9+marg 2.1-3","code_information":[{"code":"11423","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1225.21,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1633.61,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3152.87,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1225.21,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1666.28,"additional_payer_notes":"APC"}]}]},{"description":"Exc face-mm b9+marg >4 cm","code_information":[{"code":"11446","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2154.81,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2873.08,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5545.05,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2154.81,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2930.54,"additional_payer_notes":"APC"}]}]},{"description":"Exc tr-ext mal+marg 0.6-1 cm","code_information":[{"code":"11601","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":525.32,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":700.42,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1351.81,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":525.32,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":714.43,"additional_payer_notes":"APC"}]}]},{"description":"Exc s/n/h/f/g mal+mrg 2.1-3","code_information":[{"code":"11623","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1225.21,"maximum":4106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1633.61,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3152.87,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1225.21,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1666.28,"additional_payer_notes":"APC"}]}]},{"description":"Exc f/e/e/n/l mal+mrg >4 cm","code_information":[{"code":"11646","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2154.81,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2873.08,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5545.05,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2154.81,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2930.54,"additional_payer_notes":"APC"}]}]},{"description":"Biopsy nail unit","code_information":[{"code":"11755","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":525.32,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":700.42,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1351.81,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":525.32,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":714.43,"additional_payer_notes":"APC"}]}]},{"description":"Inject skin lesions >7","code_information":[{"code":"11901","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":148.84,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":198.45,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":383.01,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":148.84,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":202.42,"additional_payer_notes":"APC"}]}]},{"description":"Insert tissue expander(s)","code_information":[{"code":"11960","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2628.85,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3505.13,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6764.9,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2628.85,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3575.23,"additional_payer_notes":"APC"}]}]},{"description":"Rpr s/n/ax/gen/trnk 2.5cm/<","code_information":[{"code":"12001","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":148.84,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":198.45,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":383.01,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":148.84,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":202.42,"additional_payer_notes":"APC"}]}]},{"description":"Rpr f/e/e/n/l/m 5.1-7.5 cm","code_information":[{"code":"12014","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":148.84,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":198.45,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":383.01,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":148.84,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":202.42,"additional_payer_notes":"APC"}]}]},{"description":"Intmd rpr s/a/t/ext 2.6-7.5","code_information":[{"code":"12032","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":301.57,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":402.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":776.03,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":301.57,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":410.13,"additional_payer_notes":"APC"}]}]},{"description":"Amputate leg at thigh","code_information":[{"code":"27592","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":27583.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":27583.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Drain lower leg lesion","code_information":[{"code":"27603","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2154.81,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2873.08,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5545.05,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2154.81,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2930.54,"additional_payer_notes":"APC"}]}]},{"description":"Biopsy lower leg soft tissue","code_information":[{"code":"27614","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2154.81,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2873.08,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5545.05,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2154.81,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2930.54,"additional_payer_notes":"APC"}]}]},{"description":"Removal of tendon lesion","code_information":[{"code":"27630","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Resect tibia tumor","code_information":[{"code":"27645","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Repair of leg tendon each","code_information":[{"code":"27658","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Revision of lower leg tendon","code_information":[{"code":"27685","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Repair of ankle ligament","code_information":[{"code":"27698","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":13851.98,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Realignment of lower leg","code_information":[{"code":"27712","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":24508.8,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12698.86,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":24508.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9524.15,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12952.84,"additional_payer_notes":"APC"}]}]},{"description":"Repair of tibia epiphysis","code_information":[{"code":"27730","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Treatment of tibia fracture","code_information":[{"code":"27756","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":13851.98,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Optx post ankle fx","code_information":[{"code":"27769","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Treatment of ankle fracture","code_information":[{"code":"27810","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1192.86,"maximum":4106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1590.48,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3069.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1192.86,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1622.29,"additional_payer_notes":"APC"}]}]},{"description":"Treat lower leg fracture","code_information":[{"code":"27826","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Treat ankle dislocation","code_information":[{"code":"27842","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1192.86,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1590.48,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3069.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1192.86,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1622.29,"additional_payer_notes":"APC"}]}]},{"description":"Amputation of lower leg","code_information":[{"code":"27882","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Leg/ankle surgery procedure","code_information":[{"code":"27899","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":182.99,"maximum":13249.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":243.98,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":13249.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":10779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":13249.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":470.88,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":182.99,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":248.86,"additional_payer_notes":"APC"}]}]},{"description":"Exploration of foot joint","code_information":[{"code":"28020","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Resect foot/toe tumor < 3 cm","code_information":[{"code":"28046","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2154.81,"maximum":5545.05,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2873.08,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5545.05,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2154.81,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2930.54,"additional_payer_notes":"APC"}]}]},{"description":"Removal of foot joint lining","code_information":[{"code":"28070","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":13851.98,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Shoulder arthroscopy/surgery","code_information":[{"code":"29825","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Shoulder arthroscopy/surgery","code_information":[{"code":"29806","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Repair of body cast","code_information":[{"code":"29720","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":120.55,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":160.73,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":310.21,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":120.55,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":163.95,"additional_payer_notes":"APC"}]}]},{"description":"Strapping of ankle and/or ft","code_information":[{"code":"29540","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":120.55,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":160.73,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":310.21,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":120.55,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":163.95,"additional_payer_notes":"APC"}]}]},{"description":"Apply short leg cast","code_information":[{"code":"29435","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":207.48,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":276.65,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":533.93,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":207.48,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":282.18,"additional_payer_notes":"APC"}]}]},{"description":"Application of hip cast","code_information":[{"code":"29305","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":207.48,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":276.65,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":533.93,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":207.48,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":282.18,"additional_payer_notes":"APC"}]}]},{"description":"Apply forearm splint","code_information":[{"code":"29125","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":98.7,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":131.6,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":253.99,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":98.7,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":134.23,"additional_payer_notes":"APC"}]}]},{"description":"Application of figure eight","code_information":[{"code":"29049","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":207.48,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":276.65,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":533.93,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":207.48,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":282.18,"additional_payer_notes":"APC"}]}]},{"description":"Foot/toes surgery procedure","code_information":[{"code":"28899","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":182.99,"maximum":13249.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":243.98,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":13249.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":10779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":13249.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":470.88,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":182.99,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":248.86,"additional_payer_notes":"APC"}]}]},{"description":"Fusion of big toe joint","code_information":[{"code":"28755","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":13851.98,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Fusion of foot bones","code_information":[{"code":"28705","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8923.0,"maximum":33471.73,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17342.86,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":10765.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":8923.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":10765.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":33471.73,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13007.15,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17689.72,"additional_payer_notes":"APC"}]}]},{"description":"Treat toe dislocation","code_information":[{"code":"28630","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":182.99,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":243.98,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":470.88,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":182.99,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":248.86,"additional_payer_notes":"APC"}]}]},{"description":"Treat foot dislocation","code_information":[{"code":"28570","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":182.99,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":243.98,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":470.88,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":182.99,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":248.86,"additional_payer_notes":"APC"}]}]},{"description":"Treatment of toe fracture","code_information":[{"code":"28515","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":182.99,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":243.98,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":470.88,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":182.99,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":248.86,"additional_payer_notes":"APC"}]}]},{"description":"Treat metatarsal fracture","code_information":[{"code":"28475","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":182.99,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":243.98,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":470.88,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":182.99,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":248.86,"additional_payer_notes":"APC"}]}]},{"description":"Treatment of ankle fracture","code_information":[{"code":"28436","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":13851.98,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Intmd rpr n-hf/genit12.6-20","code_information":[{"code":"12045","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":548.27,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":731.02,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1410.87,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":548.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":745.64,"additional_payer_notes":"APC"}]}]},{"description":"Intmd rpr face/mm 20.1-30.0","code_information":[{"code":"12056","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":301.57,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":402.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":776.03,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":301.57,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":410.13,"additional_payer_notes":"APC"}]}]},{"description":"Cmplx rpr f/c/c/m/n/ax/g/h/f","code_information":[{"code":"13131","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":301.57,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":402.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":776.03,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":301.57,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":410.13,"additional_payer_notes":"APC"}]}]},{"description":"Tis trnfr trunk 10.1-30sqcm","code_information":[{"code":"14001","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1530.61,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2040.81,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3938.76,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1530.61,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2081.63,"additional_payer_notes":"APC"}]}]},{"description":"Tis trnfr addl 30 sq cm/<","code_information":[{"code":"14302","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Skin splt grft trnk/arm/leg","code_information":[{"code":"15100","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1530.61,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2040.81,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3938.76,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1530.61,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2081.63,"additional_payer_notes":"APC"}]}]},{"description":"Derm autograft trnk/arm/leg","code_information":[{"code":"15130","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1530.61,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2040.81,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3938.76,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1530.61,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2081.63,"additional_payer_notes":"APC"}]}]},{"description":"Cult skin grft f/n/hfg add","code_information":[{"code":"15156","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Skin full graft een & lips","code_information":[{"code":"15260","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1530.61,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2040.81,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3938.76,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1530.61,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2081.63,"additional_payer_notes":"APC"}]}]},{"description":"Skn sub grft f/n/hf/g child","code_information":[{"code":"15277","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1530.61,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2040.81,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3938.76,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1530.61,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2081.63,"additional_payer_notes":"APC"}]}]},{"description":"Delay flap f/c/c/n/ax/g/h/f","code_information":[{"code":"15620","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1530.61,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2040.81,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3938.76,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1530.61,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2081.63,"additional_payer_notes":"APC"}]}]},{"description":"Neurovascular pedicle flap","code_information":[{"code":"15750","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2628.85,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3505.13,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6764.9,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2628.85,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3575.23,"additional_payer_notes":"APC"}]}]},{"description":"Acellular derm matrix implt","code_information":[{"code":"15777","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Chemical peel face dermal","code_information":[{"code":"15789","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":548.27,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":731.02,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1410.87,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":548.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":745.64,"additional_payer_notes":"APC"}]}]},{"description":"Removal of neck wrinkles","code_information":[{"code":"15825","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2628.85,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3505.13,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6764.9,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2628.85,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3575.23,"additional_payer_notes":"APC"}]}]},{"description":"Excise excessive skin buttck","code_information":[{"code":"15835","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2154.81,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2873.08,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5545.05,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2154.81,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2930.54,"additional_payer_notes":"APC"}]}]},{"description":"Skin and muscle repair face","code_information":[{"code":"15845","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2628.85,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3505.13,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6764.9,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2628.85,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3575.23,"additional_payer_notes":"APC"}]}]},{"description":"Suction lipectomy lwr extrem","code_information":[{"code":"15879","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2628.85,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3505.13,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6764.9,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2628.85,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3575.23,"additional_payer_notes":"APC"}]}]},{"description":"Remove sacrum pressure sore","code_information":[{"code":"15937","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1530.61,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2040.81,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3938.76,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1530.61,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2081.63,"additional_payer_notes":"APC"}]}]},{"description":"Remove thigh pressure sore","code_information":[{"code":"15952","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1530.61,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2040.81,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3938.76,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1530.61,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2081.63,"additional_payer_notes":"APC"}]}]},{"description":"Dress/debrid p-thick burn l","code_information":[{"code":"16030","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":301.57,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":402.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":776.03,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":301.57,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":410.13,"additional_payer_notes":"APC"}]}]},{"description":"Ablate bone tumor(s) perq","code_information":[{"code":"20982","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6779.0,"maximum":33471.73,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17342.86,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":33471.73,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13007.15,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17689.72,"additional_payer_notes":"APC"}]}]},{"description":"Exc face tum deep 2 cm/>","code_information":[{"code":"21014","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2154.81,"maximum":5545.05,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2873.08,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5545.05,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2154.81,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2930.54,"additional_payer_notes":"APC"}]}]},{"description":"Remove exostosis maxilla","code_information":[{"code":"21032","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2459.51,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3279.35,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6329.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2459.51,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3344.94,"additional_payer_notes":"APC"}]}]},{"description":"Excis uppr jaw cyst w/repair","code_information":[{"code":"21049","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Electrical bone stimulation","code_information":[{"code":"20974","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":34.51,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":46.01,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":88.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":34.51,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":46.93,"additional_payer_notes":"APC"}]}]},{"description":"Fibula bone graft microvasc","code_information":[{"code":"20955","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Removal of fascia for graft","code_information":[{"code":"20922","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1530.61,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2040.81,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3938.76,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1530.61,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2081.63,"additional_payer_notes":"APC"}]}]},{"description":"Replantation thumb complete","code_information":[{"code":"20824","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1192.86,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1590.48,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3069.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1192.86,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1622.29,"additional_payer_notes":"APC"}]}]},{"description":"Remove bone fixation device","code_information":[{"code":"20694","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1192.86,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1590.48,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3069.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1192.86,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1622.29,"additional_payer_notes":"APC"}]}]},{"description":"Application of thigh brace","code_information":[{"code":"20663","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Drain/inj joint/bursa w/o us","code_information":[{"code":"20610","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":227.71,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":303.61,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":585.96,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":227.71,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":309.68,"additional_payer_notes":"APC"}]}]},{"description":"Inj tendon origin/insertion","code_information":[{"code":"20551","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":227.71,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":303.61,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":585.96,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":227.71,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":309.68,"additional_payer_notes":"APC"}]}]},{"description":"Open bone biopsy","code_information":[{"code":"20251","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":13851.98,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Muscle biopsy","code_information":[{"code":"20200","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1225.21,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1633.61,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3152.87,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1225.21,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1666.28,"additional_payer_notes":"APC"}]}]},{"description":"Revise breast reconstruction","code_information":[{"code":"19380","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4925.89,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6567.85,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":7398.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6019.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":7398.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":12675.95,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4925.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6699.21,"additional_payer_notes":"APC"}]}]},{"description":"Reconstruct cleft foot","code_information":[{"code":"28360","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Repair deformity of toe","code_information":[{"code":"28313","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Incision of midfoot bones","code_information":[{"code":"28304","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Corrj halux rigdus w/o implt","code_information":[{"code":"28289","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Revision of foot and ankle","code_information":[{"code":"28262","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":13851.98,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Incision of foot tendon(s)","code_information":[{"code":"28230","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1192.86,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1590.48,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3069.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1192.86,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1622.29,"additional_payer_notes":"APC"}]}]},{"description":"Repair of foot tendon","code_information":[{"code":"28200","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7009.0},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Partial removal of toe","code_information":[{"code":"28153","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Removal of heel spur","code_information":[{"code":"28119","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Removal of toe lesions","code_information":[{"code":"28108","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1192.86,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1590.48,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3069.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1192.86,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1622.29,"additional_payer_notes":"APC"}]}]},{"description":"Removal of foot lesion","code_information":[{"code":"28090","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1192.86,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1590.48,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3069.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1192.86,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1622.29,"additional_payer_notes":"APC"}]}]},{"description":"Insert cath pleura w/o image","code_information":[{"code":"32556","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1423.51,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1898.01,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3663.16,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1423.51,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1935.97,"additional_payer_notes":"APC"}]}]},{"description":"Thoracoscopy w/bx infiltrate","code_information":[{"code":"32607","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5257.0,"maximum":20292.15,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10514.07,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5257.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":20292.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7885.55,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10724.35,"additional_payer_notes":"APC"}]}]},{"description":"Thoracoscopy resect bullae","code_information":[{"code":"32655","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5257.0,"maximum":27583.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5257.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":27583.0}]}]},{"description":"Thoracoscop w/esoph musc exc","code_information":[{"code":"32665","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5257.0,"maximum":6462.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5257.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6462.0}]}]},{"description":"Remove nasal foreign body","code_information":[{"code":"30320","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1151.01,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1534.69,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2961.94,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1151.01,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1565.38,"additional_payer_notes":"APC"}]}]},{"description":"Resect inferior turbinate","code_information":[{"code":"30140","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2459.51,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3279.35,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6329.15,"additional_payer_notes":"APC"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":4226.0},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2459.51,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3344.94,"additional_payer_notes":"APC"}]}]},{"description":"Removal of nose polyp(s)","code_information":[{"code":"30110","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1151.01,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1534.69,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2961.94,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1151.01,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1565.38,"additional_payer_notes":"APC"}]}]},{"description":"Subtalar arthro w/fusion","code_information":[{"code":"29907","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":24508.8,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12698.86,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":24508.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9524.15,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12952.84,"additional_payer_notes":"APC"}]}]},{"description":"Ankle arthroscopy/surgery","code_information":[{"code":"29898","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Knee arthroscopy/surgery","code_information":[{"code":"29888","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7455.0},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Knee arthroscopy/surgery","code_information":[{"code":"29880","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5067.0},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Knee arthroscopy dx","code_information":[{"code":"29870","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Tibial arthroscopy/surgery","code_information":[{"code":"29856","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":24508.8,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12698.86,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":24508.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9524.15,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12952.84,"additional_payer_notes":"APC"}]}]},{"description":"Wrist arthroscopy/surgery","code_information":[{"code":"29844","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Revision of nose","code_information":[{"code":"30460","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Repair mouth/nose fistula","code_information":[{"code":"30600","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Repeat control of nosebleed","code_information":[{"code":"30906","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":175.7,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":234.27,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":452.14,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":175.7,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":238.96,"additional_payer_notes":"APC"}]}]},{"description":"Exploration maxillary sinus","code_information":[{"code":"31030","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Removal of frontal sinus","code_information":[{"code":"31081","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Removal of ethmoid sinus","code_information":[{"code":"31205","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2459.51,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3279.35,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6329.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2459.51,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3344.94,"additional_payer_notes":"APC"}]}]},{"description":"Nasal/sinus endoscopy surg","code_information":[{"code":"31239","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2765.81,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3687.74,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7117.34,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2765.81,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3761.5,"additional_payer_notes":"APC"}]}]},{"description":"Nasal/sinus endoscopy surg","code_information":[{"code":"31288","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4956.0,"maximum":13472.56,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6980.6,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":7398.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6019.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":7398.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13472.56,"additional_payer_notes":"APC"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":4956.0},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5235.45,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7120.21,"additional_payer_notes":"APC"}]}]},{"description":"Sinus endo w/balloon dil","code_information":[{"code":"31297","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5235.45,"maximum":13472.56,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6980.6,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":7398.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6019.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":7398.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13472.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5235.45,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7120.21,"additional_payer_notes":"APC"}]}]},{"description":"Partial removal of larynx","code_information":[{"code":"31375","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Change of windpipe airway","code_information":[{"code":"31502","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":175.7,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":234.27,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":452.14,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":175.7,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":238.96,"additional_payer_notes":"APC"}]}]},{"description":"Breast reconstruction","code_information":[{"code":"19357","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":26307.58,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13630.87,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":26307.58,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10223.15,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13903.49,"additional_payer_notes":"APC"}]}]},{"description":"Reduction of large breast","code_information":[{"code":"19318","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4925.89,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6567.85,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":7398.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6019.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":7398.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":12675.95,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4925.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6699.21,"additional_payer_notes":"APC"}]}]},{"description":"Removal of Breast Tissue","code_information":[{"code":"19300","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2904.59,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3872.79,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7474.49,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2904.59,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3950.25,"additional_payer_notes":"APC"}]}]},{"description":"Perq dev breast add strtctc","code_information":[{"code":"19284","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Nipple exploration","code_information":[{"code":"19110","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2904.59,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3872.79,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7474.49,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2904.59,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3950.25,"additional_payer_notes":"APC"}]}]},{"description":"Bx breast add lesion strtctc","code_information":[{"code":"19082","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Skin peel therapy","code_information":[{"code":"17360","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":148.84,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":198.45,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":383.01,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":148.84,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":202.42,"additional_payer_notes":"APC"}]}]},{"description":"Destruction of skin lesions","code_information":[{"code":"17284","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":548.27,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":731.02,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1410.87,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":548.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":745.64,"additional_payer_notes":"APC"}]}]},{"description":"Destruction of skin lesions","code_information":[{"code":"17272","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":148.84,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":198.45,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":383.01,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":148.84,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":202.42,"additional_payer_notes":"APC"}]}]},{"description":"Destruction of skin lesions","code_information":[{"code":"17260","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":148.84,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":198.45,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":383.01,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":148.84,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":202.42,"additional_payer_notes":"APC"}]}]},{"description":"Prepare face/oral prosthesis","code_information":[{"code":"21081","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Prepare face/oral prosthesis","code_information":[{"code":"21089","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":175.7,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":234.27,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":452.14,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":175.7,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":238.96,"additional_payer_notes":"APC"}]}]},{"description":"Augmentation lower jaw bone","code_information":[{"code":"21125","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":11300.84,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Lefort i-1 piece w/ graft","code_information":[{"code":"21145","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Lefort iii w/fhd w/ lefort i","code_information":[{"code":"21160","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Reconstruct cranial bone","code_information":[{"code":"21184","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Reconstruct upper jaw bone","code_information":[{"code":"21206","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Reconstruction of jaw joint","code_information":[{"code":"21242","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Reconstruct lower jaw bone","code_information":[{"code":"21255","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Revision orbitofacial bones","code_information":[{"code":"21275","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Open tx nose fx uncomplicatd","code_information":[{"code":"21325","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2459.51,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3279.35,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6329.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2459.51,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3344.94,"additional_payer_notes":"APC"}]}]},{"description":"Open tx dprsd front sinus fx","code_information":[{"code":"21343","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Opn tx dprsd malar fracture","code_information":[{"code":"21360","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":11300.84,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Closed tx orbit w/o manipulj","code_information":[{"code":"21400","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":400.09,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":533.45,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1029.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":400.09,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":544.12,"additional_payer_notes":"APC"}]}]},{"description":"Treat craniofacial fracture","code_information":[{"code":"21431","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Treat lower jaw fracture","code_information":[{"code":"21451","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1151.01,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1534.69,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2961.94,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1151.01,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1565.38,"additional_payer_notes":"APC"}]}]},{"description":"Reset dislocated jaw","code_information":[{"code":"21480","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":182.99,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":243.98,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":470.88,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":182.99,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":248.86,"additional_payer_notes":"APC"}]}]},{"description":"Biopsy of neck/chest","code_information":[{"code":"21550","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1225.21,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1633.61,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3152.87,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1225.21,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1666.28,"additional_payer_notes":"APC"}]}]},{"description":"Partial removal of rib","code_information":[{"code":"21610","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Revision of neck muscle/rib","code_information":[{"code":"21705","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3388.0,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Treatment of rib fracture","code_information":[{"code":"21812","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":13851.98,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Exc back les sc 3 cm/>","code_information":[{"code":"21931","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1225.21,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1633.61,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3152.87,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1225.21,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1666.28,"additional_payer_notes":"APC"}]}]},{"description":"Remove part thorax vertebra","code_information":[{"code":"22101","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Incis spine 3 column lumbar","code_information":[{"code":"22207","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Incis w/discectomy lumbar","code_information":[{"code":"22224","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Treat thorax spine fracture","code_information":[{"code":"22327","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":24508.8,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12698.86,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":24508.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9524.15,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12952.84,"additional_payer_notes":"APC"}]}]},{"description":"Perq vertebral augmentation","code_information":[{"code":"22515","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Addl neck spine fusion","code_information":[{"code":"22552","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5512.0,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0}]}]},{"description":"Neck spine fusion","code_information":[{"code":"22600","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":33471.73,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17342.86,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":33471.73,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13007.15,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":27583.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17689.72,"additional_payer_notes":"APC"}]}]},{"description":"Post fusion <=6 vert seg","code_information":[{"code":"22800","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":33471.73,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17342.86,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":33471.73,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13007.15,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":27583.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17689.72,"additional_payer_notes":"APC"}]}]},{"description":"Exploration of spinal fusion","code_information":[{"code":"22830","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Insert spine fixation device","code_information":[{"code":"22847","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3388.0,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0}]}]},{"description":"Second level cer diskectomy","code_information":[{"code":"22858","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Exc abd les sc < 3 cm","code_information":[{"code":"22902","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1225.21,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1633.61,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3152.87,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1225.21,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1666.28,"additional_payer_notes":"APC"}]}]},{"description":"Drain shoulder bursa","code_information":[{"code":"23031","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2154.81,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2873.08,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5545.05,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2154.81,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2930.54,"additional_payer_notes":"APC"}]}]},{"description":"Exc shoulder les sc < 3 cm","code_information":[{"code":"23075","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1225.21,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1633.61,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3152.87,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1225.21,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1666.28,"additional_payer_notes":"APC"}]}]},{"description":"Explore treat shoulder joint","code_information":[{"code":"23107","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":13851.98,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Removal of humerus lesion","code_information":[{"code":"23155","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":13851.98,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Partial removal of scapula","code_information":[{"code":"23190","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Shoulder prosthesis removal","code_information":[{"code":"23335","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":13851.98,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Repair rotator cuff chronic","code_information":[{"code":"23412","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Repair shoulder capsule","code_information":[{"code":"23462","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Revision of collar bone","code_information":[{"code":"23485","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":24508.8,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12698.86,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":24508.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9524.15,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12952.84,"additional_payer_notes":"APC"}]}]},{"description":"Treat clavicle dislocation","code_information":[{"code":"23530","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Treat scapula fracture","code_information":[{"code":"23585","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Treat shoulder dislocation","code_information":[{"code":"23650","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":182.99,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":243.98,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":470.88,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":182.99,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":248.86,"additional_payer_notes":"APC"}]}]},{"description":"Fusion of shoulder joint","code_information":[{"code":"23800","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Drain arm/elbow bone lesion","code_information":[{"code":"23935","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Ex arm/elbow tum deep < 5 cm","code_information":[{"code":"24076","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2154.81,"maximum":5545.05,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2873.08,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5545.05,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2154.81,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2930.54,"additional_payer_notes":"APC"}]}]},{"description":"Remove/graft bone lesion","code_information":[{"code":"24115","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":13851.98,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Remove elbow bone lesion","code_information":[{"code":"24138","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":13851.98,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Remove elbow joint implant","code_information":[{"code":"24160","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Revision of arm tendon","code_information":[{"code":"24310","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Repr elbow lat ligmnt w/tiss","code_information":[{"code":"24343","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Reconstruct elbow joint","code_information":[{"code":"24361","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8923.0,"maximum":33471.73,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17342.86,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":10765.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":8923.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":10765.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":33471.73,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13007.15,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":27583.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17689.72,"additional_payer_notes":"APC"}]}]},{"description":"Revision of humerus","code_information":[{"code":"24410","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":24508.8,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12698.86,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":24508.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9524.15,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12952.84,"additional_payer_notes":"APC"}]}]},{"description":"Treat humerus fracture","code_information":[{"code":"24505","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1192.86,"maximum":4106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1590.48,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3069.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1192.86,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1622.29,"additional_payer_notes":"APC"}]}]},{"description":"Treat humerus fracture","code_information":[{"code":"24560","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":182.99,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":243.98,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":470.88,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":182.99,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":248.86,"additional_payer_notes":"APC"}]}]},{"description":"Treat elbow fracture","code_information":[{"code":"24586","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":24508.8,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12698.86,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":24508.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9524.15,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12952.84,"additional_payer_notes":"APC"}]}]},{"description":"Treat radius fracture","code_information":[{"code":"24650","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":182.99,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":243.98,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":470.88,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":182.99,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":248.86,"additional_payer_notes":"APC"}]}]},{"description":"Fusion/graft of elbow joint","code_information":[{"code":"24802","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":24508.8,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12698.86,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":24508.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9524.15,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12952.84,"additional_payer_notes":"APC"}]}]},{"description":"Upper arm/elbow surgery","code_information":[{"code":"24999","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":182.99,"maximum":13249.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":243.98,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":13249.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":10779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":13249.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":470.88,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":182.99,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":248.86,"additional_payer_notes":"APC"}]}]},{"description":"Dx laryngoscopy excl nb","code_information":[{"code":"31525","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1320.39,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1760.51,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3397.79,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1320.39,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1795.72,"additional_payer_notes":"APC"}]}]},{"description":"Laryngoscopy w/bx & op scope","code_information":[{"code":"31536","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2765.81,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3687.74,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7117.34,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2765.81,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3761.5,"additional_payer_notes":"APC"}]}]},{"description":"Laryngoscop w/vc inj + scope","code_information":[{"code":"31571","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2765.81,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3687.74,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7117.34,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2765.81,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3761.5,"additional_payer_notes":"APC"}]}]},{"description":"Laryngoplasty cricoid split","code_information":[{"code":"31587","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Surgery/speech prosthesis","code_information":[{"code":"31611","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2459.51,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3279.35,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6329.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2459.51,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3344.94,"additional_payer_notes":"APC"}]}]},{"description":"Bronchoscopy w/biopsy(s)","code_information":[{"code":"31625","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1320.39,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1760.51,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3397.79,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1320.39,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1795.72,"additional_payer_notes":"APC"}]}]},{"description":"Bronchoscopy/needle bx addl","code_information":[{"code":"31633","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Diag bronchoscope/catheter","code_information":[{"code":"31643","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1320.39,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1760.51,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3397.79,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1320.39,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1795.72,"additional_payer_notes":"APC"}]}]},{"description":"Bronch ebus samplng 3/> node","code_information":[{"code":"31653","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2765.81,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3687.74,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7117.34,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2765.81,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3761.5,"additional_payer_notes":"APC"}]}]},{"description":"Repair of windpipe","code_information":[{"code":"31750","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Remove windpipe lesion","code_information":[{"code":"31785","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":11300.84,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Thoracostomy w/rib resection","code_information":[{"code":"32035","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5257.0,"maximum":6462.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5257.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6462.0}]}]},{"description":"Explore chest free adhesions","code_information":[{"code":"32124","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6019.0,"maximum":7398.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":7398.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6019.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":7398.0}]}]},{"description":"Release of lung","code_information":[{"code":"32220","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5257.0,"maximum":6462.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5257.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6462.0}]}]},{"description":"Partial removal of lung","code_information":[{"code":"32480","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":9356.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0}]}]},{"description":"Resect apical lung tum/chest","code_information":[{"code":"32504","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":9356.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0}]}]},{"description":"Thoracoscopy bilobectomy","code_information":[{"code":"32670","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5257.0,"maximum":6462.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5257.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6462.0}]}]},{"description":"Close bronchial fistula","code_information":[{"code":"32815","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5257.0,"maximum":6462.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5257.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6462.0}]}]},{"description":"Prepare donor lung double","code_information":[{"code":"32856","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5257.0,"maximum":6462.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5257.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6462.0}]}]},{"description":"Chest surgery procedure","code_information":[{"code":"32999","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":465.35,"maximum":13249.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":620.47,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":13249.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":10779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":13249.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1197.51,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":465.35,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":632.88,"additional_payer_notes":"APC"}]}]},{"description":"Heart revascularize (tmr)","code_information":[{"code":"33140","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6019.0,"maximum":7398.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":7398.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6019.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":7398.0}]}]},{"description":"Insert card electrodes dual","code_information":[{"code":"33211","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6138.95,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8185.27,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":15797.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6138.95,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8348.97,"additional_payer_notes":"APC"}]}]},{"description":"Repair lead pace-defib dual","code_information":[{"code":"33220","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2772.2,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3696.26,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7133.79,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2772.2,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3770.19,"additional_payer_notes":"APC"}]}]},{"description":"Remv&replc pm gen dual lead","code_information":[{"code":"33228","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":27583.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10338.17,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":19952.66,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7753.63,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":27583.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10544.93,"additional_payer_notes":"APC"}]}]},{"description":"Remove electrode/thoracotomy","code_information":[{"code":"33237","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Ablate heart dysrhythm focus","code_information":[{"code":"33251","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6019.0,"maximum":7398.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":7398.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6019.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":7398.0}]}]},{"description":"Rmvl& replc pulse gen 1 lead","code_information":[{"code":"33262","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8923.0,"maximum":54996.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22001.33,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":10765.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":8923.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":10765.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":54996.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":54996.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":54996.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":42462.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16501.0,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":51942.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22441.36,"additional_payer_notes":"APC"}]}]},{"description":"Repos prev impltbl subq dfb","code_information":[{"code":"33273","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2772.2,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3696.26,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7133.79,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2772.2,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3770.19,"additional_payer_notes":"APC"}]}]},{"description":"Insert major vessel graft","code_information":[{"code":"33330","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6019.0,"maximum":7398.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":7398.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6019.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":7398.0}]}]},{"description":"Replace aortic valve w/byp","code_information":[{"code":"33367","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":9356.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0}]}]},{"description":"Replacement of aortic valve","code_information":[{"code":"33412","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":9356.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0}]}]},{"description":"Revision of mitral valve","code_information":[{"code":"33420","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":9356.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0}]}]},{"description":"Valvuloplasty tricuspid","code_information":[{"code":"33464","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":9356.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0}]}]},{"description":"Repair prosth valve clot","code_information":[{"code":"33496","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6019.0,"maximum":7398.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":7398.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6019.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":7398.0}]}]},{"description":"Repair art intramural","code_information":[{"code":"33507","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":9356.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0}]}]},{"description":"Cabg artery-vein single","code_information":[{"code":"33517","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":9356.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0}]}]},{"description":"Drainage of forearm bursa","code_information":[{"code":"25031","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1192.86,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1590.48,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3069.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1192.86,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1622.29,"additional_payer_notes":"APC"}]}]},{"description":"Exc forearm tum deep < 3 cm","code_information":[{"code":"25076","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1225.21,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1633.61,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3152.87,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1225.21,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1666.28,"additional_payer_notes":"APC"}]}]},{"description":"Excise tendon forearm/wrist","code_information":[{"code":"25109","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Removal of forearm lesion","code_information":[{"code":"25120","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Partial removal of radius","code_information":[{"code":"25151","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Removal of wrist prosthesis","code_information":[{"code":"25250","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1192.86,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1590.48,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3069.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1192.86,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1622.29,"additional_payer_notes":"APC"}]}]},{"description":"Repair forearm tendon/muscle","code_information":[{"code":"25274","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Transplant forearm tendon","code_information":[{"code":"25312","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Revision of radius","code_information":[{"code":"25355","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Lengthen radius & ulna","code_information":[{"code":"25393","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Vasc graft into carpal bone","code_information":[{"code":"25430","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Wrist replacement","code_information":[{"code":"25446","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8923.0,"maximum":33471.73,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17342.86,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":10765.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":8923.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":10765.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":33471.73,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13007.15,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":27583.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17689.72,"additional_payer_notes":"APC"}]}]},{"description":"Treat fracture of radius","code_information":[{"code":"25500","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":182.99,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":243.98,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":470.88,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":182.99,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":248.86,"additional_payer_notes":"APC"}]}]},{"description":"Treat fracture of ulna","code_information":[{"code":"25545","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Treat Fx Rad Extra-Articul","code_information":[{"code":"25607","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Treat wrist bone fracture","code_information":[{"code":"25645","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Treat wrist dislocation","code_information":[{"code":"25676","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":13851.98,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Fusion of hand bones","code_information":[{"code":"25820","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Amputate hand at wrist","code_information":[{"code":"25920","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Drainage of finger abscess","code_information":[{"code":"26011","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1225.21,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1633.61,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3152.87,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1225.21,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1666.28,"additional_payer_notes":"APC"}]}]},{"description":"Release palm contracture","code_information":[{"code":"26045","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Biopsy finger joint lining","code_information":[{"code":"26110","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1192.86,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1590.48,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3069.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1192.86,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1622.29,"additional_payer_notes":"APC"}]}]},{"description":"Release palm contracture","code_information":[{"code":"26123","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Removal of finger tendon","code_information":[{"code":"26180","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1192.86,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1590.48,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3069.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1192.86,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1622.29,"additional_payer_notes":"APC"}]}]},{"description":"Partial removal finger bone","code_information":[{"code":"26236","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1192.86,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1590.48,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3069.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1192.86,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1622.29,"additional_payer_notes":"APC"}]}]},{"description":"Repair/graft hand tendon","code_information":[{"code":"26352","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":13851.98,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Repair/graft hand tendon","code_information":[{"code":"26392","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":13851.98,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Repair/graft finger tendon","code_information":[{"code":"26428","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Release forearm/hand tendon","code_information":[{"code":"26449","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Lengthening of hand tendon","code_information":[{"code":"26478","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":6246.19,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Hand tendon/muscle transfer","code_information":[{"code":"26494","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Thumb tendon transfer","code_information":[{"code":"26510","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Revise finger joint","code_information":[{"code":"26535","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Construct thumb replacement","code_information":[{"code":"26550","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Repair of web finger","code_information":[{"code":"26562","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Release muscles of hand","code_information":[{"code":"26593","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":6246.19,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Cabg arterial two","code_information":[{"code":"33534","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":9356.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0}]}]},{"description":"Closure of valve","code_information":[{"code":"33602","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":9356.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0}]}]},{"description":"Repair single ventricle","code_information":[{"code":"33619","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":9356.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0}]}]},{"description":"Repair of heart defects","code_information":[{"code":"33665","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":9356.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0}]}]},{"description":"Reinforce pulmonary artery","code_information":[{"code":"33690","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6019.0,"maximum":7398.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":7398.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6019.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":7398.0}]}]},{"description":"Repair Pul Venous Stenosis","code_information":[{"code":"33726","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6019.0,"maximum":7398.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":7398.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6019.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":7398.0}]}]},{"description":"Major vessel shunt & graft","code_information":[{"code":"33764","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6019.0,"maximum":7398.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":7398.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6019.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":7398.0}]}]},{"description":"Repair great vessels defect","code_information":[{"code":"33776","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6019.0,"maximum":7398.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":7398.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6019.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":7398.0}]}]},{"description":"Repair arterial trunk","code_information":[{"code":"33786","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6019.0,"maximum":7398.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":7398.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6019.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":7398.0}]}]},{"description":"Revise major vessel","code_information":[{"code":"33824","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6019.0,"maximum":43643.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":7398.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6019.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":7398.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43643.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43643.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43643.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":41120.0}]}]},{"description":"Thoracic aortic graft","code_information":[{"code":"33875","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":9356.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0}]}]},{"description":"Car-car bp grft/endovas taa","code_information":[{"code":"33891","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":9356.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0}]}]},{"description":"Rpr pul art unifocal w/o cpb","code_information":[{"code":"33925","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6019.0,"maximum":7398.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":7398.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6019.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":7398.0}]}]},{"description":"Ecmo/ecls initiation venous","code_information":[{"code":"33946","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3388.0,"maximum":4106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0}]}]},{"description":"Ecmo/ecls insj ctr cannula","code_information":[{"code":"33955","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3388.0,"maximum":4106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0}]}]},{"description":"Ecmo/ecls rmvl perph cannula","code_information":[{"code":"33965","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3388.0,"maximum":4106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0}]}]},{"description":"Remove intra-aortic balloon","code_information":[{"code":"33974","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Replace vad intra w/o bp","code_information":[{"code":"33982","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":9356.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0}]}]},{"description":"Insert vad artery access","code_information":[{"code":"33990","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":9356.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0}]}]},{"description":"Removal of arm artery clot","code_information":[{"code":"34111","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4127.91,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5503.89,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":10622.5,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4127.91,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5613.96,"additional_payer_notes":"APC"}]}]},{"description":"Removal of vein clot","code_information":[{"code":"34490","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2342.32,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3123.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6027.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2342.32,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3185.56,"additional_payer_notes":"APC"}]}]},{"description":"Femoral endovas graft add-on","code_information":[{"code":"34813","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Endovasc visc aorta 1 graft","code_information":[{"code":"34841","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6019.0,"maximum":7398.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":7398.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6019.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":7398.0}]}]},{"description":"Repair defect of artery","code_information":[{"code":"35001","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6019.0,"maximum":7398.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":7398.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6019.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":7398.0}]}]},{"description":"Repair defect of artery","code_information":[{"code":"35081","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Repair defect of artery","code_information":[{"code":"35121","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Repair blood vessel lesion","code_information":[{"code":"35180","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1167.76,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1557.01,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3005.03,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1167.76,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1588.15,"additional_payer_notes":"APC"}]}]},{"description":"Repair blood vessel lesion","code_information":[{"code":"35207","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2342.32,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3123.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6027.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2342.32,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3185.56,"additional_payer_notes":"APC"}]}]},{"description":"Repair blood vessel lesion","code_information":[{"code":"35246","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Repair blood vessel lesion","code_information":[{"code":"35286","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4127.91,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5503.89,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":10622.5,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4127.91,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5613.96,"additional_payer_notes":"APC"}]}]},{"description":"Rechanneling of artery","code_information":[{"code":"35321","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4127.91,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5503.89,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":10622.5,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4127.91,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5613.96,"additional_payer_notes":"APC"}]}]},{"description":"Rechanneling of artery","code_information":[{"code":"35372","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5503.89,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":10622.5,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4127.91,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5613.96,"additional_payer_notes":"APC"}]}]},{"description":"Art byp grft carotid-brchial","code_information":[{"code":"35510","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Art byp grft brchl-ulnr-rdl","code_information":[{"code":"35523","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Art byp grft aortobi-iliac","code_information":[{"code":"35538","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Art byp fem-ant-post tib/prl","code_information":[{"code":"35566","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Treatment of heel fracture","code_information":[{"code":"28400","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":182.99,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":243.98,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":470.88,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":182.99,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":248.86,"additional_payer_notes":"APC"}]}]},{"description":"Removal of sesamoid bone","code_information":[{"code":"28315","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Incise/graft midfoot bones","code_information":[{"code":"28305","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Correction hallux valgus","code_information":[{"code":"28292","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Release of midfoot joint","code_information":[{"code":"28264","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1192.86,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1590.48,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3069.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1192.86,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1622.29,"additional_payer_notes":"APC"}]}]},{"description":"Incision of toe tendon","code_information":[{"code":"28232","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1192.86,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1590.48,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3069.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1192.86,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1622.29,"additional_payer_notes":"APC"}]}]},{"description":"Repair/graft of foot tendon","code_information":[{"code":"28202","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":13851.98,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Partial removal of toe","code_information":[{"code":"28160","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Part removal of ankle/heel","code_information":[{"code":"28120","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Part removal of metatarsal","code_information":[{"code":"28110","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Removal of toe lesions","code_information":[{"code":"28092","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1192.86,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1590.48,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3069.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1192.86,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1622.29,"additional_payer_notes":"APC"}]}]},{"description":"Aspirate pleura w/ imaging","code_information":[{"code":"32555","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":465.35,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":620.47,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1197.51,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":465.35,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":632.88,"additional_payer_notes":"APC"}]}]},{"description":"Thoracoscopy w/bx med space","code_information":[{"code":"32606","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4484.77,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5979.69,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5257.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11540.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4484.77,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6099.28,"additional_payer_notes":"APC"}]}]},{"description":"Thoracoscopy contrl bleeding","code_information":[{"code":"32654","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5257.0,"maximum":6462.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5257.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6462.0}]}]},{"description":"Thoracoscopy w/ th nrv exc","code_information":[{"code":"32664","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5257.0,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5257.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0}]}]},{"description":"Reconstruction of nose","code_information":[{"code":"30400","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":11300.84,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Partial removal of nose","code_information":[{"code":"30150","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Removal of nose polyp(s)","code_information":[{"code":"30115","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2459.51,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3279.35,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6329.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2459.51,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3344.94,"additional_payer_notes":"APC"}]}]},{"description":"Hip arthro w/femoroplasty","code_information":[{"code":"29914","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Ankle arthroscopy/surgery","code_information":[{"code":"29899","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":13249.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":10779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":13249.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Knee arthroscopy/surgery","code_information":[{"code":"29889","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":24508.8,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12698.86,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":24508.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9524.15,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12952.84,"additional_payer_notes":"APC"}]}]},{"description":"Knee arthroscopy/surgery","code_information":[{"code":"29881","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5067.0},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Knee arthroscopy/drainage","code_information":[{"code":"29871","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Hip arthroscopy dx","code_information":[{"code":"29860","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Wrist arthroscopy/surgery","code_information":[{"code":"29845","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Revision of nose","code_information":[{"code":"30450","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Repair upper jaw fistula","code_information":[{"code":"30580","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Control of nosebleed","code_information":[{"code":"30905","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":98.7,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":131.6,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":253.99,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":98.7,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":134.23,"additional_payer_notes":"APC"}]}]},{"description":"Exploration maxillary sinus","code_information":[{"code":"31020","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2459.51,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3279.35,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6329.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2459.51,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3344.94,"additional_payer_notes":"APC"}]}]},{"description":"Removal of frontal sinus","code_information":[{"code":"31080","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Removal of ethmoid sinus","code_information":[{"code":"31201","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1151.01,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1534.69,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2961.94,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1151.01,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1565.38,"additional_payer_notes":"APC"}]}]},{"description":"Nasal/sinus endoscopy surg","code_information":[{"code":"31238","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1320.39,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1760.51,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3397.79,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1320.39,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1795.72,"additional_payer_notes":"APC"}]}]},{"description":"Nasal/sinus endoscopy surg","code_information":[{"code":"31287","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4956.0,"maximum":13472.56,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6980.6,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":7398.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6019.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":7398.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13472.56,"additional_payer_notes":"APC"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":4956.0},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5235.45,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7120.21,"additional_payer_notes":"APC"}]}]},{"description":"Sinus endo w/balloon dil","code_information":[{"code":"31296","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5235.45,"maximum":13472.56,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6980.6,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":7398.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6019.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":7398.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13472.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5235.45,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7120.21,"additional_payer_notes":"APC"}]}]},{"description":"Partial removal of larynx","code_information":[{"code":"31370","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Insert emergency airway","code_information":[{"code":"31500","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":175.7,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":234.27,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":452.14,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":175.7,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":238.96,"additional_payer_notes":"APC"}]}]},{"description":"Treat thumb fracture","code_information":[{"code":"26645","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1192.86,"maximum":4106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1590.48,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3069.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1192.86,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1622.29,"additional_payer_notes":"APC"}]}]},{"description":"Treat knuckle dislocation","code_information":[{"code":"26700","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":182.99,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":243.98,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":470.88,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":182.99,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":248.86,"additional_payer_notes":"APC"}]}]},{"description":"Treat finger fracture each","code_information":[{"code":"26740","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":182.99,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":243.98,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":470.88,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":182.99,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":248.86,"additional_payer_notes":"APC"}]}]},{"description":"Treat finger dislocation","code_information":[{"code":"26775","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":207.48,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":276.65,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":533.93,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":207.48,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":282.18,"additional_payer_notes":"APC"}]}]},{"description":"Fusion of knuckle","code_information":[{"code":"26850","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":13851.98,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Amputation of finger/thumb","code_information":[{"code":"26952","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":6246.19,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Incision of hip tendon","code_information":[{"code":"27005","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Biopsy of soft tissues","code_information":[{"code":"27040","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1225.21,"maximum":4106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1633.61,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3152.87,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1225.21,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1666.28,"additional_payer_notes":"APC"}]}]},{"description":"Biopsy of hip joint","code_information":[{"code":"27052","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1192.86,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1590.48,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3069.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1192.86,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1622.29,"additional_payer_notes":"APC"}]}]},{"description":"Remove/graft hip bone lesion","code_information":[{"code":"27067","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":13851.98,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Remove hip foreign body","code_information":[{"code":"27086","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2154.81,"maximum":5545.05,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2873.08,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5545.05,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2154.81,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2930.54,"additional_payer_notes":"APC"}]}]},{"description":"Transfer tendon to pelvis","code_information":[{"code":"27098","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Total hip arthroplasty","code_information":[{"code":"27130","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6779.0,"maximum":27583.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12698.86,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":24508.8,"additional_payer_notes":"APC"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11502.0},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9524.15,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":27583.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12952.84,"additional_payer_notes":"APC"}]}]},{"description":"Incision of hip bones","code_information":[{"code":"27151","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Treat slipped epiphysis","code_information":[{"code":"27177","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Treat pelvic fracture(s)","code_information":[{"code":"27215","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2959.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0}]}]},{"description":"Treat hip fracture(s)","code_information":[{"code":"27228","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Treat thigh fracture","code_information":[{"code":"27245","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Treat hip dislocation","code_information":[{"code":"27257","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1192.86,"maximum":4106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1590.48,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3069.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1192.86,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1622.29,"additional_payer_notes":"APC"}]}]},{"description":"Manipulation of hip joint","code_information":[{"code":"27275","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1192.86,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1590.48,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3069.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1192.86,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1622.29,"additional_payer_notes":"APC"}]}]},{"description":"Pelvis/hip joint surgery","code_information":[{"code":"27299","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":182.99,"maximum":13249.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":243.98,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":13249.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":10779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":13249.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":470.88,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":182.99,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":248.86,"additional_payer_notes":"APC"}]}]},{"description":"Biopsy thigh soft tissues","code_information":[{"code":"27324","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2154.81,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2873.08,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5545.05,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2154.81,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2930.54,"additional_payer_notes":"APC"}]}]},{"description":"Removal of knee cartilage","code_information":[{"code":"27332","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Remove knee cyst","code_information":[{"code":"27347","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Resect femur/knee tumor","code_information":[{"code":"27365","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Incision of thigh tendons","code_information":[{"code":"27392","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Repair of knee ligament","code_information":[{"code":"27405","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Revision of unstable kneecap","code_information":[{"code":"27422","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Revise kneecap","code_information":[{"code":"27437","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Total knee arthroplasty","code_information":[{"code":"27447","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":27583.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12698.86,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":24508.8,"additional_payer_notes":"APC"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10165.0},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9524.15,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":27583.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12952.84,"additional_payer_notes":"APC"}]}]},{"description":"Shorten/lengthen thighs","code_information":[{"code":"27468","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0}]}]},{"description":"Revise/replace knee joint","code_information":[{"code":"27487","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6779.0,"maximum":33471.73,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17342.86,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":33471.73,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13007.15,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":27583.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17689.72,"additional_payer_notes":"APC"}]}]},{"description":"Treatment of thigh fracture","code_information":[{"code":"27501","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":182.99,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":243.98,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":470.88,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":182.99,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":248.86,"additional_payer_notes":"APC"}]}]},{"description":"Treatment of thigh fracture","code_information":[{"code":"27511","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":24508.8,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12698.86,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":24508.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9524.15,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12952.84,"additional_payer_notes":"APC"}]}]},{"description":"Treat knee fracture","code_information":[{"code":"27530","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":182.99,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":243.98,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":470.88,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":182.99,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":248.86,"additional_payer_notes":"APC"}]}]},{"description":"Treat knee dislocation","code_information":[{"code":"27556","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Art byp common ipsi carotid","code_information":[{"code":"35601","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Art byp ilio-celiac","code_information":[{"code":"35632","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Art byp aortobifemoral","code_information":[{"code":"35646","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Art byp fem-ant-post tib/prl","code_information":[{"code":"35666","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Art trnsposj subclavian","code_information":[{"code":"35693","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Explore abdominal vessels","code_information":[{"code":"35840","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Revise graft w/vein","code_information":[{"code":"35884","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4127.91,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5503.89,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":10622.5,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4127.91,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5613.96,"additional_payer_notes":"APC"}]}]},{"description":"Place catheter in vein","code_information":[{"code":"36010","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Establish access to aorta","code_information":[{"code":"36160","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Place cath carotid/inom art","code_information":[{"code":"36223","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4127.91,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5503.89,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":10622.5,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4127.91,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5613.96,"additional_payer_notes":"APC"}]}]},{"description":"Ins cath abd/l-ext art 3rd","code_information":[{"code":"36247","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Removal of infusion pump","code_information":[{"code":"36262","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2772.2,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3696.26,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7133.79,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2772.2,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3770.19,"additional_payer_notes":"APC"}]}]},{"description":"Injection therapy of vein","code_information":[{"code":"36470","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":301.57,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":402.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":776.03,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":301.57,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":410.13,"additional_payer_notes":"APC"}]}]},{"description":"Insertion of catheter vein","code_information":[{"code":"36510","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Insert non-tunnel cv cath","code_information":[{"code":"36556","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2342.32,"maximum":6027.57,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3123.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6027.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2342.32,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3185.56,"additional_payer_notes":"APC"}]}]},{"description":"Insert picc cath","code_information":[{"code":"36568","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1167.76,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1557.01,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3005.03,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1167.76,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1588.15,"additional_payer_notes":"APC"}]}]},{"description":"Replace tunneled cv cath","code_information":[{"code":"36581","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2342.32,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3123.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6027.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2342.32,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3185.56,"additional_payer_notes":"APC"}]}]},{"description":"Mech remov tunneled cv cath","code_information":[{"code":"36596","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1167.76,"maximum":4106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1557.01,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3005.03,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1167.76,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1588.15,"additional_payer_notes":"APC"}]}]},{"description":"Insertion of cannula","code_information":[{"code":"36800","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4127.91,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5503.89,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":10622.5,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4127.91,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5613.96,"additional_payer_notes":"APC"}]}]},{"description":"Artery-vein autograft","code_information":[{"code":"36825","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4127.91,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5503.89,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":10622.5,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4127.91,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5613.96,"additional_payer_notes":"APC"}]}]},{"description":"Cannula declotting","code_information":[{"code":"36861","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4127.91,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5503.89,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":10622.5,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4127.91,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5613.96,"additional_payer_notes":"APC"}]}]},{"description":"Prim art m-thrmbc 1st vsl","code_information":[{"code":"37184","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6019.0,"maximum":34994.75,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18131.99,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":7398.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6019.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":7398.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":34994.75,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13599.0,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18494.63,"additional_payer_notes":"APC"}]}]},{"description":"Thrombolytic therapy stroke","code_information":[{"code":"37195","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":245.03,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":326.71,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":630.55,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":245.03,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":333.24,"additional_payer_notes":"APC"}]}]},{"description":"Transcath stent cca w/o eps","code_information":[{"code":"37216","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6779.0,"maximum":8333.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0}]}]},{"description":"Fem/popl revas w/ather","code_information":[{"code":"37225","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":27583.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":27583.0}]}]},{"description":"Tibper revasc w/ather add-on","code_information":[{"code":"37233","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5512.0,"maximum":27583.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":27583.0}]}]},{"description":"Vasc embolize/occlude artery","code_information":[{"code":"37242","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":34994.75,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18131.99,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":34994.75,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13599.0,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":27583.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18494.63,"additional_payer_notes":"APC"}]}]},{"description":"Ligation of neck artery","code_information":[{"code":"37600","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2342.32,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3123.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6027.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2342.32,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3185.56,"additional_payer_notes":"APC"}]}]},{"description":"Ligation of extremity artery","code_information":[{"code":"37618","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Ligate leg veins radical","code_information":[{"code":"37760","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2342.32,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3123.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6027.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2342.32,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3185.56,"additional_payer_notes":"APC"}]}]},{"description":"Vascular surgery procedure","code_information":[{"code":"37799","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":465.35,"maximum":13249.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":620.47,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":13249.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":10779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":13249.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1197.51,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":465.35,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":632.88,"additional_payer_notes":"APC"}]}]},{"description":"Bl donor search management","code_information":[{"code":"38204","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5512.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0}]}]},{"description":"Rbc depletion of harvest","code_information":[{"code":"38212","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":327.28,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":436.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":842.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":327.28,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":445.1,"additional_payer_notes":"APC"}]}]},{"description":"Transplt allo hct/donor","code_information":[{"code":"38240","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8923.0,"maximum":120077.04,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":62216.08,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":10765.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":8923.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":10765.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":120077.04,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":46662.06,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":63460.41,"additional_payer_notes":"APC"}]}]},{"description":"Thoracic duct procedure","code_information":[{"code":"38381","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Explore deep node(s) neck","code_information":[{"code":"38542","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4484.77,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5979.69,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5257.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11540.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4484.77,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6099.28,"additional_payer_notes":"APC"}]}]},{"description":"Dx laryngoscopy newborn","code_information":[{"code":"31520","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":290.14,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":386.86,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":746.64,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":290.14,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":394.6,"additional_payer_notes":"APC"}]}]},{"description":"Laryngoscopy w/biopsy","code_information":[{"code":"31535","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2765.81,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3687.74,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7117.34,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2765.81,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3761.5,"additional_payer_notes":"APC"}]}]},{"description":"Laryngoscope w/vc inj","code_information":[{"code":"31570","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2765.81,"maximum":7117.34,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3687.74,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7117.34,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2765.81,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3761.5,"additional_payer_notes":"APC"}]}]},{"description":"Laryngoplasty fx rdctj fixj","code_information":[{"code":"31584","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":11300.84,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Incision of windpipe","code_information":[{"code":"31610","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":11300.84,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Dx bronchoscope/lavage","code_information":[{"code":"31624","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1320.39,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1760.51,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3397.79,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1320.39,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1795.72,"additional_payer_notes":"APC"}]}]},{"description":"Bronchoscopy/lung bx addl","code_information":[{"code":"31632","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Bronchoscopy treat blockage","code_information":[{"code":"31641","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2765.81,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3687.74,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7117.34,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2765.81,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3761.5,"additional_payer_notes":"APC"}]}]},{"description":"Bronch ebus samplng 1/2 node","code_information":[{"code":"31652","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2765.81,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3687.74,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7117.34,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2765.81,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3761.5,"additional_payer_notes":"APC"}]}]},{"description":"Intro windpipe wire/tube","code_information":[{"code":"31730","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1320.39,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1760.51,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3397.79,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1320.39,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1795.72,"additional_payer_notes":"APC"}]}]},{"description":"Reconstruct windpipe","code_information":[{"code":"31781","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Airways surgical procedure","code_information":[{"code":"31899","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":148.07,"maximum":13249.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":197.43,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":13249.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":10779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":13249.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":381.05,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":148.07,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":201.38,"additional_payer_notes":"APC"}]}]},{"description":"Re-exploration of chest","code_information":[{"code":"32120","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6019.0,"maximum":7398.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":7398.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6019.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":7398.0}]}]},{"description":"Treat chest lining","code_information":[{"code":"32215","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5257.0,"maximum":6462.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5257.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6462.0}]}]},{"description":"Removal of lung extrapleural","code_information":[{"code":"32445","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":9356.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0}]}]},{"description":"Resect apical lung tumor","code_information":[{"code":"32503","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":9356.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0}]}]},{"description":"Thoracoscopy remove segment","code_information":[{"code":"32669","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5257.0,"maximum":6462.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5257.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6462.0}]}]},{"description":"Close chest after drainage","code_information":[{"code":"32810","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5257.0,"maximum":6462.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5257.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6462.0}]}]},{"description":"Prepare donor lung single","code_information":[{"code":"32855","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5257.0,"maximum":6462.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5257.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6462.0}]}]},{"description":"Perq rf ablate tx pul tumor","code_information":[{"code":"32998","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4484.77,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5979.69,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5257.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11540.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4484.77,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6099.28,"additional_payer_notes":"APC"}]}]},{"description":"Removal of heart lesion","code_information":[{"code":"33130","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6019.0,"maximum":7398.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":7398.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6019.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":7398.0}]}]},{"description":"Insert electrd/pm cath sngl","code_information":[{"code":"33210","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6138.95,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8185.27,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":15797.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6138.95,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8348.97,"additional_payer_notes":"APC"}]}]},{"description":"Repair lead pace-defib one","code_information":[{"code":"33218","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2772.2,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3696.26,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7133.79,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2772.2,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3770.19,"additional_payer_notes":"APC"}]}]},{"description":"Remove&replace pm gen singl","code_information":[{"code":"33227","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6138.95,"maximum":27583.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8185.27,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":15797.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6138.95,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":27583.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8348.97,"additional_payer_notes":"APC"}]}]},{"description":"Remove electrode/thoracotomy","code_information":[{"code":"33236","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Ablate heart dysrhythm focus","code_information":[{"code":"33250","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6019.0,"maximum":7398.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":7398.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6019.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":7398.0}]}]},{"description":"Ablate heart dysrhythm focus","code_information":[{"code":"33261","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6019.0,"maximum":7398.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":7398.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6019.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":7398.0}]}]},{"description":"Rmvl of subq defibrillator","code_information":[{"code":"33272","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2772.2,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3696.26,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7133.79,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2772.2,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3770.19,"additional_payer_notes":"APC"}]}]},{"description":"Repair major blood vessel(s)","code_information":[{"code":"33322","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6019.0,"maximum":7398.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":7398.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6019.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":7398.0}]}]},{"description":"Trcath replace aortic valve","code_information":[{"code":"33366","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":9356.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0}]}]},{"description":"Replacement of aortic valve","code_information":[{"code":"33411","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":9356.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0}]}]},{"description":"Repair tcat mitral valve","code_information":[{"code":"33419","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Valvuloplasty tricuspid","code_information":[{"code":"33463","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":9356.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0}]}]},{"description":"Revision of heart chamber","code_information":[{"code":"33478","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":9356.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0}]}]},{"description":"Repair artery translocation","code_information":[{"code":"33506","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":9356.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0}]}]},{"description":"Cabg vein six or more","code_information":[{"code":"33516","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":9356.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0}]}]},{"description":"Amputate leg at thigh","code_information":[{"code":"27590","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":27583.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":27583.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Decompression of lower leg","code_information":[{"code":"27601","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Exploration of ankle joint","code_information":[{"code":"27612","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Remove ankle joint lining","code_information":[{"code":"27625","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Partial removal of tibia","code_information":[{"code":"27640","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Repair of achilles tendon","code_information":[{"code":"27654","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Release of lower leg tendon","code_information":[{"code":"27680","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Repair of ankle ligament","code_information":[{"code":"27695","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":13851.98,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Incision of fibula","code_information":[{"code":"27707","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Repair fibula nonunion","code_information":[{"code":"27726","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Treatment of tibia fracture","code_information":[{"code":"27750","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":182.99,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":243.98,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":470.88,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":182.99,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":248.86,"additional_payer_notes":"APC"}]}]},{"description":"Cltx post ankle fx","code_information":[{"code":"27767","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":182.99,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":243.98,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":470.88,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":182.99,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":248.86,"additional_payer_notes":"APC"}]}]},{"description":"Treatment of ankle fracture","code_information":[{"code":"27792","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Treat lower leg fracture","code_information":[{"code":"27824","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":182.99,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":243.98,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":470.88,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":182.99,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":248.86,"additional_payer_notes":"APC"}]}]},{"description":"Treat lower leg dislocation","code_information":[{"code":"27832","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Amputation of lower leg","code_information":[{"code":"27880","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":27583.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":27583.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Decompression of leg","code_information":[{"code":"27893","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":13851.98,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Incision of toe tendon","code_information":[{"code":"28010","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1192.86,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1590.48,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3069.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1192.86,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1622.29,"additional_payer_notes":"APC"}]}]},{"description":"Exc foot/toe tum sc < 1.5 cm","code_information":[{"code":"28043","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1225.21,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1633.61,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3152.87,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1225.21,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1666.28,"additional_payer_notes":"APC"}]}]},{"description":"Partial removal foot fascia","code_information":[{"code":"28060","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Arthroscop rotator cuff repr","code_information":[{"code":"29827","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8265.0},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Shoulder arthroscopy/surgery","code_information":[{"code":"29819","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Wedging of cast","code_information":[{"code":"29740","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":207.48,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":276.65,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":533.93,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":207.48,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":282.18,"additional_payer_notes":"APC"}]}]},{"description":"Application of paste boot","code_information":[{"code":"29580","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":120.55,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":160.73,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":310.21,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":120.55,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":163.95,"additional_payer_notes":"APC"}]}]},{"description":"Apply rigid leg cast","code_information":[{"code":"29445","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":207.48,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":276.65,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":533.93,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":207.48,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":282.18,"additional_payer_notes":"APC"}]}]},{"description":"Application of long leg cast","code_information":[{"code":"29345","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":207.48,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":276.65,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":533.93,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":207.48,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":282.18,"additional_payer_notes":"APC"}]}]},{"description":"Application of finger splint","code_information":[{"code":"29130","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":98.7,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":131.6,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":253.99,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":98.7,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":134.23,"additional_payer_notes":"APC"}]}]},{"description":"Application of shoulder cast","code_information":[{"code":"29058","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":207.48,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":276.65,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":533.93,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":207.48,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":282.18,"additional_payer_notes":"APC"}]}]},{"description":"Application of body cast","code_information":[{"code":"29010","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":207.48,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":276.65,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":533.93,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":207.48,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":282.18,"additional_payer_notes":"APC"}]}]},{"description":"Amputation of midfoot","code_information":[{"code":"28800","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Fusion of foot bones","code_information":[{"code":"28725","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":24508.8,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12698.86,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":24508.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9524.15,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12952.84,"additional_payer_notes":"APC"}]}]},{"description":"Treat toe dislocation","code_information":[{"code":"28636","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Treat foot dislocation","code_information":[{"code":"28576","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":13851.98,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Treat sesamoid bone fracture","code_information":[{"code":"28530","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":182.99,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":243.98,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":470.88,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":182.99,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":248.86,"additional_payer_notes":"APC"}]}]},{"description":"Treat metatarsal fracture","code_information":[{"code":"28485","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Osteochondral talus autogrft","code_information":[{"code":"28446","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Treat metacarpal fracture","code_information":[{"code":"26615","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Treat hand dislocation","code_information":[{"code":"26685","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Treat finger fracture each","code_information":[{"code":"26727","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Treat finger fracture each","code_information":[{"code":"26765","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Fusion of hand joint","code_information":[{"code":"26843","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":13851.98,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Amputate metacarpal bone","code_information":[{"code":"26910","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Incision of hip tendon","code_information":[{"code":"27001","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Denervation of hip joint","code_information":[{"code":"27035","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Resect hip/pelv tum < 5 cm","code_information":[{"code":"27049","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2154.81,"maximum":5545.05,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2873.08,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5545.05,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2154.81,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2930.54,"additional_payer_notes":"APC"}]}]},{"description":"Remove hip bone les super","code_information":[{"code":"27065","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":13851.98,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Rsect hip tum incl femur","code_information":[{"code":"27078","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Inject sacroiliac joint","code_information":[{"code":"27096","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Reconstruction of hip socket","code_information":[{"code":"27122","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Incision of hip bone","code_information":[{"code":"27146","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Treat slipped epiphysis","code_information":[{"code":"27175","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Treat tail bone fracture","code_information":[{"code":"27200","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":182.99,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":243.98,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":470.88,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":182.99,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":248.86,"additional_payer_notes":"APC"}]}]},{"description":"Treat hip wall fracture","code_information":[{"code":"27226","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Treat thigh fracture","code_information":[{"code":"27240","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1192.86,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1590.48,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3069.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1192.86,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1622.29,"additional_payer_notes":"APC"}]}]},{"description":"Treat hip dislocation","code_information":[{"code":"27254","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":13851.98,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Cltx thigh fx w/mnpj","code_information":[{"code":"27268","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1192.86,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1590.48,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3069.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1192.86,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1622.29,"additional_payer_notes":"APC"}]}]},{"description":"Amputation of leg at hip","code_information":[{"code":"27290","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":33471.73,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17342.86,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":33471.73,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13007.15,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":27583.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17689.72,"additional_payer_notes":"APC"}]}]},{"description":"Exploration of knee joint","code_information":[{"code":"27310","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Biopsy knee joint lining","code_information":[{"code":"27330","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Removal of kneecap bursa","code_information":[{"code":"27340","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Partial removal leg bone(s)","code_information":[{"code":"27360","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Incision of thigh tendon","code_information":[{"code":"27390","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Revise thigh muscles/tendons","code_information":[{"code":"27400","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Repair degenerated kneecap","code_information":[{"code":"27418","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Revision of thigh muscles","code_information":[{"code":"27430","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Revision of knee joint","code_information":[{"code":"27445","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6779.0,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0}]}]},{"description":"Shortening of thigh bone","code_information":[{"code":"27465","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Surgery to stop leg growth","code_information":[{"code":"27485","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":13851.98,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Decompression of thigh/knee","code_information":[{"code":"27499","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":13851.98,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":13249.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":10779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":13249.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Treatment of thigh fracture","code_information":[{"code":"27509","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":13851.98,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Treat kneecap fracture","code_information":[{"code":"27520","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":182.99,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":243.98,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":470.88,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":182.99,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":248.86,"additional_payer_notes":"APC"}]}]},{"description":"Treat knee dislocation","code_information":[{"code":"27550","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":182.99,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":243.98,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":470.88,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":182.99,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":248.86,"additional_payer_notes":"APC"}]}]},{"description":"Laparoscope proc lymphatic","code_information":[{"code":"38589","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4484.77,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5979.69,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5257.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11540.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4484.77,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6099.28,"additional_payer_notes":"APC"}]}]},{"description":"Remove groin lymph nodes","code_information":[{"code":"38760","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4925.89,"maximum":12675.95,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6567.85,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":7398.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6019.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":7398.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":12675.95,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4925.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6699.21,"additional_payer_notes":"APC"}]}]},{"description":"Blood/lymph system procedure","code_information":[{"code":"38999","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":327.28,"maximum":13249.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":436.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":13249.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":10779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":13249.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":842.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":327.28,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":445.1,"additional_payer_notes":"APC"}]}]},{"description":"Repair diaphragm laceration","code_information":[{"code":"39501","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5257.0,"maximum":6462.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5257.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6462.0}]}]},{"description":"Biopsy of lip","code_information":[{"code":"40490","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":175.7,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":234.27,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":452.14,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":175.7,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":238.96,"additional_payer_notes":"APC"}]}]},{"description":"Repair lip","code_information":[{"code":"40652","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":400.09,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":533.45,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1029.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":400.09,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":544.12,"additional_payer_notes":"APC"}]}]},{"description":"Drainage of mouth lesion","code_information":[{"code":"40800","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":525.32,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":700.42,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1351.81,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":525.32,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":714.43,"additional_payer_notes":"APC"}]}]},{"description":"Excise/repair mouth lesion","code_information":[{"code":"40814","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2459.51,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3279.35,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6329.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2459.51,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3344.94,"additional_payer_notes":"APC"}]}]},{"description":"Reconstruction of mouth","code_information":[{"code":"40842","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":11300.84,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Drainage of mouth lesion","code_information":[{"code":"41007","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1151.01,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1534.69,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2961.94,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1151.01,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1565.38,"additional_payer_notes":"APC"}]}]},{"description":"Place needles h&n for rt","code_information":[{"code":"41019","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":11300.84,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Excision of tongue fold","code_information":[{"code":"41115","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1151.01,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1534.69,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2961.94,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1151.01,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1565.38,"additional_payer_notes":"APC"}]}]},{"description":"Tongue mouth neck surgery","code_information":[{"code":"41153","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Tongue base vol reduction","code_information":[{"code":"41530","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2459.51,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3279.35,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6329.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2459.51,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3344.94,"additional_payer_notes":"APC"}]}]},{"description":"Excision of gum lesion","code_information":[{"code":"41823","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":11300.84,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Repair gum","code_information":[{"code":"41872","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2459.51,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3279.35,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6329.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2459.51,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3344.94,"additional_payer_notes":"APC"}]}]},{"description":"Remove palate/lesion","code_information":[{"code":"42120","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":11300.84,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Reconstruct cleft palate","code_information":[{"code":"42210","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Preparation palate mold","code_information":[{"code":"42280","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":400.09,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":533.45,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1029.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":400.09,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":544.12,"additional_payer_notes":"APC"}]}]},{"description":"Removal of salivary stone","code_information":[{"code":"42335","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2459.51,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3279.35,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6329.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2459.51,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3344.94,"additional_payer_notes":"APC"}]}]},{"description":"Excise parotid gland/lesion","code_information":[{"code":"42420","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Parotid duct diversion","code_information":[{"code":"42509","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Drainage of tonsil abscess","code_information":[{"code":"42700","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":175.7,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":234.27,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":452.14,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":175.7,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":238.96,"additional_payer_notes":"APC"}]}]},{"description":"Excision of neck cyst","code_information":[{"code":"42810","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2459.51,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3279.35,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6329.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2459.51,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3344.94,"additional_payer_notes":"APC"}]}]},{"description":"Removal of adenoids","code_information":[{"code":"42835","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2459.51,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3279.35,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6329.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2459.51,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3344.94,"additional_payer_notes":"APC"}]}]},{"description":"Revision of pharyngeal walls","code_information":[{"code":"42892","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Control throat bleeding","code_information":[{"code":"42962","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2459.51,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3279.35,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6329.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2459.51,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3344.94,"additional_payer_notes":"APC"}]}]},{"description":"Excision of esophagus lesion","code_information":[{"code":"43100","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Partial removal of esophagus","code_information":[{"code":"43118","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Esophagoscopy rigid trnso dx","code_information":[{"code":"43191","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1423.51,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1898.01,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3663.16,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1423.51,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1935.97,"additional_payer_notes":"APC"}]}]},{"description":"Esophagoscopy flexible brush","code_information":[{"code":"43200","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":672.83,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":897.11,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1731.42,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":672.83,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":915.05,"additional_payer_notes":"APC"}]}]},{"description":"Esophagoscop stent placement","code_information":[{"code":"43212","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":11589.23,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6004.78,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11589.23,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4503.59,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6124.88,"additional_payer_notes":"APC"}]}]},{"description":"Esophagoscopy control bleed","code_information":[{"code":"43227","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1423.51,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1898.01,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3663.16,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1423.51,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1935.97,"additional_payer_notes":"APC"}]}]},{"description":"Egd us fine needle bx/aspir","code_information":[{"code":"43238","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1423.51,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1898.01,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3663.16,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1423.51,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1935.97,"additional_payer_notes":"APC"}]}]},{"description":"Egd place gastrostomy tube","code_information":[{"code":"43246","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1423.51,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1898.01,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3663.16,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1423.51,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1935.97,"additional_payer_notes":"APC"}]}]},{"description":"Egd endo mucosal resection","code_information":[{"code":"43254","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1423.51,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1898.01,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3663.16,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1423.51,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1935.97,"additional_payer_notes":"APC"}]}]},{"description":"Fixation of knee joint","code_information":[{"code":"27570","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1192.86,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1590.48,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3069.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1192.86,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1622.29,"additional_payer_notes":"APC"}]}]},{"description":"Leg surgery procedure","code_information":[{"code":"27599","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":182.99,"maximum":13249.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":243.98,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":13249.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":10779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":13249.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":470.88,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":182.99,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":248.86,"additional_payer_notes":"APC"}]}]},{"description":"Treat lower leg bone lesion","code_information":[{"code":"27607","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Exc leg/ankle tum deep <5 cm","code_information":[{"code":"27619","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2154.81,"maximum":5545.05,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2873.08,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5545.05,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2154.81,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2930.54,"additional_payer_notes":"APC"}]}]},{"description":"Remove/graft leg bone lesion","code_information":[{"code":"27637","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":13851.98,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Repair achilles tendon","code_information":[{"code":"27650","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Repair lower leg tendons","code_information":[{"code":"27675","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Revise lower leg tendon","code_information":[{"code":"27691","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Removal of ankle implant","code_information":[{"code":"27704","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Repair/graft of tibia","code_information":[{"code":"27724","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Repair of leg epiphyses","code_information":[{"code":"27742","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Cltx med ankle fx w/mnpj","code_information":[{"code":"27762","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1192.86,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1590.48,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3069.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1192.86,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1622.29,"additional_payer_notes":"APC"}]}]},{"description":"Treatment of ankle fracture","code_information":[{"code":"27786","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":182.99,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":243.98,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":470.88,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":182.99,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":248.86,"additional_payer_notes":"APC"}]}]},{"description":"Treatment of ankle fracture","code_information":[{"code":"27822","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Treat lower leg dislocation","code_information":[{"code":"27830","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":182.99,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":243.98,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":470.88,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":182.99,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":248.86,"additional_payer_notes":"APC"}]}]},{"description":"Fusion of ankle joint open","code_information":[{"code":"27870","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":24508.8,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12698.86,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":24508.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9524.15,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12952.84,"additional_payer_notes":"APC"}]}]},{"description":"Amputation of foot at ankle","code_information":[{"code":"27889","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":13851.98,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Treat foot bone lesion","code_information":[{"code":"28005","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Exc foot/toe tum sc 1.5 cm/>","code_information":[{"code":"28039","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2154.81,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2873.08,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5545.05,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2154.81,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2930.54,"additional_payer_notes":"APC"}]}]},{"description":"Biopsy of toe joint lining","code_information":[{"code":"28054","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Elbow arthroscopy","code_information":[{"code":"29830","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Shoulder arthroscopy/surgery","code_information":[{"code":"29821","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Casting/strapping procedure","code_information":[{"code":"29799","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":120.55,"maximum":13249.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":160.73,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":13249.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":10779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":13249.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":310.21,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":120.55,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":163.95,"additional_payer_notes":"APC"}]}]},{"description":"Appl multlay comprs arm/hand","code_information":[{"code":"29584","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":120.55,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":160.73,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":310.21,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":120.55,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":163.95,"additional_payer_notes":"APC"}]}]},{"description":"Application long leg splint","code_information":[{"code":"29505","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":120.55,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":160.73,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":310.21,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":120.55,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":163.95,"additional_payer_notes":"APC"}]}]},{"description":"Apply long leg cast brace","code_information":[{"code":"29358","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":207.48,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":276.65,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":533.93,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":207.48,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":282.18,"additional_payer_notes":"APC"}]}]},{"description":"Strapping of chest","code_information":[{"code":"29200","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":120.55,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":160.73,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":310.21,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":120.55,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":163.95,"additional_payer_notes":"APC"}]}]},{"description":"Application of forearm cast","code_information":[{"code":"29075","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":207.48,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":276.65,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":533.93,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":207.48,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":282.18,"additional_payer_notes":"APC"}]}]},{"description":"Application of body cast","code_information":[{"code":"29035","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":207.48,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":276.65,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":533.93,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":207.48,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":282.18,"additional_payer_notes":"APC"}]}]},{"description":"Amputation toe & metatarsal","code_information":[{"code":"28810","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Fusion of foot bones","code_information":[{"code":"28735","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":24508.8,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12698.86,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":24508.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9524.15,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12952.84,"additional_payer_notes":"APC"}]}]},{"description":"Treat toe dislocation","code_information":[{"code":"28660","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":182.99,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":243.98,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":470.88,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":182.99,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":248.86,"additional_payer_notes":"APC"}]}]},{"description":"Treat foot dislocation","code_information":[{"code":"28600","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":182.99,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":243.98,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":470.88,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":182.99,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":248.86,"additional_payer_notes":"APC"}]}]},{"description":"Treat foot dislocation","code_information":[{"code":"28540","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":182.99,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":243.98,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":470.88,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":182.99,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":248.86,"additional_payer_notes":"APC"}]}]},{"description":"Treat big toe fracture","code_information":[{"code":"28495","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":182.99,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":243.98,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":470.88,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":182.99,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":248.86,"additional_payer_notes":"APC"}]}]},{"description":"Treat midfoot fracture each","code_information":[{"code":"28455","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1192.86,"maximum":4106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1590.48,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3069.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1192.86,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1622.29,"additional_payer_notes":"APC"}]}]},{"description":"Treatment of heel fracture","code_information":[{"code":"28405","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":182.99,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":243.98,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":470.88,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":182.99,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":248.86,"additional_payer_notes":"APC"}]}]},{"description":"Repair of foot bones","code_information":[{"code":"28320","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":24508.8,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12698.86,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":24508.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9524.15,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12952.84,"additional_payer_notes":"APC"}]}]},{"description":"Incision of metatarsal","code_information":[{"code":"28306","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":13851.98,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Correction hallux valgus","code_information":[{"code":"28296","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Release of foot contracture","code_information":[{"code":"28270","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Incision of foot tendon","code_information":[{"code":"28234","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1192.86,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1590.48,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3069.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1192.86,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1622.29,"additional_payer_notes":"APC"}]}]},{"description":"Repair of foot tendon","code_information":[{"code":"28208","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Resect tarsal tumor","code_information":[{"code":"28171","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Partial removal of foot bone","code_information":[{"code":"28122","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Part removal of metatarsal","code_information":[{"code":"28111","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Removal of ankle/heel lesion","code_information":[{"code":"28100","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Aspirate pleura w/o imaging","code_information":[{"code":"32554","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":465.35,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":620.47,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1197.51,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":465.35,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":632.88,"additional_payer_notes":"APC"}]}]},{"description":"Thoracoscopy wbx sac","code_information":[{"code":"32604","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5257.0,"maximum":20292.15,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10514.07,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5257.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":20292.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7885.55,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10724.35,"additional_payer_notes":"APC"}]}]},{"description":"Thoracoscopy remov fb/fibrin","code_information":[{"code":"32653","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5257.0,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5257.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0}]}]},{"description":"Thoracoscopy w/lobectomy","code_information":[{"code":"32663","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5257.0,"maximum":6462.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5257.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6462.0}]}]},{"description":"Reconstruction of nose","code_information":[{"code":"30410","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Removal of nose","code_information":[{"code":"30160","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Removal of intranasal lesion","code_information":[{"code":"30117","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2459.51,"maximum":6329.15,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3279.35,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6329.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2459.51,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3344.94,"additional_payer_notes":"APC"}]}]},{"description":"Hip arthro acetabuloplasty","code_information":[{"code":"29915","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Mcp joint arthroscopy dx","code_information":[{"code":"29900","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Ankle arthroscopy/surgery","code_information":[{"code":"29891","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Knee arthroscopy/surgery","code_information":[{"code":"29882","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Knee arthroscopy/surgery","code_information":[{"code":"29873","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Hip arthro w/fb removal","code_information":[{"code":"29861","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Wrist arthroscopy/surgery","code_information":[{"code":"29846","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Elbow arthroscopy/surgery","code_information":[{"code":"29835","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Release of nasal adhesions","code_information":[{"code":"30560","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":400.09,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":533.45,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1029.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":400.09,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":544.12,"additional_payer_notes":"APC"}]}]},{"description":"Control of nosebleed","code_information":[{"code":"30903","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":98.7,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":131.6,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":253.99,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":98.7,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":134.23,"additional_payer_notes":"APC"}]}]},{"description":"Irrigation sphenoid sinus","code_information":[{"code":"31002","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1151.01,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1534.69,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2961.94,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1151.01,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1565.38,"additional_payer_notes":"APC"}]}]},{"description":"Exploration of frontal sinus","code_information":[{"code":"31075","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Removal of ethmoid sinus","code_information":[{"code":"31200","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Nasal/sinus endoscopy surg","code_information":[{"code":"31237","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1320.39,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1760.51,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3397.79,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1320.39,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1795.72,"additional_payer_notes":"APC"}]}]},{"description":"Sinus endoscopy surgical","code_information":[{"code":"31276","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5235.45,"maximum":13472.56,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6980.6,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":7398.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6019.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":7398.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13472.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5235.45,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7120.21,"additional_payer_notes":"APC"}]}]},{"description":"Sinus endo w/balloon dil","code_information":[{"code":"31295","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5235.45,"maximum":13472.56,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6980.6,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":7398.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6019.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":7398.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13472.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5235.45,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7120.21,"additional_payer_notes":"APC"}]}]},{"description":"Partial removal of larynx","code_information":[{"code":"31368","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Removal of epiglottis","code_information":[{"code":"31420","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Treat heel fracture","code_information":[{"code":"28415","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Resect enlarged toe tissue","code_information":[{"code":"28340","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Incision of metatarsal","code_information":[{"code":"28308","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Correction hallux valgus","code_information":[{"code":"28298","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":13851.98,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Fusion of toes","code_information":[{"code":"28280","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Release of big toe","code_information":[{"code":"28240","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Release of foot tendon","code_information":[{"code":"28220","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1192.86,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1590.48,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3069.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1192.86,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1622.29,"additional_payer_notes":"APC"}]}]},{"description":"Resect phalanx of toe tumor","code_information":[{"code":"28175","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1192.86,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1590.48,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3069.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1192.86,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1622.29,"additional_payer_notes":"APC"}]}]},{"description":"Partial removal of toe","code_information":[{"code":"28126","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Part removal of metatarsal","code_information":[{"code":"28113","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Remove/graft foot lesion","code_information":[{"code":"28103","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Remove lung catheter","code_information":[{"code":"32552","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":465.35,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":620.47,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1197.51,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":465.35,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":632.88,"additional_payer_notes":"APC"}]}]},{"description":"Lyse chest fibrin subq day","code_information":[{"code":"32562","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":465.35,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":620.47,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1197.51,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":465.35,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":632.88,"additional_payer_notes":"APC"}]}]},{"description":"Thoracoscopy remove cortex","code_information":[{"code":"32651","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5257.0,"maximum":27583.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5257.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":27583.0}]}]},{"description":"Thoracoscopy w/pericard exc","code_information":[{"code":"32661","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5257.0,"maximum":6462.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5257.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6462.0}]}]},{"description":"Revision of nose","code_information":[{"code":"30430","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":11300.84,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Nasal sinus therapy","code_information":[{"code":"30210","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1151.01,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1534.69,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2961.94,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1151.01,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1565.38,"additional_payer_notes":"APC"}]}]},{"description":"Revision of nose","code_information":[{"code":"30120","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2459.51,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3279.35,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6329.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2459.51,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3344.94,"additional_payer_notes":"APC"}]}]},{"description":"Arthroscopy of joint","code_information":[{"code":"29999","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":182.99,"maximum":13249.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":243.98,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":13249.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":10779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":13249.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":470.88,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":182.99,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":248.86,"additional_payer_notes":"APC"}]}]},{"description":"Mcp joint arthroscopy surg","code_information":[{"code":"29902","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1192.86,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1590.48,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3069.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1192.86,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1622.29,"additional_payer_notes":"APC"}]}]},{"description":"Scope plantar fasciotomy","code_information":[{"code":"29893","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Knee arthroscopy/surgery","code_information":[{"code":"29884","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Knee arthroscopy/surgery","code_information":[{"code":"29875","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Hip arthr0 w/synovectomy","code_information":[{"code":"29863","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Wrist endoscopy/surgery","code_information":[{"code":"29848","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1192.86,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1590.48,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3069.63,"additional_payer_notes":"APC"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5067.0},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1192.86,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1622.29,"additional_payer_notes":"APC"}]}]},{"description":"Elbow arthroscopy/surgery","code_information":[{"code":"29837","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Repair nasal defect","code_information":[{"code":"30540","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Ablate inf turbinate submuc","code_information":[{"code":"30802","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1151.01,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1534.69,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2961.94,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1151.01,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1565.38,"additional_payer_notes":"APC"}]}]},{"description":"Nasal surgery procedure","code_information":[{"code":"30999","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":175.7,"maximum":13249.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":234.27,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":13249.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":10779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":13249.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":452.14,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":175.7,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":238.96,"additional_payer_notes":"APC"}]}]},{"description":"Sphenoid sinus surgery","code_information":[{"code":"31051","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Removal of frontal sinus","code_information":[{"code":"31087","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Nasal/sinus endoscopy dx","code_information":[{"code":"31233","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":290.14,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":386.86,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":746.64,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":290.14,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":394.6,"additional_payer_notes":"APC"}]}]},{"description":"Exploration maxillary sinus","code_information":[{"code":"31256","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2765.81,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3687.74,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7117.34,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2765.81,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3761.5,"additional_payer_notes":"APC"}]}]},{"description":"Nasal/sinus endoscopy surg","code_information":[{"code":"31293","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5235.45,"maximum":13472.56,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6980.6,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":7398.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6019.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":7398.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13472.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5235.45,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7120.21,"additional_payer_notes":"APC"}]}]},{"description":"Removal of larynx","code_information":[{"code":"31365","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Reconstruct larynx & pharynx","code_information":[{"code":"31395","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Removal of larynx lesion","code_information":[{"code":"31512","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2765.81,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3687.74,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7117.34,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2765.81,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3761.5,"additional_payer_notes":"APC"}]}]},{"description":"Laryngoscopy and dilation","code_information":[{"code":"31529","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2765.81,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3687.74,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7117.34,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2765.81,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3761.5,"additional_payer_notes":"APC"}]}]},{"description":"Remove vc lesion scope/graft","code_information":[{"code":"31546","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5235.45,"maximum":13472.56,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6980.6,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":7398.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6019.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":7398.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13472.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5235.45,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7120.21,"additional_payer_notes":"APC"}]}]},{"description":"Largsc w/removal lesion","code_information":[{"code":"31578","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2765.81,"maximum":7117.34,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3687.74,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7117.34,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2765.81,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3761.5,"additional_payer_notes":"APC"}]}]},{"description":"Incision of windpipe","code_information":[{"code":"31601","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":11300.84,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Visualization of windpipe","code_information":[{"code":"31615","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":400.09,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":533.45,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1029.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":400.09,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":544.12,"additional_payer_notes":"APC"}]}]},{"description":"Bronchoscopy/needle bx each","code_information":[{"code":"31629","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2765.81,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3687.74,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7117.34,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2765.81,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3761.5,"additional_payer_notes":"APC"}]}]},{"description":"Bronchoscopy stent add-on","code_information":[{"code":"31637","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Bronchial valve remov init","code_information":[{"code":"31648","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2765.81,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3687.74,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7117.34,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2765.81,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3761.5,"additional_payer_notes":"APC"}]}]},{"description":"Bronchial brush biopsy","code_information":[{"code":"31717","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":290.14,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":386.86,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":746.64,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":290.14,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":394.6,"additional_payer_notes":"APC"}]}]},{"description":"Repair/graft of bronchus","code_information":[{"code":"31770","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Closure of windpipe lesion","code_information":[{"code":"31820","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2459.51,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3279.35,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6329.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2459.51,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3344.94,"additional_payer_notes":"APC"}]}]},{"description":"Open biopsy of lung pleura","code_information":[{"code":"32098","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5257.0,"maximum":6462.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5257.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6462.0}]}]},{"description":"Remove lung foreign body","code_information":[{"code":"32151","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6019.0,"maximum":7398.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":7398.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6019.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":7398.0}]}]},{"description":"Needle biopsy chest lining","code_information":[{"code":"32400","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1225.21,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1633.61,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3152.87,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1225.21,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1666.28,"additional_payer_notes":"APC"}]}]},{"description":"Completion pneumonectomy","code_information":[{"code":"32488","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":9356.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0}]}]},{"description":"Removal of lung lesion","code_information":[{"code":"32540","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":9356.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0}]}]},{"description":"Thoracoscopy lymph node exc","code_information":[{"code":"32674","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5257.0,"maximum":6462.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5257.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6462.0}]}]},{"description":"Lung transplant with bypass","code_information":[{"code":"32852","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8923.0,"maximum":10765.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":10765.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":8923.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":10765.0}]}]},{"description":"Revision of lung","code_information":[{"code":"32940","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":9356.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0}]}]},{"description":"Partial removal of heart sac","code_information":[{"code":"33031","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6019.0,"maximum":7398.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":7398.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6019.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":7398.0}]}]},{"description":"Insert heart pm atrial","code_information":[{"code":"33206","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":27583.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10338.17,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":19952.66,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7753.63,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":27583.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10544.93,"additional_payer_notes":"APC"}]}]},{"description":"Reposition pacing-defib lead","code_information":[{"code":"33215","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2342.32,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3123.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6027.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2342.32,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3185.56,"additional_payer_notes":"APC"}]}]},{"description":"Insert pacing lead & connect","code_information":[{"code":"33224","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":43643.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10338.17,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43643.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43643.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43643.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":19952.66,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7753.63,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":41120.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10544.93,"additional_payer_notes":"APC"}]}]},{"description":"Removal of pm generator","code_information":[{"code":"33233","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6138.95,"maximum":15797.56,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8185.27,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":15797.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6138.95,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8348.97,"additional_payer_notes":"APC"}]}]},{"description":"Remove eltrd/thoracotomy","code_information":[{"code":"33243","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0}]}]},{"description":"Ablate atria lmtd add-on","code_information":[{"code":"33257","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6019.0,"maximum":7398.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":7398.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6019.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":7398.0}]}]},{"description":"Ablate atria x10sv endo","code_information":[{"code":"33266","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6019.0,"maximum":7398.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":7398.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6019.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":7398.0}]}]},{"description":"Exploratory heart surgery","code_information":[{"code":"33315","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":9356.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0}]}]},{"description":"Replace aortic valve open","code_information":[{"code":"33363","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":9356.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0}]}]},{"description":"Replacement aortic valve opn","code_information":[{"code":"33405","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":9356.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0}]}]},{"description":"Revise ventricle muscle","code_information":[{"code":"33416","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":9356.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0}]}]},{"description":"Repair of mitral valve","code_information":[{"code":"33427","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":9356.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0}]}]},{"description":"Replacement pulmonary valve","code_information":[{"code":"33475","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":9356.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0}]}]},{"description":"Coronary artery graft","code_information":[{"code":"33503","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":9356.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0}]}]},{"description":"Cabg vein three","code_information":[{"code":"33512","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":9356.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0}]}]},{"description":"N block inj occipital","code_information":[{"code":"64405","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":227.71,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":303.61,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":585.96,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":227.71,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":309.68,"additional_payer_notes":"APC"}]}]},{"description":"N block inj ilio-ing/hypogi","code_information":[{"code":"64425","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":523.65,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":698.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1347.51,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":523.65,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":712.16,"additional_payer_notes":"APC"}]}]},{"description":"N block other peripheral","code_information":[{"code":"64450","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":523.65,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":698.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1347.51,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":523.65,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":712.16,"additional_payer_notes":"APC"}]}]},{"description":"Inj foramen epidural add-on","code_information":[{"code":"64484","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1221.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1221.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Inj paravert f jnt l/s 1 lev","code_information":[{"code":"64493","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":656.13,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":874.84,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1688.44,"additional_payer_notes":"APC"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1221.0},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":656.13,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":892.34,"additional_payer_notes":"APC"}]}]},{"description":"Implant neuroelectrodes","code_information":[{"code":"64553","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":21271.19,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11021.34,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":21271.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8266.01,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11241.77,"additional_payer_notes":"APC"}]}]},{"description":"Implant neuroelectrodes","code_information":[{"code":"64580","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8923.0,"maximum":37034.45,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19188.83,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":10765.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":8923.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":10765.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":37034.45,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14391.63,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":27583.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19572.61,"additional_payer_notes":"APC"}]}]},{"description":"Chemodenerv saliv glands","code_information":[{"code":"64611","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":227.71,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":303.61,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":585.96,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":227.71,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":309.68,"additional_payer_notes":"APC"}]}]},{"description":"Destroy cerv/thor facet jnt","code_information":[{"code":"64633","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1448.59,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1931.46,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3727.72,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1448.59,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1970.09,"additional_payer_notes":"APC"}]}]},{"description":"Chemodenerv 1 extrem 5/> ea","code_information":[{"code":"64645","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Revise hand/foot nerve","code_information":[{"code":"64704","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1448.59,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1931.46,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3727.72,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1448.59,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1970.09,"additional_payer_notes":"APC"}]}]},{"description":"Carpal tunnel surgery","code_information":[{"code":"64721","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1448.59,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1931.46,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3727.72,"additional_payer_notes":"APC"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3170.0},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1448.59,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1970.09,"additional_payer_notes":"APC"}]}]},{"description":"Incision of tongue nerve","code_information":[{"code":"64740","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1448.59,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1931.46,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3727.72,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1448.59,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1970.09,"additional_payer_notes":"APC"}]}]},{"description":"Sever cranial nerve","code_information":[{"code":"64771","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1448.59,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1931.46,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3727.72,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1448.59,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1970.09,"additional_payer_notes":"APC"}]}]},{"description":"Remove sciatic nerve lesion","code_information":[{"code":"64786","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2534.21,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3378.94,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6521.36,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2534.21,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3446.52,"additional_payer_notes":"APC"}]}]},{"description":"Remove sympathetic nerves","code_information":[{"code":"64809","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Repair of hand or foot nerve","code_information":[{"code":"64834","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2534.21,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3378.94,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6521.36,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2534.21,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3446.52,"additional_payer_notes":"APC"}]}]},{"description":"Nerve surgery","code_information":[{"code":"64859","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Repair & revise nerve add-on","code_information":[{"code":"64874","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Nerve graft hand/foot <=4 cm","code_information":[{"code":"64895","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":16752.93,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8680.28,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":16752.93,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6510.21,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8853.88,"additional_payer_notes":"APC"}]}]},{"description":"Nerve repair w/allograft","code_information":[{"code":"64910","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":16752.93,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8680.28,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":16752.93,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6510.21,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8853.88,"additional_payer_notes":"APC"}]}]},{"description":"Removal of eye","code_information":[{"code":"65110","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2916.44,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3888.58,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7504.96,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2916.44,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3966.35,"additional_payer_notes":"APC"}]}]},{"description":"Reinsert ocular implant","code_information":[{"code":"65155","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2916.44,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3888.58,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7504.96,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2916.44,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3966.35,"additional_payer_notes":"APC"}]}]},{"description":"Remove foreign body from eye","code_information":[{"code":"65265","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1712.02,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2282.69,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4405.59,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1712.02,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2328.34,"additional_payer_notes":"APC"}]}]},{"description":"Repair of eye socket wound","code_information":[{"code":"65290","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2916.44,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3888.58,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7504.96,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2916.44,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3966.35,"additional_payer_notes":"APC"}]}]},{"description":"Treatment of corneal lesion","code_information":[{"code":"65450","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":235.46,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":313.95,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":605.92,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":235.46,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":320.23,"additional_payer_notes":"APC"}]}]},{"description":"Revision of cornea","code_information":[{"code":"65760","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0}]}]},{"description":"Cover eye w/membrane suture","code_information":[{"code":"65779","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2916.44,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3888.58,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7504.96,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2916.44,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3966.35,"additional_payer_notes":"APC"}]}]},{"description":"Relieve inner eye pressure","code_information":[{"code":"65820","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3066.31,"maximum":7890.63,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4088.41,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7890.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3066.31,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4170.17,"additional_payer_notes":"APC"}]}]},{"description":"Remove eye lesion","code_information":[{"code":"65900","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1712.02,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2282.69,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4405.59,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1712.02,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2328.34,"additional_payer_notes":"APC"}]}]},{"description":"Glaucoma surgery","code_information":[{"code":"66160","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1712.02,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2282.69,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4405.59,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1712.02,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2328.34,"additional_payer_notes":"APC"}]}]},{"description":"Revision of aqueous shunt","code_information":[{"code":"66184","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1712.02,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2282.69,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4405.59,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1712.02,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2328.34,"additional_payer_notes":"APC"}]}]},{"description":"Removal of iris","code_information":[{"code":"66625","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1712.02,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2282.69,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4405.59,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1712.02,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2328.34,"additional_payer_notes":"APC"}]}]},{"description":"Destruction ciliary body","code_information":[{"code":"66720","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1763.69,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2351.59,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4538.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1763.69,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2398.62,"additional_payer_notes":"APC"}]}]},{"description":"Removal of lens lesion","code_information":[{"code":"66830","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1712.02,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2282.69,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4405.59,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1712.02,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2328.34,"additional_payer_notes":"APC"}]}]},{"description":"Cataract surg w/iol 1 stage","code_information":[{"code":"66983","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1712.02,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2282.69,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4405.59,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1712.02,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2328.34,"additional_payer_notes":"APC"}]}]},{"description":"Sigmoidoscopy w/fb removal","code_information":[{"code":"45332","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":887.71,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1183.61,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2284.37,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":887.71,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1207.28,"additional_payer_notes":"APC"}]}]},{"description":"Sigmoidoscopy W/Us Guide Bx","code_information":[{"code":"45342","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":887.71,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1183.61,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2284.37,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":887.71,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1207.28,"additional_payer_notes":"APC"}]}]},{"description":"Colonoscopy submucous njx","code_information":[{"code":"45381","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":887.71,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1183.61,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2284.37,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":887.71,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1207.28,"additional_payer_notes":"APC"}]}]},{"description":"Colonoscopy w/endoscope us","code_information":[{"code":"45391","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":887.71,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1183.61,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2284.37,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":887.71,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1207.28,"additional_payer_notes":"APC"}]}]},{"description":"Lap proctopexy w/sig resect","code_information":[{"code":"45402","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Repair of rectocele","code_information":[{"code":"45560","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2059.07,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2745.43,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5298.68,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2059.07,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2800.34,"additional_payer_notes":"APC"}]}]},{"description":"Dilation of anal sphincter","code_information":[{"code":"45905","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":887.71,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1183.61,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2284.37,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":887.71,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1207.28,"additional_payer_notes":"APC"}]}]},{"description":"Incision of rectal abscess","code_information":[{"code":"46045","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2059.07,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2745.43,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5298.68,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2059.07,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2800.34,"additional_payer_notes":"APC"}]}]},{"description":"Ligation of hemorrhoid(s)","code_information":[{"code":"46221","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":689.87,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":919.83,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1775.27,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":689.87,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":938.23,"additional_payer_notes":"APC"}]}]},{"description":"Remove in/ex hem grps w/fist","code_information":[{"code":"46262","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2059.07,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2745.43,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5298.68,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2059.07,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2800.34,"additional_payer_notes":"APC"}]}]},{"description":"Chemodenervation anal musc","code_information":[{"code":"46505","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":887.71,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1183.61,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2284.37,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":887.71,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1207.28,"additional_payer_notes":"APC"}]}]},{"description":"Anoscopy","code_information":[{"code":"46611","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":689.87,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":919.83,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1775.27,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":689.87,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":938.23,"additional_payer_notes":"APC"}]}]},{"description":"Repr per/vag pouch sngl proc","code_information":[{"code":"46710","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Repair of cloacal anomaly","code_information":[{"code":"46744","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Repair of anal sphincter","code_information":[{"code":"46761","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2059.07,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2745.43,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5298.68,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2059.07,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2800.34,"additional_payer_notes":"APC"}]}]},{"description":"Treatment of anal fissure","code_information":[{"code":"46940","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2059.07,"maximum":5298.68,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2745.43,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5298.68,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2059.07,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2800.34,"additional_payer_notes":"APC"}]}]},{"description":"Open drainage liver lesion","code_information":[{"code":"47010","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3388.0,"maximum":4106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0}]}]},{"description":"Transplantation of liver","code_information":[{"code":"47135","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8923.0,"maximum":10765.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":10765.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":8923.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":10765.0}]}]},{"description":"Prep donor liver/arterial","code_information":[{"code":"47147","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Laparoscope procedure liver","code_information":[{"code":"47379","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4484.77,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5979.69,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5257.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11540.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4484.77,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6099.28,"additional_payer_notes":"APC"}]}]},{"description":"Incision of bile duct","code_information":[{"code":"47425","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Conversion ext bil drg cath","code_information":[{"code":"47535","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2656.06,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3541.41,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6834.92,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2656.06,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3612.24,"additional_payer_notes":"APC"}]}]},{"description":"Endoluminal bx biliary tree","code_information":[{"code":"47543","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Laparoscopic cholecystectomy","code_information":[{"code":"47562","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4484.77,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5979.69,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5257.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11540.8,"additional_payer_notes":"APC"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7926.0},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4484.77,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6099.28,"additional_payer_notes":"APC"}]}]},{"description":"Removal of gallbladder","code_information":[{"code":"47612","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Fuse upper gi structures","code_information":[{"code":"47721","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Placement bile duct support","code_information":[{"code":"47801","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Resect/Debride Pancreas","code_information":[{"code":"48105","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Pancreatectomy","code_information":[{"code":"48153","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Fuse pancreas cyst and bowel","code_information":[{"code":"48540","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Removal allograft pancreas","code_information":[{"code":"48556","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Drain to peritoneal cavity","code_information":[{"code":"49062","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Removal of omentum","code_information":[{"code":"49255","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":12358.4,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6403.32,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":12358.4,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4802.49,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6531.38,"additional_payer_notes":"APC"}]}]},{"description":"Lap ins device for rt","code_information":[{"code":"49327","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Ins device for rt guide open","code_information":[{"code":"49412","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Revise abdomen-venous shunt","code_information":[{"code":"49426","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2656.06,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3541.41,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6834.92,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2656.06,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3612.24,"additional_payer_notes":"APC"}]}]},{"description":"Cabg artery-vein five","code_information":[{"code":"33522","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":9356.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0}]}]},{"description":"Repair of heart damage","code_information":[{"code":"33545","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":9356.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0}]}]},{"description":"Repair double ventricle","code_information":[{"code":"33611","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":9356.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0}]}]},{"description":"Repair heart septum defect","code_information":[{"code":"33641","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":9356.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0}]}]},{"description":"Cl mult vsd w/rem pul band","code_information":[{"code":"33677","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":9356.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0}]}]},{"description":"Repair of heart defects","code_information":[{"code":"33702","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":9356.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0}]}]},{"description":"Revision of heart chamber","code_information":[{"code":"33736","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8923.0,"maximum":10765.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":10765.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":8923.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":10765.0}]}]},{"description":"Repair great vessels defect","code_information":[{"code":"33770","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6019.0,"maximum":7398.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":7398.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6019.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":7398.0}]}]},{"description":"Repair great vessels defect","code_information":[{"code":"33780","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6019.0,"maximum":7398.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":7398.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6019.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":7398.0}]}]},{"description":"Repair vessel defect","code_information":[{"code":"33803","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6019.0,"maximum":7398.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":7398.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6019.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":7398.0}]}]},{"description":"Repair septal defect","code_information":[{"code":"33852","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":9356.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0}]}]},{"description":"Insert endovasc prosth taa","code_information":[{"code":"33883","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":9356.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0}]}]},{"description":"Repair pulmonary artery","code_information":[{"code":"33917","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6019.0,"maximum":7398.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":7398.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6019.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":7398.0}]}]},{"description":"Transplantation heart/lung","code_information":[{"code":"33935","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8923.0,"maximum":10765.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":10765.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":8923.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":10765.0}]}]},{"description":"Ecmo/ecls insj prph cannula","code_information":[{"code":"33951","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3388.0,"maximum":4106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0}]}]},{"description":"Ecmo/ecls repos perph cnula","code_information":[{"code":"33959","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3388.0,"maximum":4106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0}]}]},{"description":"Ecmo/ecls rmvl perph cannula","code_information":[{"code":"33969","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3388.0,"maximum":4106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0}]}]},{"description":"Remove ventricular device","code_information":[{"code":"33978","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":9356.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0}]}]},{"description":"Ecmo/ecls rmvl ctr cannula","code_information":[{"code":"33986","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3388.0,"maximum":4106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0}]}]},{"description":"Cardiac surgery procedure","code_information":[{"code":"33999","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":465.35,"maximum":13249.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":620.47,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":13249.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":10779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":13249.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1197.51,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":465.35,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":632.88,"additional_payer_notes":"APC"}]}]},{"description":"Removal of vein clot","code_information":[{"code":"34401","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Cross-over vein graft","code_information":[{"code":"34520","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4127.91,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5503.89,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":10622.5,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4127.91,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5613.96,"additional_payer_notes":"APC"}]}]},{"description":"Open Aortofemor Prosth Repr","code_information":[{"code":"34832","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":9356.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0}]}]},{"description":"Visc & infraren abd 1 prosth","code_information":[{"code":"34845","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6019.0,"maximum":7398.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":7398.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6019.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":7398.0}]}]},{"description":"Repair artery rupture arm","code_information":[{"code":"35013","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Repair defect of artery","code_information":[{"code":"35102","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Repair defect of artery","code_information":[{"code":"35141","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Repair blood vessel lesion","code_information":[{"code":"35189","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Repair blood vessel lesion","code_information":[{"code":"35226","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":525.32,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":700.42,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1351.81,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":525.32,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":714.43,"additional_payer_notes":"APC"}]}]},{"description":"Repair blood vessel lesion","code_information":[{"code":"35266","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4127.91,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5503.89,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":10622.5,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4127.91,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5613.96,"additional_payer_notes":"APC"}]}]},{"description":"Rechanneling of Artery","code_information":[{"code":"35304","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Rechanneling of artery","code_information":[{"code":"35355","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Art byp grft ipsilat carotid","code_information":[{"code":"35501","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Art byp grft subclav-axilary","code_information":[{"code":"35516","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Art byp grft axill/fem/fem","code_information":[{"code":"35533","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Art byp grft fem-femoral","code_information":[{"code":"35558","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Place cecostomy tube perc","code_information":[{"code":"49442","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":887.71,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1183.61,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2284.37,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":887.71,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1207.28,"additional_payer_notes":"APC"}]}]},{"description":"Rpr ing hern premie blocked","code_information":[{"code":"49492","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2656.06,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3541.41,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6834.92,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2656.06,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3612.24,"additional_payer_notes":"APC"}]}]},{"description":"Rerepair ing hernia blocked","code_information":[{"code":"49521","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":12358.4,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6403.32,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":12358.4,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4802.49,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6531.38,"additional_payer_notes":"APC"}]}]},{"description":"Repair umbilical lesion","code_information":[{"code":"49605","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Omental flap extra-abdom","code_information":[{"code":"49904","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Removal of kidney stone","code_information":[{"code":"50060","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Explore and drain kidney","code_information":[{"code":"50125","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Removal of kidney & ureter","code_information":[{"code":"50236","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Prep donor renal graft","code_information":[{"code":"50325","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Reimplantation of kidney","code_information":[{"code":"50380","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8923.0,"maximum":10765.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":10765.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":8923.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":10765.0}]}]},{"description":"Instll rx agnt into rnal tub","code_information":[{"code":"50391","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":185.35,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":247.13,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":476.96,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":185.35,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":252.07,"additional_payer_notes":"APC"}]}]},{"description":"Convert nephrostomy catheter","code_information":[{"code":"50434","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1550.71,"maximum":4106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2067.62,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3990.5,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1550.71,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2108.97,"additional_payer_notes":"APC"}]}]},{"description":"Laparo ablate renal mass","code_information":[{"code":"50542","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":27583.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10514.07,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":20292.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7885.55,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":27583.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10724.35,"additional_payer_notes":"APC"}]}]},{"description":"Kidney endoscopy","code_information":[{"code":"50551","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3579.0,"maximum":10235.57,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5303.4,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":10235.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3977.55,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5409.47,"additional_payer_notes":"APC"}]}]},{"description":"Kidney endoscopy & biopsy","code_information":[{"code":"50574","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2614.94,"maximum":6729.12,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3486.59,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6729.12,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2614.94,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3556.32,"additional_payer_notes":"APC"}]}]},{"description":"Insert ureteral support","code_information":[{"code":"50605","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Measure ureter pressure","code_information":[{"code":"50686","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":95.45,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":127.27,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":245.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":95.45,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":129.82,"additional_payer_notes":"APC"}]}]},{"description":"Balloon dilate urtrl strix","code_information":[{"code":"50706","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Fusion of ureters","code_information":[{"code":"50760","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Urine shunt to intestine","code_information":[{"code":"50815","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Closure ureter/skin fistula","code_information":[{"code":"50920","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Endoscopy of ureter","code_information":[{"code":"50953","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2614.94,"maximum":6729.12,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3486.59,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6729.12,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2614.94,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3556.32,"additional_payer_notes":"APC"}]}]},{"description":"Ureter endoscopy & treatment","code_information":[{"code":"50980","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3977.55,"maximum":10235.57,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5303.4,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":10235.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3977.55,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5409.47,"additional_payer_notes":"APC"}]}]},{"description":"Drain bladder by needle","code_information":[{"code":"51100","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":185.35,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":247.13,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":476.96,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":185.35,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":252.07,"additional_payer_notes":"APC"}]}]},{"description":"Partial removal of bladder","code_information":[{"code":"51550","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Remove bladder/revise tract","code_information":[{"code":"51595","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Insert temp bladder cath","code_information":[{"code":"51702","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":98.7,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":131.6,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":253.99,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":98.7,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":134.23,"additional_payer_notes":"APC"}]}]},{"description":"Cystometrogram w/up","code_information":[{"code":"51727","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":517.28,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":689.7,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1331.13,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":517.28,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":703.5,"additional_payer_notes":"APC"}]}]},{"description":"Intraabdominal pressure test","code_information":[{"code":"51797","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Repair of bladder wound","code_information":[{"code":"51865","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0}]}]},{"description":"Laparo urethral suspension","code_information":[{"code":"51990","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4484.77,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5979.69,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5257.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11540.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4484.77,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6099.28,"additional_payer_notes":"APC"}]}]},{"description":"Cystoscopy w/biopsy(s)","code_information":[{"code":"52204","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1550.71,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2067.62,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3990.5,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1550.71,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2108.97,"additional_payer_notes":"APC"}]}]},{"description":"Cystoscopy and treatment","code_information":[{"code":"52265","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1550.71,"maximum":4106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2067.62,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3990.5,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1550.71,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2108.97,"additional_payer_notes":"APC"}]}]},{"description":"Cystoscopy and treatment","code_information":[{"code":"52285","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":517.28,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":689.7,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1331.13,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":517.28,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":703.5,"additional_payer_notes":"APC"}]}]},{"description":"Remove bladder stone","code_information":[{"code":"52317","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2614.94,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3486.59,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6729.12,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2614.94,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3556.32,"additional_payer_notes":"APC"}]}]},{"description":"Cysto W/Ureter Stricture Tx","code_information":[{"code":"52341","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2614.94,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3486.59,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6729.12,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2614.94,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3556.32,"additional_payer_notes":"APC"}]}]},{"description":"Ercp remove duct calculi","code_information":[{"code":"43264","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2860.11,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3813.48,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7360.02,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2860.11,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3889.75,"additional_payer_notes":"APC"}]}]},{"description":"Ercp ea duct/ampulla dilate","code_information":[{"code":"43277","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2860.11,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3813.48,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7360.02,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2860.11,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3889.75,"additional_payer_notes":"APC"}]}]},{"description":"Repair of esophagus","code_information":[{"code":"43300","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Esoph fundoplasty lap","code_information":[{"code":"43327","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5257.0,"maximum":6462.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5257.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6462.0}]}]},{"description":"Thorabd diaphr hern repair","code_information":[{"code":"43336","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5257.0,"maximum":6462.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5257.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6462.0}]}]},{"description":"Gastrointestinal repair","code_information":[{"code":"43361","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Dilate esophagus","code_information":[{"code":"43453","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1423.51,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1898.01,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3663.16,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1423.51,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1935.97,"additional_payer_notes":"APC"}]}]},{"description":"Incision of pyloric muscle","code_information":[{"code":"43520","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Removal of stomach partial","code_information":[{"code":"43632","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Lap impl electrode antrum","code_information":[{"code":"43647","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":27583.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11021.34,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":21271.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8266.01,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":27583.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11241.77,"additional_payer_notes":"APC"}]}]},{"description":"Dx gastr intub w/asp spec","code_information":[{"code":"43754","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":160.18,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":213.57,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":412.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":160.18,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":217.84,"additional_payer_notes":"APC"}]}]},{"description":"Lap replace gastr adj device","code_information":[{"code":"43773","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4484.77,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5979.69,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5257.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11540.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4484.77,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6099.28,"additional_payer_notes":"APC"}]}]},{"description":"Place gastrostomy tube","code_information":[{"code":"43831","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":672.83,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":897.11,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1731.42,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":672.83,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":915.05,"additional_payer_notes":"APC"}]}]},{"description":"Revision gastroplasty","code_information":[{"code":"43848","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Remove gastric port open","code_information":[{"code":"43887","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1530.61,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2040.81,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3938.76,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1530.61,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2081.63,"additional_payer_notes":"APC"}]}]},{"description":"Incision of large bowel","code_information":[{"code":"44025","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Removal of small intestine","code_information":[{"code":"44125","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Intestine transplant live","code_information":[{"code":"44136","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Partial removal of colon","code_information":[{"code":"44146","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Removal of colon","code_information":[{"code":"44160","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Lap colectomy part w/ileum","code_information":[{"code":"44205","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5257.0,"maximum":6462.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5257.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6462.0}]}]},{"description":"Lap close enterostomy","code_information":[{"code":"44227","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5257.0,"maximum":6462.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5257.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6462.0}]}]},{"description":"Colostomy with biopsies","code_information":[{"code":"44322","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Small bowel endoscopy","code_information":[{"code":"44365","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1423.51,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1898.01,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3663.16,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1423.51,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1935.97,"additional_payer_notes":"APC"}]}]},{"description":"Small bowel endoscopy","code_information":[{"code":"44378","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1423.51,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1898.01,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3663.16,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1423.51,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1935.97,"additional_payer_notes":"APC"}]}]},{"description":"Colonoscopy thru stoma spx","code_information":[{"code":"44388","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":689.87,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":919.83,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1775.27,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":689.87,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":938.23,"additional_payer_notes":"APC"}]}]},{"description":"Colonoscopy w/resection","code_information":[{"code":"44403","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":887.71,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1183.61,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2284.37,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":887.71,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1207.28,"additional_payer_notes":"APC"}]}]},{"description":"Suture small intestine","code_information":[{"code":"44603","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Repair bowel fistula","code_information":[{"code":"44650","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Prep donor intestine/venous","code_information":[{"code":"44720","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Appendectomy","code_information":[{"code":"44950","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":12358.4,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6403.32,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":12358.4,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4802.49,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6531.38,"additional_payer_notes":"APC"}]}]},{"description":"Biopsy of rectum","code_information":[{"code":"45100","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2059.07,"maximum":5298.68,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2745.43,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5298.68,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2059.07,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2800.34,"additional_payer_notes":"APC"}]}]},{"description":"Remove rectum w/reservoir","code_information":[{"code":"45119","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Excision of rectal stricture","code_information":[{"code":"45150","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":887.71,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1183.61,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2284.37,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":887.71,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1207.28,"additional_payer_notes":"APC"}]}]},{"description":"Proctosigmoidoscopy fb","code_information":[{"code":"45307","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2059.07,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2745.43,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5298.68,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2059.07,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2800.34,"additional_payer_notes":"APC"}]}]},{"description":"Diagnostic sigmoidoscopy","code_information":[{"code":"45330","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":689.87,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":919.83,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1775.27,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":689.87,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":938.23,"additional_payer_notes":"APC"}]}]},{"description":"Laryngoscopy for aspiration","code_information":[{"code":"31515","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":290.14,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":386.86,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":746.64,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":290.14,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":394.6,"additional_payer_notes":"APC"}]}]},{"description":"Laryngoscopy w/fb & op scope","code_information":[{"code":"31531","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2765.81,"maximum":7117.34,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3687.74,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7117.34,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2765.81,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3761.5,"additional_payer_notes":"APC"}]}]},{"description":"Larynscop remve cart + scop","code_information":[{"code":"31561","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5235.45,"maximum":13472.56,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6980.6,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":7398.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6019.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":7398.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13472.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5235.45,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7120.21,"additional_payer_notes":"APC"}]}]},{"description":"Laryngoplasty laryngeal web","code_information":[{"code":"31580","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Incision of windpipe","code_information":[{"code":"31605","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":175.7,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":234.27,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":452.14,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":175.7,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":238.96,"additional_payer_notes":"APC"}]}]},{"description":"Dx bronchoscope/brush","code_information":[{"code":"31623","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1320.39,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1760.51,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3397.79,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1320.39,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1795.72,"additional_payer_notes":"APC"}]}]},{"description":"Bronchoscopy dilate w/stent","code_information":[{"code":"31631","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5235.45,"maximum":13472.56,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6980.6,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":7398.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6019.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":7398.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13472.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5235.45,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7120.21,"additional_payer_notes":"APC"}]}]},{"description":"Bronchoscopy w/tumor excise","code_information":[{"code":"31640","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2765.81,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3687.74,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7117.34,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2765.81,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3761.5,"additional_payer_notes":"APC"}]}]},{"description":"Bronchial valve addl insert","code_information":[{"code":"31651","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Clearance of airways","code_information":[{"code":"31725","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3388.0,"maximum":4106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0}]}]},{"description":"Reconstruct windpipe","code_information":[{"code":"31780","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Revise windpipe scar","code_information":[{"code":"31830","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2459.51,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3279.35,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6329.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2459.51,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3344.94,"additional_payer_notes":"APC"}]}]},{"description":"Explore/repair chest","code_information":[{"code":"32110","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6019.0,"maximum":7398.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":7398.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6019.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":7398.0}]}]},{"description":"Drain open lung lesion","code_information":[{"code":"32200","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5257.0,"maximum":6462.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5257.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6462.0}]}]},{"description":"Sleeve pneumonectomy","code_information":[{"code":"32442","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":9356.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0}]}]},{"description":"Repair bronchus add-on","code_information":[{"code":"32501","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":9356.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0}]}]},{"description":"Insertion of chest tube","code_information":[{"code":"32551","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1167.76,"maximum":4106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1557.01,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3005.03,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1167.76,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1588.15,"additional_payer_notes":"APC"}]}]},{"description":"Repair lung hernia","code_information":[{"code":"32800","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5257.0,"maximum":6462.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5257.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6462.0}]}]},{"description":"Lung transplant with bypass","code_information":[{"code":"32854","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8923.0,"maximum":10765.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":10765.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":8923.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":10765.0}]}]},{"description":"Total lung lavage","code_information":[{"code":"32997","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3579.0,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0}]}]},{"description":"Removal of heart lesion","code_information":[{"code":"33120","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":9356.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0}]}]},{"description":"Insrt heart pm atrial & vent","code_information":[{"code":"33208","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":43643.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10338.17,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43643.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43643.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43643.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":19952.66,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7753.63,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":41120.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10544.93,"additional_payer_notes":"APC"}]}]},{"description":"Insert 2 electrode pm-defib","code_information":[{"code":"33217","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6138.95,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8185.27,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":15797.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6138.95,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8348.97,"additional_payer_notes":"APC"}]}]},{"description":"Reposition l ventric lead","code_information":[{"code":"33226","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2342.32,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3123.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6027.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2342.32,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3185.56,"additional_payer_notes":"APC"}]}]},{"description":"Removal pacemaker electrode","code_information":[{"code":"33235","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2772.2,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3696.26,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7133.79,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2772.2,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3770.19,"additional_payer_notes":"APC"}]}]},{"description":"Insj/rplcmt defib w/lead(s)","code_information":[{"code":"33249","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8923.0,"maximum":59920.75,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":31047.02,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":10765.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":8923.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":10765.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":54996.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":54996.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":54996.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":59920.75,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23285.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":51942.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":31667.96,"additional_payer_notes":"APC"}]}]},{"description":"Ablate atria w/bypass add-on","code_information":[{"code":"33259","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6019.0,"maximum":7398.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":7398.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6019.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":7398.0}]}]},{"description":"Insj subq impltbl dfb elctrd","code_information":[{"code":"33271","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6138.95,"maximum":27583.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8185.27,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":15797.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6138.95,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":27583.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8348.97,"additional_payer_notes":"APC"}]}]},{"description":"Repair major vessel","code_information":[{"code":"33321","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6019.0,"maximum":7398.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":7398.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6019.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":7398.0}]}]},{"description":"Replace aortic valve open","code_information":[{"code":"33365","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":9356.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0}]}]},{"description":"Replacement aortic valve opn","code_information":[{"code":"33410","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":9356.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0}]}]},{"description":"Repair tcat mitral valve","code_information":[{"code":"33418","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Revision of tricuspid valve","code_information":[{"code":"33460","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":9356.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0}]}]},{"description":"Implant tcat pulm vlv perq","code_information":[{"code":"33477","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6019.0,"maximum":7398.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":7398.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6019.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":7398.0}]}]},{"description":"Repair artery w/tunnel","code_information":[{"code":"33505","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":9356.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0}]}]},{"description":"Cabg vein five","code_information":[{"code":"33514","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":9356.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0}]}]},{"description":"Vein byp grft fem-popliteal","code_information":[{"code":"35583","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Art byp axillary-femoral","code_information":[{"code":"35621","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Art byp aortoiliac","code_information":[{"code":"35637","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Art byp femoral-popliteal","code_information":[{"code":"35656","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Composite byp grft 3/> segmt","code_information":[{"code":"35683","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Reoperation bypass graft","code_information":[{"code":"35700","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Removal of clot in graft","code_information":[{"code":"35876","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4127.91,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5503.89,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":10622.5,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4127.91,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5613.96,"additional_payer_notes":"APC"}]}]},{"description":"Excision graft abdomen","code_information":[{"code":"35907","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Place catheter in artery","code_information":[{"code":"36014","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Place catheter in artery","code_information":[{"code":"36217","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Place cath xtrnl carotid","code_information":[{"code":"36227","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Ins cath ren art 2nd+ unilat","code_information":[{"code":"36253","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4127.91,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5503.89,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":10622.5,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4127.91,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5613.96,"additional_payer_notes":"APC"}]}]},{"description":"Bl exchange/transfuse nb","code_information":[{"code":"36450","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":327.28,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":436.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":842.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":327.28,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":445.1,"additional_payer_notes":"APC"}]}]},{"description":"Endovenous laser 1st vein","code_information":[{"code":"36478","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2342.32,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3123.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6027.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2342.32,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3185.56,"additional_payer_notes":"APC"}]}]},{"description":"Apheresis plasma","code_information":[{"code":"36514","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1155.35,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1540.47,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2973.1,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1155.35,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1571.27,"additional_payer_notes":"APC"}]}]},{"description":"Insert tunneled cv cath","code_information":[{"code":"36561","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2342.32,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3123.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6027.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2342.32,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3185.56,"additional_payer_notes":"APC"}]}]},{"description":"Repair tunneled cv cath","code_information":[{"code":"36575","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":465.35,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":620.47,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1197.51,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":465.35,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":632.88,"additional_payer_notes":"APC"}]}]},{"description":"Replace picvad cath","code_information":[{"code":"36585","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2342.32,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3123.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6027.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2342.32,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3185.56,"additional_payer_notes":"APC"}]}]},{"description":"Insertion catheter artery","code_information":[{"code":"36625","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Av fuse uppr arm basilic","code_information":[{"code":"36819","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4127.91,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5503.89,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":10622.5,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4127.91,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5613.96,"additional_payer_notes":"APC"}]}]},{"description":"Av fistula revision","code_information":[{"code":"36833","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4127.91,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5503.89,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":10622.5,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4127.91,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5613.96,"additional_payer_notes":"APC"}]}]},{"description":"Revision of circulation","code_information":[{"code":"37180","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Venous m-thrombectomy add-on","code_information":[{"code":"37188","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2342.32,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3123.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6027.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2342.32,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3185.56,"additional_payer_notes":"APC"}]}]},{"description":"Thrombolytic venous therapy","code_information":[{"code":"37212","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2342.32,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3123.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6027.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2342.32,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3185.56,"additional_payer_notes":"APC"}]}]},{"description":"Iliac revasc w/stent","code_information":[{"code":"37221","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":27583.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":27583.0}]}]},{"description":"Tib/per revasc w/ather","code_information":[{"code":"37229","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8923.0,"maximum":27583.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":10765.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":8923.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":10765.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":27583.0}]}]},{"description":"Open/perq place stent ea add","code_information":[{"code":"37237","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5512.0,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0}]}]},{"description":"Intrvasc us noncoronary addl","code_information":[{"code":"37253","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Temporal artery procedure","code_information":[{"code":"37609","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1225.21,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1633.61,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3152.87,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1225.21,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1666.28,"additional_payer_notes":"APC"}]}]},{"description":"Revise leg vein","code_information":[{"code":"37700","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2342.32,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3123.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6027.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2342.32,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3185.56,"additional_payer_notes":"APC"}]}]},{"description":"Revision of leg vein","code_information":[{"code":"37780","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2342.32,"maximum":6027.57,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3123.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6027.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2342.32,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3185.56,"additional_payer_notes":"APC"}]}]},{"description":"Repair of ruptured spleen","code_information":[{"code":"38115","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Thaw preserved stem cells","code_information":[{"code":"38208","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":327.28,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":436.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":842.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":327.28,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":445.1,"additional_payer_notes":"APC"}]}]},{"description":"Bone marrow aspiration","code_information":[{"code":"38220","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1225.21,"maximum":4106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1633.61,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3152.87,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1225.21,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1666.28,"additional_payer_notes":"APC"}]}]},{"description":"Drainage lymph node lesion","code_information":[{"code":"38300","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2154.81,"maximum":5545.05,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2873.08,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5545.05,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2154.81,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2930.54,"additional_payer_notes":"APC"}]}]},{"description":"Biopsy/removal lymph nodes","code_information":[{"code":"38510","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2904.59,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3872.79,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7474.49,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2904.59,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3950.25,"additional_payer_notes":"APC"}]}]},{"description":"Sig w/tndsc balloon dilation","code_information":[{"code":"45340","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":887.71,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1183.61,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2284.37,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":887.71,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1207.28,"additional_payer_notes":"APC"}]}]},{"description":"Colonoscopy w/fb removal","code_information":[{"code":"45379","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":887.71,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1183.61,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2284.37,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":887.71,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1207.28,"additional_payer_notes":"APC"}]}]},{"description":"Colonoscopy w/stent plcmt","code_information":[{"code":"45389","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3579.0,"maximum":11589.23,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6004.78,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11589.23,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4503.59,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6124.88,"additional_payer_notes":"APC"}]}]},{"description":"Unlisted procedure colon","code_information":[{"code":"45399","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":689.87,"maximum":13249.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":919.83,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":13249.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":10779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":13249.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1775.27,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":689.87,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":938.23,"additional_payer_notes":"APC"}]}]},{"description":"Correct rectal prolapse","code_information":[{"code":"45541","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2059.07,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2745.43,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5298.68,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2059.07,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2800.34,"additional_payer_notes":"APC"}]}]},{"description":"Repair fistula w/colostomy","code_information":[{"code":"45825","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Removal of rectal marker","code_information":[{"code":"46030","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":887.71,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1183.61,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2284.37,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":887.71,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1207.28,"additional_payer_notes":"APC"}]}]},{"description":"Removal of anal fissure","code_information":[{"code":"46200","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2059.07,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2745.43,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5298.68,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2059.07,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2800.34,"additional_payer_notes":"APC"}]}]},{"description":"Remove in/ex hem groups 2+","code_information":[{"code":"46260","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2059.07,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2745.43,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5298.68,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2059.07,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2800.34,"additional_payer_notes":"APC"}]}]},{"description":"Removal of hemorrhoid clot","code_information":[{"code":"46320","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":887.71,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1183.61,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2284.37,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":887.71,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1207.28,"additional_payer_notes":"APC"}]}]},{"description":"Anoscopy remove for body","code_information":[{"code":"46608","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":689.87,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":919.83,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1775.27,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":689.87,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":938.23,"additional_payer_notes":"APC"}]}]},{"description":"Repr of anal fistula w/glue","code_information":[{"code":"46706","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2059.07,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2745.43,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5298.68,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2059.07,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2800.34,"additional_payer_notes":"APC"}]}]},{"description":"Construction of absent anus","code_information":[{"code":"46740","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Removal of suture from anus","code_information":[{"code":"46754","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2059.07,"maximum":5298.68,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2745.43,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5298.68,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2059.07,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2800.34,"additional_payer_notes":"APC"}]}]},{"description":"Destruction anal lesion(s)","code_information":[{"code":"46924","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2059.07,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2745.43,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5298.68,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2059.07,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2800.34,"additional_payer_notes":"APC"}]}]},{"description":"Needle biopsy of liver","code_information":[{"code":"47000","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1225.21,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1633.61,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3152.87,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1225.21,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1666.28,"additional_payer_notes":"APC"}]}]},{"description":"Partial removal of liver","code_information":[{"code":"47130","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Prep donor liver lobe split","code_information":[{"code":"47145","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Laparo ablate liver tumor rf","code_information":[{"code":"47370","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":27583.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10514.07,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":20292.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7885.55,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":27583.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10724.35,"additional_payer_notes":"APC"}]}]},{"description":"Incision of liver duct","code_information":[{"code":"47400","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Plmt biliary drainage cath","code_information":[{"code":"47533","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2656.06,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3541.41,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6834.92,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2656.06,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3612.24,"additional_payer_notes":"APC"}]}]},{"description":"Plmt access bil tree sm bwl","code_information":[{"code":"47541","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":12358.4,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6403.32,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":12358.4,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4802.49,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6531.38,"additional_payer_notes":"APC"}]}]},{"description":"Biliary endoscopy thru skin","code_information":[{"code":"47555","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":12358.4,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6403.32,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":12358.4,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4802.49,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6531.38,"additional_payer_notes":"APC"}]}]},{"description":"Removal of gallbladder","code_information":[{"code":"47605","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Excision of bile duct cyst","code_information":[{"code":"47715","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Fuse bile ducts and bowel","code_information":[{"code":"47785","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Biopsy of pancreas open","code_information":[{"code":"48100","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Partial removal of pancreas","code_information":[{"code":"48150","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Drain pancreatic pseudocyst","code_information":[{"code":"48510","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Prep donor pancreas/venous","code_information":[{"code":"48552","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Drain open abdom abscess","code_information":[{"code":"49040","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Excise sacral spine tumor","code_information":[{"code":"49215","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Lap Revision Perm IP Cath","code_information":[{"code":"49325","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4484.77,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5979.69,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5257.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11540.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4484.77,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6099.28,"additional_payer_notes":"APC"}]}]},{"description":"Image cath fluid trns/vgnl","code_information":[{"code":"49407","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1225.21,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1633.61,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3152.87,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1225.21,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1666.28,"additional_payer_notes":"APC"}]}]},{"description":"Assess cyst contrast inject","code_information":[{"code":"49424","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Place gastrostomy tube perc","code_information":[{"code":"49440","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1423.51,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1898.01,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3663.16,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1423.51,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1935.97,"additional_payer_notes":"APC"}]}]},{"description":"X-ray exam thorac spine 3vws","code_information":[{"code":"72072","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":77.56,"maximum":199.58,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":103.41,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":80.72},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":77.94},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":80.72},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":199.58,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":77.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":105.48,"additional_payer_notes":"APC"}]}]},{"description":"Mri Chest W/Dye","code_information":[{"code":"71551","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":581.54,"maximum":1496.49,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":775.38,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":1278.91},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1234.75},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":1278.91},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1496.49,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":581.54,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":790.89,"additional_payer_notes":"APC"}]}]},{"description":"X-ray exam breastbone 2/>vws","code_information":[{"code":"71120","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":63.69,"maximum":166.13,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":86.08,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":65.95},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":63.69},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":65.95},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":166.13,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":64.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":87.8,"additional_payer_notes":"APC"}]}]},{"description":"X-ray exam chest 1 view","code_information":[{"code":"71045","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":34.96,"maximum":166.13,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":86.08,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":36.2},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":34.96},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":36.2},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":166.13,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":64.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":87.8,"additional_payer_notes":"APC"}]}]},{"description":"Mri brain stem w/o dye","code_information":[{"code":"70551","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":177.0,"maximum":536.07,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":236.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":536.07},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":517.56},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":536.07},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":455.49,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":177.0,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":240.72,"additional_payer_notes":"APC"}]}]},{"description":"Mri Orbit/Face/Neck W/Dye","code_information":[{"code":"70542","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":258.81,"maximum":1102.92,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":345.07,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":1102.92},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1064.84},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":1102.92},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":665.99,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":258.81,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":351.98,"additional_payer_notes":"APC"}]}]},{"description":"Ct maxillofacial w/dye","code_information":[{"code":"70487","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":130.12,"maximum":382.23,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":173.49,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":382.23},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":369.03},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":382.23},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":334.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":130.12,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":176.96,"additional_payer_notes":"APC"}]}]},{"description":"X-ray exam of salivary duct","code_information":[{"code":"70390","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":177.0,"maximum":455.49,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":236.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":257.93},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":249.03},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":257.93},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":455.49,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":177.0,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":240.72,"additional_payer_notes":"APC"}]}]},{"description":"X-ray exam of jaw joint","code_information":[{"code":"70332","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":165.86,"maximum":455.49,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":236.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":171.8},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":165.86},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":171.8},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":455.49,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":177.0,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":240.72,"additional_payer_notes":"APC"}]}]},{"description":"X-ray exam pituitary saddle","code_information":[{"code":"70240","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":64.56,"maximum":166.13,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":86.08,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":68.41},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":66.04},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":68.41},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":166.13,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":64.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":87.8,"additional_payer_notes":"APC"}]}]},{"description":"X-ray exam of facial bones","code_information":[{"code":"70140","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":62.49,"maximum":166.13,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":86.08,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":64.73},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":62.49},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":64.73},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":166.13,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":64.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":87.8,"additional_payer_notes":"APC"}]}]},{"description":"Contrast x-ray of brain","code_information":[{"code":"70010","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":209.76,"maximum":665.99,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":345.07,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":217.25},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":209.76},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":217.25},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":665.99,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":258.81,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":351.98,"additional_payer_notes":"APC"}]}]},{"description":"Molec fluor img sus nev ea","code_information":[{"code":"0701T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":32.16,"maximum":34.74,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":34.74},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":32.16},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":34.74}]}]},{"description":"Quan mr alys tiss w/o mri","code_information":[{"code":"0648T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":328.24,"maximum":1776.02,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":920.22,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":354.64},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":328.24},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":354.64},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1776.02,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":690.16,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":938.62,"additional_payer_notes":"APC"}]}]},{"description":"Mrs disc pain alg alys data","code_information":[{"code":"0611T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":177.0,"maximum":455.49,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":236.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":216.79},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":213.5},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":216.79},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":455.49,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":177.0,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":240.72,"additional_payer_notes":"APC"}]}]},{"description":"Antmc guide 3d print ea addl","code_information":[{"code":"0562T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":75.36,"maximum":76.51,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":76.51},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":75.36},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":76.51}]}]},{"description":"Insj wcs lv eltrd only","code_information":[{"code":"0516T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1409.5,"maximum":27583.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10338.17,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":1431.15},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1409.5},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":1431.15},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":19952.66,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7753.63,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":27583.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10544.93,"additional_payer_notes":"APC"}]}]},{"description":"Oct breast surg cavity i&r","code_information":[{"code":"0354T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3401.23,"maximum":3453.5,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3453.5},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3401.23},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3453.5}]}]},{"description":"Heart symp image plnr","code_information":[{"code":"0331T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":741.71,"maximum":2471.46,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1280.55,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":753.11},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":741.71},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":753.11},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2471.46,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":960.41,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1306.16,"additional_payer_notes":"APC"}]}]},{"description":"Drainage of skin abscess","code_information":[{"code":"10061","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":301.57,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":402.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":776.03,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":301.57,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":410.13,"additional_payer_notes":"APC"}]}]},{"description":"Debride infected skin","code_information":[{"code":"11000","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":301.57,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":402.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":776.03,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":301.57,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":410.13,"additional_payer_notes":"APC"}]}]},{"description":"Deb skin bone at fx site","code_information":[{"code":"11012","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2154.81,"maximum":5545.05,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2873.08,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5545.05,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2154.81,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2930.54,"additional_payer_notes":"APC"}]}]},{"description":"Trim skin lesions 2 to 4","code_information":[{"code":"11056","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":148.84,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":198.45,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":383.01,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":148.84,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":202.42,"additional_payer_notes":"APC"}]}]},{"description":"Shave skin lesion 0.5 cm/<","code_information":[{"code":"11305","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":148.84,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":198.45,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":383.01,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":148.84,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":202.42,"additional_payer_notes":"APC"}]}]},{"description":"Exc tr-ext b9+marg 0.5 cm<","code_information":[{"code":"11400","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":525.32,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":700.42,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1351.81,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":525.32,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":714.43,"additional_payer_notes":"APC"}]}]},{"description":"Exc h-f-nk-sp b9+marg 1.1-2","code_information":[{"code":"11422","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1225.21,"maximum":4106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1633.61,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3152.87,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1225.21,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1666.28,"additional_payer_notes":"APC"}]}]},{"description":"Exc face-mm b9+marg 3.1-4 cm","code_information":[{"code":"11444","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1225.21,"maximum":4106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1633.61,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3152.87,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1225.21,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1666.28,"additional_payer_notes":"APC"}]}]},{"description":"Exc tr-ext mal+marg 0.5 cm/<","code_information":[{"code":"11600","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":525.32,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":700.42,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1351.81,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":525.32,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":714.43,"additional_payer_notes":"APC"}]}]},{"description":"Exc s/n/h/f/g mal+mrg 1.1-2","code_information":[{"code":"11622","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":525.32,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":700.42,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1351.81,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":525.32,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":714.43,"additional_payer_notes":"APC"}]}]},{"description":"Exc f/e/e/n/l mal+mrg 3.1-4","code_information":[{"code":"11644","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1225.21,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1633.61,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3152.87,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1225.21,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1666.28,"additional_payer_notes":"APC"}]}]},{"description":"Removal of nail bed","code_information":[{"code":"11750","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":301.57,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":402.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":776.03,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":301.57,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":410.13,"additional_payer_notes":"APC"}]}]},{"description":"Inject skin lesions <=w 7","code_information":[{"code":"11900","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":148.84,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":198.45,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":383.01,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":148.84,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":202.42,"additional_payer_notes":"APC"}]}]},{"description":"Tx contour defects >10.0 cc","code_information":[{"code":"11954","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":548.27,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":731.02,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1410.87,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":548.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":745.64,"additional_payer_notes":"APC"}]}]},{"description":"Remove/insert drug implant","code_information":[{"code":"11983","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":331.39,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":441.86,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":852.79,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":331.39,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":450.7,"additional_payer_notes":"APC"}]}]},{"description":"Rpr f/e/e/n/l/m 2.6-5.0 cm","code_information":[{"code":"12013","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":148.84,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":198.45,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":383.01,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":148.84,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":202.42,"additional_payer_notes":"APC"}]}]},{"description":"Intmd rpr s/a/t/ext 2.5 cm/<","code_information":[{"code":"12031","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":301.57,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":402.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":776.03,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":301.57,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":410.13,"additional_payer_notes":"APC"}]}]},{"description":"Release of eye fluid","code_information":[{"code":"67015","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1712.02,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2282.69,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4405.59,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1712.02,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2328.34,"additional_payer_notes":"APC"}]}]},{"description":"Laser treatment of retina","code_information":[{"code":"67040","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3066.31,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4088.41,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7890.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3066.31,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4170.17,"additional_payer_notes":"APC"}]}]},{"description":"Repair detached retina","code_information":[{"code":"67110","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1712.02,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2282.69,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4405.59,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1712.02,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2328.34,"additional_payer_notes":"APC"}]}]},{"description":"Treatment of retinal lesion","code_information":[{"code":"67210","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":408.01,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":544.01,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1049.93,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":408.01,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":554.89,"additional_payer_notes":"APC"}]}]},{"description":"Reinforce eye wall","code_information":[{"code":"67250","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1763.69,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2351.59,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4538.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1763.69,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2398.62,"additional_payer_notes":"APC"}]}]},{"description":"Revise eye muscle(s) add-on","code_information":[{"code":"67320","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Biopsy eye muscle","code_information":[{"code":"67346","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2916.44,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3888.58,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7504.96,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2916.44,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3966.35,"additional_payer_notes":"APC"}]}]},{"description":"Explore/treat eye socket","code_information":[{"code":"67420","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2916.44,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3888.58,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7504.96,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2916.44,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3966.35,"additional_payer_notes":"APC"}]}]},{"description":"Insert eye socket implant","code_information":[{"code":"67550","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2916.44,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3888.58,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7504.96,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2916.44,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3966.35,"additional_payer_notes":"APC"}]}]},{"description":"Remove eyelid lesions","code_information":[{"code":"67801","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":739.52,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":986.02,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1903.02,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":739.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1005.74,"additional_payer_notes":"APC"}]}]},{"description":"Remove eyelid lesion","code_information":[{"code":"67840","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":739.52,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":986.02,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1903.02,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":739.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1005.74,"additional_payer_notes":"APC"}]}]},{"description":"Repair eyelid defect","code_information":[{"code":"67903","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1763.69,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2351.59,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4538.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1763.69,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2398.62,"additional_payer_notes":"APC"}]}]},{"description":"Repair eyelid defect","code_information":[{"code":"67915","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1763.69,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2351.59,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4538.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1763.69,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2398.62,"additional_payer_notes":"APC"}]}]},{"description":"Repair eyelid wound","code_information":[{"code":"67935","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1763.69,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2351.59,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4538.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1763.69,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2398.62,"additional_payer_notes":"APC"}]}]},{"description":"Reconstruction of eyelid","code_information":[{"code":"67975","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1763.69,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2351.59,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4538.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1763.69,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2398.62,"additional_payer_notes":"APC"}]}]},{"description":"Remove eyelid lining lesion","code_information":[{"code":"68135","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1763.69,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2351.59,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4538.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1763.69,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2398.62,"additional_payer_notes":"APC"}]}]},{"description":"Separate eyelid adhesions","code_information":[{"code":"68340","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1763.69,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2351.59,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4538.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1763.69,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2398.62,"additional_payer_notes":"APC"}]}]},{"description":"Removal of tear gland","code_information":[{"code":"68500","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2916.44,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3888.58,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7504.96,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2916.44,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3966.35,"additional_payer_notes":"APC"}]}]},{"description":"Repair tear ducts","code_information":[{"code":"68700","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1763.69,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2351.59,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4538.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1763.69,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2398.62,"additional_payer_notes":"APC"}]}]},{"description":"Dilate tear duct opening","code_information":[{"code":"68801","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":331.39,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":441.86,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":852.79,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":331.39,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":450.7,"additional_payer_notes":"APC"}]}]},{"description":"Drain external ear lesion","code_information":[{"code":"69000","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":525.32,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":700.42,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1351.81,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":525.32,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":714.43,"additional_payer_notes":"APC"}]}]},{"description":"Remove ear canal lesion(s)","code_information":[{"code":"69140","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":11300.84,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Clean out mastoid cavity","code_information":[{"code":"69220","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":148.84,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":198.45,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":383.01,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":148.84,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":202.42,"additional_payer_notes":"APC"}]}]},{"description":"Remove ventilating tube","code_information":[{"code":"69424","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2459.51,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3279.35,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6329.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2459.51,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3344.94,"additional_payer_notes":"APC"}]}]},{"description":"Extensive mastoid surgery","code_information":[{"code":"69511","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Mastoid surgery revision","code_information":[{"code":"69602","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Repair eardrum structures","code_information":[{"code":"69635","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Revise middle ear & mastoid","code_information":[{"code":"69646","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Remove middle ear nerve","code_information":[{"code":"69676","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2459.51,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3279.35,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6329.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2459.51,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3344.94,"additional_payer_notes":"APC"}]}]},{"description":"Repair facial nerve","code_information":[{"code":"69740","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Incise inner ear nerve","code_information":[{"code":"69915","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2459.51,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3279.35,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6329.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2459.51,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3344.94,"additional_payer_notes":"APC"}]}]},{"description":"Microsurgery add-on","code_information":[{"code":"69990","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"L hrt artery/ventricle angio","code_information":[{"code":"93458","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2404.97,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3206.62,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6188.79,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2404.97,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3270.76,"additional_payer_notes":"APC"}]}]},{"description":"Perc drug-el cor stent bran","code_information":[{"code":"C9601","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Place endorectal app","code_information":[{"code":"C9725","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":689.87,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":919.83,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1775.27,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":689.87,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":938.23,"additional_payer_notes":"APC"}]}]},{"description":"Root surgery ea add root","code_information":[{"code":"D3426","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5512.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0}]}]},{"description":"Coronary artery bypass/reop","code_information":[{"code":"33530","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":9356.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0}]}]},{"description":"Open coronary endarterectomy","code_information":[{"code":"33572","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":9356.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0}]}]},{"description":"Repair modified fontan","code_information":[{"code":"33615","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":9356.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0}]}]},{"description":"Repair heart septum defects","code_information":[{"code":"33647","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":9356.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0}]}]},{"description":"Repair heart septum defect","code_information":[{"code":"33684","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":9356.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0}]}]},{"description":"Repair of heart defect","code_information":[{"code":"33720","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":9356.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0}]}]},{"description":"Major vessel shunt","code_information":[{"code":"33755","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6019.0,"maximum":7398.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":7398.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6019.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":7398.0}]}]},{"description":"Repair great vessels defect","code_information":[{"code":"33774","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6019.0,"maximum":7398.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":7398.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6019.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":7398.0}]}]},{"description":"Nikaidoh proc","code_information":[{"code":"33782","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6019.0,"maximum":7398.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":7398.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6019.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":7398.0}]}]},{"description":"Revise major vessel","code_information":[{"code":"33820","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6019.0,"maximum":43643.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":7398.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6019.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":7398.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43643.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43643.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43643.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":41120.0}]}]},{"description":"Ascending aortic graft","code_information":[{"code":"33863","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":9356.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0}]}]},{"description":"Endovasc prosth delayed","code_information":[{"code":"33886","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":9356.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0}]}]},{"description":"Transect pulmonary artery","code_information":[{"code":"33922","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6019.0,"maximum":7398.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":7398.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6019.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":7398.0}]}]},{"description":"Prepare donor heart","code_information":[{"code":"33944","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5257.0,"maximum":6462.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5257.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6462.0}]}]},{"description":"Ecmo/ecls insj prph cannula","code_information":[{"code":"33953","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3388.0,"maximum":4106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0}]}]},{"description":"Ecmo/ecls repos perph cnula","code_information":[{"code":"33963","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3388.0,"maximum":4106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0}]}]},{"description":"Aortic circulation assist","code_information":[{"code":"33971","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Remove intracorporeal device","code_information":[{"code":"33980","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":9356.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0}]}]},{"description":"Insertion of left heart vent","code_information":[{"code":"33988","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":9356.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0}]}]},{"description":"Removal of artery clot","code_information":[{"code":"34051","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Removal of vein clot","code_information":[{"code":"34451","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Endovas iliac a device addon","code_information":[{"code":"34808","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Xpose endoprosth brachial","code_information":[{"code":"34834","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3388.0,"maximum":4106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0}]}]},{"description":"Visc & infraren abd 3 prosth","code_information":[{"code":"34847","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6019.0,"maximum":7398.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":7398.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6019.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":7398.0}]}]},{"description":"Repair artery rupture chest","code_information":[{"code":"35022","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Repair defect of artery","code_information":[{"code":"35111","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Repair defect of artery","code_information":[{"code":"35151","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Repair blood vessel lesion","code_information":[{"code":"35201","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4127.91,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5503.89,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":10622.5,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4127.91,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5613.96,"additional_payer_notes":"APC"}]}]},{"description":"Repair blood vessel lesion","code_information":[{"code":"35236","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4127.91,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5503.89,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":10622.5,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4127.91,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5613.96,"additional_payer_notes":"APC"}]}]},{"description":"Repair blood vessel lesion","code_information":[{"code":"35276","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Rechanneling of Artery","code_information":[{"code":"35306","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Rechanneling of artery","code_information":[{"code":"35363","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Art byp grft carotid-vertbrl","code_information":[{"code":"35508","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Art byp grft axill-femoral","code_information":[{"code":"35521","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Art byp grft splenorenal","code_information":[{"code":"35536","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Art byp grft ilioiliac","code_information":[{"code":"35563","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Gingivectomy/plasty 4 or mor","code_information":[{"code":"D4210","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2459.51,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3279.35,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6329.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2459.51,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3344.94,"additional_payer_notes":"APC"}]}]},{"description":"Crown lengthen hard tissue","code_information":[{"code":"D4249","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":479.59,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":639.45,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1234.13,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":479.59,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":652.24,"additional_payer_notes":"APC"}]}]},{"description":"Pedicle soft tissue graft pr","code_information":[{"code":"D4270","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1151.01,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1534.69,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2961.94,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1151.01,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1565.38,"additional_payer_notes":"APC"}]}]},{"description":"Second stage implant surgery","code_information":[{"code":"D6011","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5512.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0}]}]},{"description":"Extraction coronal remnants","code_information":[{"code":"D7111","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":479.59,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":639.45,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1234.13,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":479.59,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":652.24,"additional_payer_notes":"APC"}]}]},{"description":"Coronectomy","code_information":[{"code":"D7251","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1151.01,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1534.69,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2961.94,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1151.01,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1565.38,"additional_payer_notes":"APC"}]}]},{"description":"Biopsy of oral tissue hard","code_information":[{"code":"D7285","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5512.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0}]}]},{"description":"Temp anchorage dev w/o flap","code_information":[{"code":"D7294","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5512.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0}]}]},{"description":"Rad exc lesion up to 1.25 cm","code_information":[{"code":"D7410","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1151.01,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1534.69,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2961.94,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1151.01,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1565.38,"additional_payer_notes":"APC"}]}]},{"description":"Rem odontogen cyst to 1.25cm","code_information":[{"code":"D7450","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2459.51,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3279.35,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6329.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2459.51,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3344.94,"additional_payer_notes":"APC"}]}]},{"description":"Surg reduct osseoustuberosit","code_information":[{"code":"D7485","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":11300.84,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Removal of sloughed off bone","code_information":[{"code":"D7550","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":479.59,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":639.45,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1234.13,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":479.59,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":652.24,"additional_payer_notes":"APC"}]}]},{"description":"Open reduct compd mandble fx","code_information":[{"code":"D7730","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5512.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0}]}]},{"description":"Tmj repair of joint disc","code_information":[{"code":"D7852","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5512.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0}]}]},{"description":"Tmj diagnostic arthroscopy","code_information":[{"code":"D7872","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5512.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0}]}]},{"description":"Suture complicate wnd > 5 cm","code_information":[{"code":"D7912","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5512.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0}]}]},{"description":"Reconstruction maxilla total","code_information":[{"code":"D7946","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5512.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0}]}]},{"description":"Repair maxillofacial defects","code_information":[{"code":"D7955","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5512.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0}]}]},{"description":"Closure of salivary fistula","code_information":[{"code":"D7983","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5512.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0}]}]},{"description":"CA screen;flexi sigmoidscope","code_information":[{"code":"G0104","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":689.87,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":919.83,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1775.27,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":689.87,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":938.23,"additional_payer_notes":"APC"}]}]},{"description":"Arthro, loose body + chondro","code_information":[{"code":"G0289","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Collagen Meniscus Implant","code_information":[{"code":"G0428","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5512.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0}]}]},{"description":"Transplant multivisceral organs","code_information":[{"code":"S2054","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5512.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0}]}]},{"description":"Cystoerethroscopy","code_information":[{"code":"S2070","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5512.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0}]}]},{"description":"Osteotomy, peracteabular, with internal fixation","code_information":[{"code":"S2115","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5512.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0}]}]},{"description":"Implant semi-imp hear","code_information":[{"code":"S2230","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5512.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0}]}]},{"description":"Fetal surg pulmon sequest","code_information":[{"code":"S2403","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5512.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0}]}]},{"description":"Njx interlaminar lmbr/sac","code_information":[{"code":"62322","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":656.13,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":874.84,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1688.44,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":656.13,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":892.34,"additional_payer_notes":"APC"}]}]},{"description":"Rmvl subq car rhythm mntr","code_information":[{"code":"33286","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":525.32,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":700.42,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1351.81,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":525.32,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":714.43,"additional_payer_notes":"APC"}]}]},{"description":"Tmvi percutaneous approach","code_information":[{"code":"0483T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":9356.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0}]}]},{"description":"Bone marrow aspir bone grfg","code_information":[{"code":"20939","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Rmvl & rplcmt tot hrt sys","code_information":[{"code":"33928","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8923.0,"maximum":10765.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":10765.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":8923.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":10765.0}]}]},{"description":"Intmd rpr n-hf/genit7.6-12.5","code_information":[{"code":"12044","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":548.27,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":731.02,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1410.87,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":548.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":745.64,"additional_payer_notes":"APC"}]}]},{"description":"Intmd rpr face/mm 12.6-20 cm","code_information":[{"code":"12055","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":301.57,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":402.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":776.03,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":301.57,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":410.13,"additional_payer_notes":"APC"}]}]},{"description":"Cmplx rpr s/a/l addl 5 cm/>","code_information":[{"code":"13122","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Tis trnfr trunk 10 sq cm/<","code_information":[{"code":"14000","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1530.61,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2040.81,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3938.76,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1530.61,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2081.63,"additional_payer_notes":"APC"}]}]},{"description":"Tis trnfr any 30.1-60 sq cm","code_information":[{"code":"14301","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2628.85,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3505.13,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6764.9,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2628.85,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3575.23,"additional_payer_notes":"APC"}]}]},{"description":"Skin pinch graft","code_information":[{"code":"15050","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":548.27,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":731.02,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1410.87,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":548.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":745.64,"additional_payer_notes":"APC"}]}]},{"description":"Skn splt a-grft f/n/hf/g add","code_information":[{"code":"15121","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Cult skin graft f/n/hf/g","code_information":[{"code":"15155","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2628.85,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3505.13,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6764.9,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2628.85,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3575.23,"additional_payer_notes":"APC"}]}]},{"description":"Skin full graft add-on","code_information":[{"code":"15241","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Skin sub graft f/n/hf/g addl","code_information":[{"code":"15276","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Delay flap arms/legs","code_information":[{"code":"15610","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1530.61,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2040.81,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3938.76,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1530.61,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2081.63,"additional_payer_notes":"APC"}]}]},{"description":"Island pedicle flap graft","code_information":[{"code":"15740","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1530.61,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2040.81,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3938.76,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1530.61,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2081.63,"additional_payer_notes":"APC"}]}]},{"description":"Hair trnspl >15 punch grafts","code_information":[{"code":"15776","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":301.57,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":402.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":776.03,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":301.57,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":410.13,"additional_payer_notes":"APC"}]}]},{"description":"Chemical peel face epiderm","code_information":[{"code":"15788","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":301.57,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":402.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":776.03,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":301.57,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":410.13,"additional_payer_notes":"APC"}]}]},{"description":"Removal of forehead wrinkles","code_information":[{"code":"15824","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1530.61,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2040.81,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3938.76,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1530.61,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2081.63,"additional_payer_notes":"APC"}]}]},{"description":"Excise excessive skin hip","code_information":[{"code":"15834","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2154.81,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2873.08,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5545.05,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2154.81,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2930.54,"additional_payer_notes":"APC"}]}]},{"description":"Nerve palsy microsurg graft","code_information":[{"code":"15842","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1530.61,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2040.81,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3938.76,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1530.61,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2081.63,"additional_payer_notes":"APC"}]}]},{"description":"Suction lipectomy upr extrem","code_information":[{"code":"15878","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1530.61,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2040.81,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3938.76,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1530.61,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2081.63,"additional_payer_notes":"APC"}]}]},{"description":"Remove sacrum pressure sore","code_information":[{"code":"15936","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1530.61,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2040.81,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3938.76,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1530.61,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2081.63,"additional_payer_notes":"APC"}]}]},{"description":"Remove thigh pressure sore","code_information":[{"code":"15951","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2154.81,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2873.08,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5545.05,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2154.81,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2930.54,"additional_payer_notes":"APC"}]}]},{"description":"Dress/debrid p-thick burn m","code_information":[{"code":"16025","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":148.84,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":198.45,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":383.01,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":148.84,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":202.42,"additional_payer_notes":"APC"}]}]},{"description":"Us bone stimulation","code_information":[{"code":"20979","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":21.46,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":28.61,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":55.21,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21.46,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":29.18,"additional_payer_notes":"APC"}]}]},{"description":"Exc face tum deep < 2 cm","code_information":[{"code":"21013","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1225.21,"maximum":4106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1633.61,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3152.87,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1225.21,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1666.28,"additional_payer_notes":"APC"}]}]},{"description":"Remove exostosis mandible","code_information":[{"code":"21031","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2459.51,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3279.35,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6329.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2459.51,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3344.94,"additional_payer_notes":"APC"}]}]},{"description":"Remove maxilla cyst complex","code_information":[{"code":"21048","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Electrical bone stimulation","code_information":[{"code":"20975","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Iliac bone graft microvasc","code_information":[{"code":"20956","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Removal of tendon for graft","code_information":[{"code":"20924","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":13851.98,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Replantation thumb complete","code_information":[{"code":"20827","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1192.86,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1590.48,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3069.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1192.86,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1622.29,"additional_payer_notes":"APC"}]}]},{"description":"Comp multiplane ext fixation","code_information":[{"code":"20696","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8657.0,"maximum":51798.34,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26838.52,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":10765.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":8923.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":10765.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":51798.34,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20128.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27375.29,"additional_payer_notes":"APC"}]}]},{"description":"Application of halo","code_information":[{"code":"20664","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1192.86,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1590.48,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3069.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1192.86,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1622.29,"additional_payer_notes":"APC"}]}]},{"description":"Drain/inj joint/bursa w/us","code_information":[{"code":"20611","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":227.71,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":303.61,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":585.96,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":227.71,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":309.68,"additional_payer_notes":"APC"}]}]},{"description":"Inj trigger point 1/2 muscl","code_information":[{"code":"20552","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":227.71,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":303.61,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":585.96,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":227.71,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":309.68,"additional_payer_notes":"APC"}]}]},{"description":"Injection of sinus tract","code_information":[{"code":"20500","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1151.01,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1534.69,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2961.94,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1151.01,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1565.38,"additional_payer_notes":"APC"}]}]},{"description":"Deep muscle biopsy","code_information":[{"code":"20205","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2154.81,"maximum":5545.05,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2873.08,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5545.05,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2154.81,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2930.54,"additional_payer_notes":"APC"}]}]},{"description":"Design custom breast implant","code_information":[{"code":"19396","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2904.59,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3872.79,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7474.49,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2904.59,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3950.25,"additional_payer_notes":"APC"}]}]},{"description":"Fluoro exam of g/colon tube","code_information":[{"code":"49465","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":177.0,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":236.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":455.49,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":177.0,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":240.72,"additional_payer_notes":"APC"}]}]},{"description":"Prp i/hern init block >5 yr","code_information":[{"code":"49507","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2656.06,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3541.41,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6834.92,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2656.06,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3612.24,"additional_payer_notes":"APC"}]}]},{"description":"Rerepair fem hernia blocked","code_information":[{"code":"49557","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2656.06,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3541.41,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6834.92,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2656.06,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3612.24,"additional_payer_notes":"APC"}]}]},{"description":"Laparo proc hernia repair","code_information":[{"code":"49659","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4484.77,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5979.69,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5257.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11540.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4484.77,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6099.28,"additional_payer_notes":"APC"}]}]},{"description":"Drainage of kidney","code_information":[{"code":"50040","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0}]}]},{"description":"Revise kidney blood vessels","code_information":[{"code":"50100","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Removal kidney open radical","code_information":[{"code":"50230","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Remove kidney living donor","code_information":[{"code":"50320","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Transplantation of kidney","code_information":[{"code":"50365","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8923.0,"maximum":10765.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":10765.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":8923.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":10765.0}]}]},{"description":"Remove renal tube w/fluoro","code_information":[{"code":"50389","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":517.28,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":689.7,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1331.13,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":517.28,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":703.5,"additional_payer_notes":"APC"}]}]},{"description":"Plmt nephrostomy catheter","code_information":[{"code":"50432","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1550.71,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2067.62,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3990.5,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1550.71,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2108.97,"additional_payer_notes":"APC"}]}]},{"description":"Revision of horseshoe kidney","code_information":[{"code":"50540","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Laparo remove w/ureter","code_information":[{"code":"50548","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5257.0,"maximum":6462.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5257.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6462.0}]}]},{"description":"Kidney endoscopy","code_information":[{"code":"50570","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2614.94,"maximum":6729.12,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3486.59,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6729.12,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2614.94,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3556.32,"additional_payer_notes":"APC"}]}]},{"description":"Perc cryo ablate renal tum","code_information":[{"code":"50593","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":20292.15,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10514.07,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":20292.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7885.55,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10724.35,"additional_payer_notes":"APC"}]}]},{"description":"Removal of ureter","code_information":[{"code":"50660","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Revision of ureter","code_information":[{"code":"50700","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Fusion of ureter & kidney","code_information":[{"code":"50740","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Implant ureter in bowel","code_information":[{"code":"50800","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Transplant ureter to skin","code_information":[{"code":"50860","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Laparoscope proc ureter","code_information":[{"code":"50949","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4484.77,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5979.69,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5257.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11540.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4484.77,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6099.28,"additional_payer_notes":"APC"}]}]},{"description":"Ureter endoscopy & biopsy","code_information":[{"code":"50974","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3579.0,"maximum":10235.57,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5303.4,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":10235.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3977.55,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5409.47,"additional_payer_notes":"APC"}]}]},{"description":"Remove ureter calculus","code_information":[{"code":"51065","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2614.94,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3486.59,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6729.12,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2614.94,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3556.32,"additional_payer_notes":"APC"}]}]},{"description":"Removal of bladder lesion","code_information":[{"code":"51530","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0}]}]},{"description":"Removal of bladder & nodes","code_information":[{"code":"51585","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Irrigation of bladder","code_information":[{"code":"51700","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":185.35,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":247.13,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":476.96,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":185.35,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":252.07,"additional_payer_notes":"APC"}]}]},{"description":"Simple cystometrogram","code_information":[{"code":"51725","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":185.35,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":247.13,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":476.96,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":185.35,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":252.07,"additional_payer_notes":"APC"}]}]},{"description":"Anal/urinary muscle study","code_information":[{"code":"51785","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":185.35,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":247.13,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":476.96,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":185.35,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":252.07,"additional_payer_notes":"APC"}]}]},{"description":"Repair bladder neck","code_information":[{"code":"51845","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3710.98,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4947.97,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":9549.58,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3710.98,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5046.93,"additional_payer_notes":"APC"}]}]},{"description":"Revision of bladder & bowel","code_information":[{"code":"51960","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Cystoscopy and biopsy","code_information":[{"code":"52007","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2614.94,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3486.59,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6729.12,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2614.94,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3556.32,"additional_payer_notes":"APC"}]}]},{"description":"Cystoscopy and radiotracer","code_information":[{"code":"52250","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2614.94,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3486.59,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6729.12,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2614.94,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3556.32,"additional_payer_notes":"APC"}]}]},{"description":"Cystoscopy implant stent","code_information":[{"code":"52282","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2614.94,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3486.59,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6729.12,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2614.94,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3556.32,"additional_payer_notes":"APC"}]}]},{"description":"Cystoscopy and treatment","code_information":[{"code":"52310","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1550.71,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2067.62,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3990.5,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1550.71,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2108.97,"additional_payer_notes":"APC"}]}]},{"description":"Cystoscopy and treatment","code_information":[{"code":"52332","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2614.94,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3486.59,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6729.12,"additional_payer_notes":"APC"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":4319.0},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2614.94,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3556.32,"additional_payer_notes":"APC"}]}]},{"description":"Cystouretero & or pyeloscope","code_information":[{"code":"52351","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2614.94,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3486.59,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6729.12,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2614.94,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3556.32,"additional_payer_notes":"APC"}]}]},{"description":"Cystouretero W/Lithotripsy","code_information":[{"code":"52353","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3977.55,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5303.4,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":10235.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3977.55,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5409.47,"additional_payer_notes":"APC"}]}]},{"description":"Incision of prostate","code_information":[{"code":"52450","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2614.94,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3486.59,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6729.12,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2614.94,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3556.32,"additional_payer_notes":"APC"}]}]},{"description":"Drainage of prostate abscess","code_information":[{"code":"52700","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2614.94,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3486.59,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6729.12,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2614.94,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3556.32,"additional_payer_notes":"APC"}]}]},{"description":"Drainage of urinary leakage","code_information":[{"code":"53085","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1550.71,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2067.62,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3990.5,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1550.71,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2108.97,"additional_payer_notes":"APC"}]}]},{"description":"Removal of urethra gland","code_information":[{"code":"53250","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2614.94,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3486.59,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6729.12,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2614.94,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3556.32,"additional_payer_notes":"APC"}]}]},{"description":"Reconstruction of urethra","code_information":[{"code":"53415","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0}]}]},{"description":"Insert uro/ves nck sphincter","code_information":[{"code":"53445","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8923.0,"maximum":43643.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20500.4,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":10765.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":8923.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":10765.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43643.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43643.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43643.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":39565.78,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15375.3,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":41120.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20910.41,"additional_payer_notes":"APC"}]}]},{"description":"Repair of urethra injury","code_information":[{"code":"53502","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2614.94,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3486.59,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6729.12,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2614.94,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3556.32,"additional_payer_notes":"APC"}]}]},{"description":"Dilate urethra stricture","code_information":[{"code":"53620","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":517.28,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":689.7,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1331.13,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":517.28,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":703.5,"additional_payer_notes":"APC"}]}]},{"description":"Transurethral rf treatment","code_information":[{"code":"53860","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1550.71,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2067.62,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3990.5,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1550.71,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2108.97,"additional_payer_notes":"APC"}]}]},{"description":"Laser surg penis lesion(s)","code_information":[{"code":"54057","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1530.61,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2040.81,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3938.76,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1530.61,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2081.63,"additional_payer_notes":"APC"}]}]},{"description":"Treatment of penis lesion","code_information":[{"code":"54115","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2154.81,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2873.08,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5545.05,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2154.81,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2930.54,"additional_payer_notes":"APC"}]}]},{"description":"Lysis penil circumic lesion","code_information":[{"code":"54162","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1550.71,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2067.62,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3990.5,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1550.71,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2108.97,"additional_payer_notes":"APC"}]}]},{"description":"Penile injection","code_information":[{"code":"54235","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":185.35,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":247.13,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":476.96,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":185.35,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":252.07,"additional_payer_notes":"APC"}]}]},{"description":"Reconstruction of urethra","code_information":[{"code":"54318","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2614.94,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3486.59,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6729.12,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2614.94,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3556.32,"additional_payer_notes":"APC"}]}]},{"description":"Secondary urethral surgery","code_information":[{"code":"54344","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":18071.3,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9363.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":18071.3,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7022.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9550.63,"additional_payer_notes":"APC"}]}]},{"description":"Insert self-contd prosthesis","code_information":[{"code":"54401","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8923.0,"maximum":43643.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20500.4,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":10765.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":8923.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":10765.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43643.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43643.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43643.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":39565.78,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15375.3,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":41120.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20910.41,"additional_payer_notes":"APC"}]}]},{"description":"Remv/replc penis pros compl","code_information":[{"code":"54417","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2959.0,"maximum":39565.78,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20500.4,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":10765.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":8923.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":10765.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":39565.78,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15375.3,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20910.41,"additional_payer_notes":"APC"}]}]},{"description":"Biopsy of testis","code_information":[{"code":"54505","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2614.94,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3486.59,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6729.12,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2614.94,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3556.32,"additional_payer_notes":"APC"}]}]},{"description":"Reduce testis torsion","code_information":[{"code":"54600","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2614.94,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3486.59,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6729.12,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2614.94,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3556.32,"additional_payer_notes":"APC"}]}]},{"description":"Laparoscopy orchiopexy","code_information":[{"code":"54692","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4484.77,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5979.69,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5257.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11540.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4484.77,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6099.28,"additional_payer_notes":"APC"}]}]},{"description":"Explore Epididymis","code_information":[{"code":"54865","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2614.94,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3486.59,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6729.12,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2614.94,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3556.32,"additional_payer_notes":"APC"}]}]},{"description":"Explore scrotum","code_information":[{"code":"55110","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2614.94,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3486.59,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6729.12,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2614.94,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3556.32,"additional_payer_notes":"APC"}]}]},{"description":"Repair of sperm duct","code_information":[{"code":"55400","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2614.94,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3486.59,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6729.12,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2614.94,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3556.32,"additional_payer_notes":"APC"}]}]},{"description":"Incise sperm duct pouch","code_information":[{"code":"55600","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1550.71,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2067.62,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3990.5,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1550.71,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2108.97,"additional_payer_notes":"APC"}]}]},{"description":"Drainage of prostate abscess","code_information":[{"code":"55725","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2614.94,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3486.59,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6729.12,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2614.94,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3556.32,"additional_payer_notes":"APC"}]}]},{"description":"Extensive prostate surgery","code_information":[{"code":"55842","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Transperi needle place pros","code_information":[{"code":"55875","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3977.55,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5303.4,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":10235.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3977.55,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5409.47,"additional_payer_notes":"APC"}]}]},{"description":"Surgery for vulva lesion","code_information":[{"code":"56440","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2401.4,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3201.87,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6179.61,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2401.4,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3265.91,"additional_payer_notes":"APC"}]}]},{"description":"Complete removal of vulva","code_information":[{"code":"56625","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2401.4,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3201.87,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6179.61,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2401.4,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3265.91,"additional_payer_notes":"APC"}]}]},{"description":"Partial removal of hymen","code_information":[{"code":"56700","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2401.4,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3201.87,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6179.61,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2401.4,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3265.91,"additional_payer_notes":"APC"}]}]},{"description":"Drainage of pelvic abscess","code_information":[{"code":"57010","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2401.4,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3201.87,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6179.61,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2401.4,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3265.91,"additional_payer_notes":"APC"}]}]},{"description":"Remove vagina wall partial","code_information":[{"code":"57106","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2401.4,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3201.87,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6179.61,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2401.4,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3265.91,"additional_payer_notes":"APC"}]}]},{"description":"Treat vagina infection","code_information":[{"code":"57150","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":43.76,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":58.35,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":112.62,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":43.76,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":59.52,"additional_payer_notes":"APC"}]}]},{"description":"Revision of urethra","code_information":[{"code":"57220","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3710.98,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4947.97,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":9549.58,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3710.98,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5046.93,"additional_payer_notes":"APC"}]}]},{"description":"Repair of bowel pouch","code_information":[{"code":"57270","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0}]}]},{"description":"Breast reconstr w/lat flap","code_information":[{"code":"19361","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6019.0,"maximum":7398.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":7398.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6019.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":7398.0}]}]},{"description":"Enlarge breast with implant","code_information":[{"code":"19325","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6063.28,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8084.38,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":15602.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6063.28,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8246.06,"additional_payer_notes":"APC"}]}]},{"description":"Partial Mastectomy","code_information":[{"code":"19301","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2904.59,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3872.79,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7474.49,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2904.59,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3950.25,"additional_payer_notes":"APC"}]}]},{"description":"Perq dev breast 1st us imag","code_information":[{"code":"19285","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":525.32,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":700.42,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1351.81,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":525.32,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":714.43,"additional_payer_notes":"APC"}]}]},{"description":"Excise breast duct fistula","code_information":[{"code":"19112","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2904.59,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3872.79,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7474.49,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2904.59,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3950.25,"additional_payer_notes":"APC"}]}]},{"description":"Bx breast 1st lesion us imag","code_information":[{"code":"19083","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1225.21,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1633.61,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3152.87,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1225.21,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1666.28,"additional_payer_notes":"APC"}]}]},{"description":"Hair removal by electrolysis","code_information":[{"code":"17380","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":548.27,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":731.02,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1410.87,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":548.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":745.64,"additional_payer_notes":"APC"}]}]},{"description":"Destruction of skin lesions","code_information":[{"code":"17286","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":548.27,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":731.02,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1410.87,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":548.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":745.64,"additional_payer_notes":"APC"}]}]},{"description":"Destruction of skin lesions","code_information":[{"code":"17273","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":301.57,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":402.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":776.03,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":301.57,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":410.13,"additional_payer_notes":"APC"}]}]},{"description":"Destruction of skin lesions","code_information":[{"code":"17261","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":148.84,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":198.45,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":383.01,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":148.84,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":202.42,"additional_payer_notes":"APC"}]}]},{"description":"Prepare face/oral prosthesis","code_information":[{"code":"21080","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2459.51,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3279.35,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6329.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2459.51,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3344.94,"additional_payer_notes":"APC"}]}]},{"description":"Prepare face/oral prosthesis","code_information":[{"code":"21088","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2459.51,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3279.35,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6329.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2459.51,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3344.94,"additional_payer_notes":"APC"}]}]},{"description":"Reconstruction of chin","code_information":[{"code":"21123","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2459.51,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3279.35,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6329.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2459.51,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3344.94,"additional_payer_notes":"APC"}]}]},{"description":"Lefort i-3/> piece w/o graft","code_information":[{"code":"21143","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Lefort iii w/fhdw/o lefort i","code_information":[{"code":"21159","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Reconstruct cranial bone","code_information":[{"code":"21183","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Reconstr Lwr Jaw W/Advance","code_information":[{"code":"21199","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":13249.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":10779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":13249.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Reconstruction of jaw joint","code_information":[{"code":"21240","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Reconstruction of jaw","code_information":[{"code":"21249","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Augmentation cheek bone","code_information":[{"code":"21270","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Closed tx nose fx w/ stablj","code_information":[{"code":"21320","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2459.51,"maximum":6329.15,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3279.35,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6329.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2459.51,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3344.94,"additional_payer_notes":"APC"}]}]},{"description":"Perq tx nasoethmoid fx","code_information":[{"code":"21340","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2459.51,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3279.35,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6329.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2459.51,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3344.94,"additional_payer_notes":"APC"}]}]},{"description":"Opn tx dprsd zygomatic arch","code_information":[{"code":"21356","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":11300.84,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Opn tx orbit periorbt w/grft","code_information":[{"code":"21395","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Treat mouth roof fracture","code_information":[{"code":"21423","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Treat lower jaw fracture","code_information":[{"code":"21450","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":400.09,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":533.45,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1029.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":400.09,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":544.12,"additional_payer_notes":"APC"}]}]},{"description":"Treat lower jaw fracture","code_information":[{"code":"21470","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Drainage of bone lesion","code_information":[{"code":"21510","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Partial removal of rib","code_information":[{"code":"21600","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":13851.98,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Revision of neck muscle","code_information":[{"code":"21700","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":13851.98,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Optx of rib fx w/fixj scope","code_information":[{"code":"21811","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":13851.98,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Exc back les sc < 3 cm","code_information":[{"code":"21930","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1225.21,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1633.61,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3152.87,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1225.21,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1666.28,"additional_payer_notes":"APC"}]}]},{"description":"Remove part of neck vertebra","code_information":[{"code":"22100","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Incis spine 3 column thorac","code_information":[{"code":"22206","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Incis w/discectomy thoracic","code_information":[{"code":"22222","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Treat neck spine fracture","code_information":[{"code":"22326","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":24508.8,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12698.86,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":24508.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9524.15,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12952.84,"additional_payer_notes":"APC"}]}]},{"description":"Repair bladder & vagina","code_information":[{"code":"57289","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5501.01,"maximum":14155.93,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7334.68,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":14155.93,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5501.01,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7481.37,"additional_payer_notes":"APC"}]}]},{"description":"Fistula repair transperine","code_information":[{"code":"57308","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0}]}]},{"description":"Remove vaginal foreign body","code_information":[{"code":"57415","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2401.4,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3201.87,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6179.61,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2401.4,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3265.91,"additional_payer_notes":"APC"}]}]},{"description":"Biopsy of cervix w/scope","code_information":[{"code":"57455","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":226.06,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":301.41,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":581.72,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":226.06,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":307.44,"additional_payer_notes":"APC"}]}]},{"description":"Laser surgery of cervix","code_information":[{"code":"57513","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2401.4,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3201.87,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6179.61,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2401.4,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3265.91,"additional_payer_notes":"APC"}]}]},{"description":"Remove cervix/repair vagina","code_information":[{"code":"57555","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3710.98,"maximum":9549.58,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4947.97,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":9549.58,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3710.98,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5046.93,"additional_payer_notes":"APC"}]}]},{"description":"Dilation and curettage","code_information":[{"code":"58120","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2401.4,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3201.87,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6179.61,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2401.4,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3265.91,"additional_payer_notes":"APC"}]}]},{"description":"Extensive hysterectomy","code_information":[{"code":"58210","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5257.0,"maximum":6462.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5257.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6462.0}]}]},{"description":"Hysterectomy/revise vagina","code_information":[{"code":"58280","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5257.0,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5257.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0}]}]},{"description":"Artificial insemination","code_information":[{"code":"58321","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":226.06,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":301.41,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":581.72,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":226.06,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":307.44,"additional_payer_notes":"APC"}]}]},{"description":"Endometrial cryoablation","code_information":[{"code":"58356","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3710.98,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4947.97,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":9549.58,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3710.98,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5046.93,"additional_payer_notes":"APC"}]}]},{"description":"LSH w/t/o Uterus Above 250 g","code_information":[{"code":"58544","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":20292.15,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10514.07,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":20292.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7885.55,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10724.35,"additional_payer_notes":"APC"}]}]},{"description":"Hysteroscopy dx sep proc","code_information":[{"code":"58555","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2401.4,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3201.87,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6179.61,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2401.4,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3265.91,"additional_payer_notes":"APC"}]}]},{"description":"Tlh uterus 250 g or less","code_information":[{"code":"58570","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":20292.15,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10514.07,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":20292.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7885.55,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10724.35,"additional_payer_notes":"APC"}]}]},{"description":"Ligate oviduct(s) add-on","code_information":[{"code":"58611","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Laparoscopy salpingostomy","code_information":[{"code":"58673","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5257.0,"maximum":20292.15,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10514.07,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5257.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":20292.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7885.55,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10724.35,"additional_payer_notes":"APC"}]}]},{"description":"Create new tubal opening","code_information":[{"code":"58770","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2401.4,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3201.87,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6179.61,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2401.4,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3265.91,"additional_payer_notes":"APC"}]}]},{"description":"Removal of ovarian cyst(s)","code_information":[{"code":"58925","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3710.98,"maximum":9549.58,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4947.97,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":9549.58,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3710.98,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5046.93,"additional_payer_notes":"APC"}]}]},{"description":"Bso omentectomy w/tah","code_information":[{"code":"58956","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Amniocentesis therapeutic","code_information":[{"code":"59001","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":226.06,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":301.41,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":581.72,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":226.06,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":307.44,"additional_payer_notes":"APC"}]}]},{"description":"Transabdom amnioinfus w/us","code_information":[{"code":"59070","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":226.06,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":301.41,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":581.72,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":226.06,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":307.44,"additional_payer_notes":"APC"}]}]},{"description":"Treat ectopic pregnancy","code_information":[{"code":"59136","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Revision of cervix","code_information":[{"code":"59325","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Antepartum care only","code_information":[{"code":"59426","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5512.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0}]}]},{"description":"Vbac care after delivery","code_information":[{"code":"59614","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Abortion","code_information":[{"code":"59840","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2401.4,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3201.87,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6179.61,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2401.4,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3265.91,"additional_payer_notes":"APC"}]}]},{"description":"Abortion (mpr)","code_information":[{"code":"59866","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":226.06,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":301.41,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":581.72,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":226.06,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":307.44,"additional_payer_notes":"APC"}]}]},{"description":"Remove thyroid lesion","code_information":[{"code":"60200","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4484.77,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5979.69,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5257.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11540.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4484.77,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6099.28,"additional_payer_notes":"APC"}]}]},{"description":"Repeat thyroid surgery","code_information":[{"code":"60260","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Explore parathyroid glands","code_information":[{"code":"60505","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Remove carotid body lesion","code_information":[{"code":"60605","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Remove brain canal fluid","code_information":[{"code":"61050","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":227.71,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":303.61,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":585.96,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":227.71,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":309.68,"additional_payer_notes":"APC"}]}]},{"description":"Pierce skull for drainage","code_information":[{"code":"61150","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Open skull for exploration","code_information":[{"code":"61304","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6779.0,"maximum":8333.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0}]}]},{"description":"Open skull for drainage","code_information":[{"code":"61321","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6779.0,"maximum":8333.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0}]}]},{"description":"Incise skull for surgery","code_information":[{"code":"61450","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6779.0,"maximum":8333.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0}]}]},{"description":"Removal of brain lesion","code_information":[{"code":"61516","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6779.0,"maximum":8333.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0}]}]},{"description":"Removal of brain lesion","code_information":[{"code":"61526","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6779.0,"maximum":8333.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0}]}]},{"description":"Removal of brain tissue","code_information":[{"code":"61538","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6779.0,"maximum":8333.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0}]}]},{"description":"Removal of pituitary gland","code_information":[{"code":"61548","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6779.0,"maximum":8333.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0}]}]},{"description":"Excision of skull tumor","code_information":[{"code":"61564","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6779.0,"maximum":8333.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0}]}]},{"description":"Craniofacial approach skull","code_information":[{"code":"61581","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6779.0,"maximum":8333.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0}]}]},{"description":"Orbitocranial approach/skull","code_information":[{"code":"61592","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6779.0,"maximum":8333.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0}]}]},{"description":"Resect/excise cranial lesion","code_information":[{"code":"61606","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6779.0,"maximum":8333.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0}]}]},{"description":"Repair dura","code_information":[{"code":"61619","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6779.0,"maximum":8333.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0}]}]},{"description":"Dilate ic vasospasm add-on","code_information":[{"code":"61642","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6779.0,"maximum":8333.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0}]}]},{"description":"Intracranial vessel surgery","code_information":[{"code":"61690","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6779.0,"maximum":8333.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0}]}]},{"description":"Revise circulation to head","code_information":[{"code":"61708","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6779.0,"maximum":8333.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0}]}]},{"description":"Incise skull for treatment","code_information":[{"code":"61770","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2534.21,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3378.94,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6521.36,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2534.21,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3446.52,"additional_payer_notes":"APC"}]}]},{"description":"Srs cranial lesion complex","code_information":[{"code":"61798","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3388.0,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0}]}]},{"description":"Implant neuroelectrde addl","code_information":[{"code":"61868","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3388.0,"maximum":4106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0}]}]},{"description":"Repair brain fluid leakage","code_information":[{"code":"62100","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6779.0,"maximum":8333.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0}]}]},{"description":"Replace skull plate/flap","code_information":[{"code":"62143","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Remove brain tumor w/scope","code_information":[{"code":"62164","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6779.0,"maximum":8333.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0}]}]},{"description":"Establish brain cavity shunt","code_information":[{"code":"62220","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Epidural lysis on single day","code_information":[{"code":"62264","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":656.13,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":874.84,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1688.44,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":656.13,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":892.34,"additional_payer_notes":"APC"}]}]},{"description":"Treat spinal cord lesion","code_information":[{"code":"62281","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":656.13,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":874.84,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1688.44,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":656.13,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":892.34,"additional_payer_notes":"APC"}]}]},{"description":"Myelography lumbar injection","code_information":[{"code":"62302","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":581.54,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":775.38,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1496.49,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":581.54,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":790.89,"additional_payer_notes":"APC"}]}]},{"description":"Implant spine infusion pump","code_information":[{"code":"62361","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8923.0,"maximum":44873.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17827.56,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":10765.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":8923.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":10765.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":44873.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":44873.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":44873.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":34407.2,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13370.67,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":43285.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18184.11,"additional_payer_notes":"APC"}]}]},{"description":"Remove spine lamina 1/2 thrc","code_information":[{"code":"63003","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Low back disk surgery","code_information":[{"code":"63030","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Remove spine lamina 1 lmbr","code_information":[{"code":"63047","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Decompress spine cord add-on","code_information":[{"code":"63066","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Remove vertebral body add-on","code_information":[{"code":"63086","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3388.0,"maximum":4106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0}]}]},{"description":"Incise spinal cord tract(s)","code_information":[{"code":"63170","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6779.0,"maximum":8333.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0}]}]},{"description":"Revise spinal cord vsls crvl","code_information":[{"code":"63250","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6779.0,"maximum":8333.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0}]}]},{"description":"Excise intrspinl lesion thrc","code_information":[{"code":"63271","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6779.0,"maximum":8333.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0}]}]},{"description":"Bx/exc idrl spine lesn thrc","code_information":[{"code":"63281","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6779.0,"maximum":8333.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0}]}]},{"description":"Remove vert xdrl body crvcl","code_information":[{"code":"63300","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6779.0,"maximum":8333.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0}]}]},{"description":"Remove vertebral body add-on","code_information":[{"code":"63308","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3388.0,"maximum":4106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0}]}]},{"description":"Remove spine eltrd plate","code_information":[{"code":"63662","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2593.52,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3458.03,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6674.0,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2593.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3527.19,"additional_payer_notes":"APC"}]}]},{"description":"Repair of spinal herniation","code_information":[{"code":"63706","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6779.0,"maximum":8333.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0}]}]},{"description":"Cystourethro w/implant","code_information":[{"code":"52441","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Laser surgery of prostate","code_information":[{"code":"52648","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3977.55,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5303.4,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":10235.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3977.55,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5409.47,"additional_payer_notes":"APC"}]}]},{"description":"Drainage of urethra abscess","code_information":[{"code":"53060","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1550.71,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2067.62,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3990.5,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1550.71,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2108.97,"additional_payer_notes":"APC"}]}]},{"description":"Removal of urethra lesion","code_information":[{"code":"53235","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3977.55,"maximum":10235.57,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5303.4,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":10235.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3977.55,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5409.47,"additional_payer_notes":"APC"}]}]},{"description":"Revise urethra stage 2","code_information":[{"code":"53405","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3977.55,"maximum":10235.57,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5303.4,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":10235.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3977.55,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5409.47,"additional_payer_notes":"APC"}]}]},{"description":"Remove/revise male sling","code_information":[{"code":"53442","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3977.55,"maximum":10235.57,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5303.4,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":10235.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3977.55,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5409.47,"additional_payer_notes":"APC"}]}]},{"description":"Revision of urethra","code_information":[{"code":"53460","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2614.94,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3486.59,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6729.12,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2614.94,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3556.32,"additional_payer_notes":"APC"}]}]},{"description":"Dilate urethra stricture","code_information":[{"code":"53601","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":98.7,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":131.6,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":253.99,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":98.7,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":134.23,"additional_payer_notes":"APC"}]}]},{"description":"Prostatic rf thermotx","code_information":[{"code":"53852","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2614.94,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3486.59,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6729.12,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2614.94,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3556.32,"additional_payer_notes":"APC"}]}]},{"description":"Destruction penis lesion(s)","code_information":[{"code":"54055","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1530.61,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2040.81,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3938.76,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1530.61,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2081.63,"additional_payer_notes":"APC"}]}]},{"description":"Treat penis lesion graft","code_information":[{"code":"54111","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3977.55,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5303.4,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":10235.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3977.55,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5409.47,"additional_payer_notes":"APC"}]}]},{"description":"Circumcision neonate","code_information":[{"code":"54160","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":517.28,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":689.7,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1331.13,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":517.28,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":703.5,"additional_payer_notes":"APC"}]}]},{"description":"Prepare penis study","code_information":[{"code":"54230","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Reconstruction of urethra","code_information":[{"code":"54312","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2614.94,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3486.59,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6729.12,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2614.94,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3556.32,"additional_payer_notes":"APC"}]}]},{"description":"Revise penis/urethra","code_information":[{"code":"54336","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2614.94,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3486.59,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6729.12,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2614.94,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3556.32,"additional_payer_notes":"APC"}]}]},{"description":"Repair penis and bladder","code_information":[{"code":"54390","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0}]}]},{"description":"Remove self-contd penis pros","code_information":[{"code":"54415","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2614.94,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3486.59,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6729.12,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2614.94,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3556.32,"additional_payer_notes":"APC"}]}]},{"description":"Preputial stretching","code_information":[{"code":"54450","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":185.35,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":247.13,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":476.96,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":185.35,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":252.07,"additional_payer_notes":"APC"}]}]},{"description":"Exploration for testis","code_information":[{"code":"54550","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2656.06,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3541.41,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6834.92,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2656.06,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3612.24,"additional_payer_notes":"APC"}]}]},{"description":"Relocation of testis(es)","code_information":[{"code":"54680","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2614.94,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3486.59,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6729.12,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2614.94,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3556.32,"additional_payer_notes":"APC"}]}]},{"description":"Removal of epididymis","code_information":[{"code":"54860","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2614.94,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3486.59,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6729.12,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2614.94,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3556.32,"additional_payer_notes":"APC"}]}]},{"description":"Repair of hydrocele","code_information":[{"code":"55060","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2614.94,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3486.59,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6729.12,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2614.94,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3556.32,"additional_payer_notes":"APC"}]}]},{"description":"Removal of sperm duct(s)","code_information":[{"code":"55250","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1550.71,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2067.62,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3990.5,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1550.71,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2108.97,"additional_payer_notes":"APC"}]}]},{"description":"Laparo ligate spermatic vein","code_information":[{"code":"55550","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4484.77,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5979.69,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5257.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11540.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4484.77,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6099.28,"additional_payer_notes":"APC"}]}]},{"description":"Prostate saturation sampling","code_information":[{"code":"55706","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2614.94,"maximum":6729.12,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3486.59,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6729.12,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2614.94,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3556.32,"additional_payer_notes":"APC"}]}]},{"description":"Removal of prostate","code_information":[{"code":"55831","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Electroejaculation","code_information":[{"code":"55870","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":683.26,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":911.02,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1758.27,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":683.26,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":929.24,"additional_payer_notes":"APC"}]}]},{"description":"I & D of vulva/perineum","code_information":[{"code":"56405","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":226.06,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":301.41,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":581.72,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":226.06,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":307.44,"additional_payer_notes":"APC"}]}]},{"description":"Biopsy of vulva/perineum","code_information":[{"code":"56606","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Extensive vulva surgery","code_information":[{"code":"56637","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":27583.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":27583.0}]}]},{"description":"Exam/biopsy of vulva w/scope","code_information":[{"code":"56821","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":226.06,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":301.41,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":581.72,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":226.06,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":307.44,"additional_payer_notes":"APC"}]}]},{"description":"Biopsy of vagina","code_information":[{"code":"57100","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":683.26,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":911.02,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1758.27,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":683.26,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":929.24,"additional_payer_notes":"APC"}]}]},{"description":"Remove vagina lesion","code_information":[{"code":"57130","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2401.4,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3201.87,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6179.61,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2401.4,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3265.91,"additional_payer_notes":"APC"}]}]},{"description":"Repair of vagina","code_information":[{"code":"57200","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2401.4,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3201.87,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6179.61,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2401.4,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3265.91,"additional_payer_notes":"APC"}]}]},{"description":"Insert mesh/pelvic flr addon","code_information":[{"code":"57267","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Revise/Remove Sling Repair","code_information":[{"code":"57287","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2401.4,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3201.87,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6179.61,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2401.4,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3265.91,"additional_payer_notes":"APC"}]}]},{"description":"Removal abdomen lymph nodes","code_information":[{"code":"38564","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5257.0,"maximum":6462.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5257.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6462.0}]}]},{"description":"Remove armpit lymph nodes","code_information":[{"code":"38740","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4484.77,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5979.69,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5257.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11540.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4484.77,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6099.28,"additional_payer_notes":"APC"}]}]},{"description":"Inject for lymphatic x-ray","code_information":[{"code":"38790","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Resect mediastinal tumor","code_information":[{"code":"39220","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5257.0,"maximum":6462.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5257.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6462.0}]}]},{"description":"Revision of diaphragm","code_information":[{"code":"39545","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5257.0,"maximum":6462.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5257.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6462.0}]}]},{"description":"Reconstruct lip with flap","code_information":[{"code":"40525","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2459.51,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3279.35,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6329.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2459.51,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3344.94,"additional_payer_notes":"APC"}]}]},{"description":"Repair cleft lip/nasal","code_information":[{"code":"40702","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Incision of lip fold","code_information":[{"code":"40806","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":400.09,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":533.45,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1029.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":400.09,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":544.12,"additional_payer_notes":"APC"}]}]},{"description":"Treatment of mouth lesion","code_information":[{"code":"40820","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2459.51,"maximum":6329.15,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3279.35,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6329.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2459.51,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3344.94,"additional_payer_notes":"APC"}]}]},{"description":"Mouth surgery procedure","code_information":[{"code":"40899","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":175.7,"maximum":13249.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":234.27,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":13249.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":10779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":13249.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":452.14,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":175.7,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":238.96,"additional_payer_notes":"APC"}]}]},{"description":"Drainage of mouth lesion","code_information":[{"code":"41015","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":400.09,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":533.45,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1029.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":400.09,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":544.12,"additional_payer_notes":"APC"}]}]},{"description":"Excision of tongue lesion","code_information":[{"code":"41110","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2459.51,"maximum":6329.15,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3279.35,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6329.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2459.51,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3344.94,"additional_payer_notes":"APC"}]}]},{"description":"Tongue and neck surgery","code_information":[{"code":"41135","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0}]}]},{"description":"Repair tongue laceration","code_information":[{"code":"41252","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":175.7,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":234.27,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":452.14,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":175.7,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":238.96,"additional_payer_notes":"APC"}]}]},{"description":"Removal foreign body jawbone","code_information":[{"code":"41806","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1151.01,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1534.69,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2961.94,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1151.01,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1565.38,"additional_payer_notes":"APC"}]}]},{"description":"Excision of gum lesion","code_information":[{"code":"41828","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1151.01,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1534.69,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2961.94,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1151.01,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1565.38,"additional_payer_notes":"APC"}]}]},{"description":"Biopsy roof of mouth","code_information":[{"code":"42100","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1151.01,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1534.69,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2961.94,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1151.01,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1565.38,"additional_payer_notes":"APC"}]}]},{"description":"Repair palate","code_information":[{"code":"42180","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":400.09,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":533.45,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1029.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":400.09,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":544.12,"additional_payer_notes":"APC"}]}]},{"description":"Lengthening of palate","code_information":[{"code":"42226","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Drainage of salivary gland","code_information":[{"code":"42305","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2459.51,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3279.35,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6329.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2459.51,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3344.94,"additional_payer_notes":"APC"}]}]},{"description":"Excision of salivary cyst","code_information":[{"code":"42408","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2459.51,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3279.35,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6329.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2459.51,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3344.94,"additional_payer_notes":"APC"}]}]},{"description":"Excise sublingual gland","code_information":[{"code":"42450","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":11300.84,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Dilation of salivary duct","code_information":[{"code":"42650","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1151.01,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1534.69,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2961.94,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1151.01,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1565.38,"additional_payer_notes":"APC"}]}]},{"description":"Biopsy of upper nose/throat","code_information":[{"code":"42804","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2459.51,"maximum":6329.15,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3279.35,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6329.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2459.51,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3344.94,"additional_payer_notes":"APC"}]}]},{"description":"Removal of tonsils","code_information":[{"code":"42825","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":11300.84,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Extensive surgery of throat","code_information":[{"code":"42845","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Repair throat esophagus","code_information":[{"code":"42953","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Throat surgery procedure","code_information":[{"code":"42999","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":175.7,"maximum":13249.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":234.27,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":13249.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":10779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":13249.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":452.14,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":175.7,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":238.96,"additional_payer_notes":"APC"}]}]},{"description":"Removal of esophagus","code_information":[{"code":"43112","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Removal of esophagus","code_information":[{"code":"43124","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Esophagoscopy rigid balloon","code_information":[{"code":"43195","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2860.11,"maximum":7360.02,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3813.48,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7360.02,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2860.11,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3889.75,"additional_payer_notes":"APC"}]}]},{"description":"Esophagus endoscopy/ligation","code_information":[{"code":"43205","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1423.51,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1898.01,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3663.16,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1423.51,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1935.97,"additional_payer_notes":"APC"}]}]},{"description":"Esophagoscopy lesion removal","code_information":[{"code":"43216","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1423.51,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1898.01,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3663.16,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1423.51,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1935.97,"additional_payer_notes":"APC"}]}]},{"description":"Egd balloon dil esoph30 mm/>","code_information":[{"code":"43233","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1423.51,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1898.01,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3663.16,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1423.51,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1935.97,"additional_payer_notes":"APC"}]}]},{"description":"Egd us fine needle bx/aspir","code_information":[{"code":"43242","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1423.51,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1898.01,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3663.16,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1423.51,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1935.97,"additional_payer_notes":"APC"}]}]},{"description":"Egd cautery tumor polyp","code_information":[{"code":"43250","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1423.51,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1898.01,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3663.16,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1423.51,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1935.97,"additional_payer_notes":"APC"}]}]},{"description":"Reloc skin pocket pls gen","code_information":[{"code":"0416T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1530.61,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2040.81,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3938.76,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1530.61,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2081.63,"additional_payer_notes":"APC"}]}]},{"description":"Rmvl nstim apnea pls gen","code_information":[{"code":"0428T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8770.0,"maximum":8770.0,"payers_information":[{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0}]}]},{"description":"Cabg arterial single","code_information":[{"code":"33533","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":9356.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0}]}]},{"description":"Closure of valve","code_information":[{"code":"33600","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":9356.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0}]}]},{"description":"Repair single ventricle","code_information":[{"code":"33617","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":9356.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0}]}]},{"description":"Repair of heart defects","code_information":[{"code":"33660","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":9356.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0}]}]},{"description":"Repair heart septum defect","code_information":[{"code":"33688","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":9356.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0}]}]},{"description":"Repair Venous Anomaly","code_information":[{"code":"33724","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6019.0,"maximum":7398.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":7398.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6019.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":7398.0}]}]},{"description":"Major vessel shunt","code_information":[{"code":"33762","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6019.0,"maximum":7398.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":7398.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6019.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":7398.0}]}]},{"description":"Repair great vessels defect","code_information":[{"code":"33775","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6019.0,"maximum":7398.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":7398.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6019.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":7398.0}]}]},{"description":"Nikaidoh proc w/ostia implt","code_information":[{"code":"33783","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6019.0,"maximum":7398.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":7398.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6019.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":7398.0}]}]},{"description":"Revise major vessel","code_information":[{"code":"33822","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6019.0,"maximum":27583.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":7398.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6019.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":7398.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":27583.0}]}]},{"description":"Ascending aortic graft","code_information":[{"code":"33864","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":9356.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0}]}]},{"description":"Artery transpose/endovas taa","code_information":[{"code":"33889","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":9356.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0}]}]},{"description":"Remove pulmonary shunt","code_information":[{"code":"33924","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6019.0,"maximum":7398.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":7398.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6019.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":7398.0}]}]},{"description":"Transplantation of heart","code_information":[{"code":"33945","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8923.0,"maximum":10765.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":10765.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":8923.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":10765.0}]}]},{"description":"Ecmo/ecls insj prph cannula","code_information":[{"code":"33954","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3388.0,"maximum":4106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0}]}]},{"description":"Ecmo/ecls repos perph cnula","code_information":[{"code":"33964","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3388.0,"maximum":4106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0}]}]},{"description":"Insert balloon device","code_information":[{"code":"33973","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Replace vad pump ext","code_information":[{"code":"33981","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":9356.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0}]}]},{"description":"Removal of left heart vent","code_information":[{"code":"33989","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":9356.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0}]}]},{"description":"Removal of artery clot","code_information":[{"code":"34101","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4127.91,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5503.89,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":10622.5,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4127.91,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5613.96,"additional_payer_notes":"APC"}]}]},{"description":"Removal of vein clot","code_information":[{"code":"34471","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":465.35,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":620.47,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1197.51,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":465.35,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":632.88,"additional_payer_notes":"APC"}]}]},{"description":"Xpose for endoprosth femorl","code_information":[{"code":"34812","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3388.0,"maximum":4106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0}]}]},{"description":"Plnning pt spec fenest graft","code_information":[{"code":"34839","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2654.0,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0}]}]},{"description":"Visc & infraren abd 4+ prost","code_information":[{"code":"34848","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6019.0,"maximum":7398.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":7398.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6019.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":7398.0}]}]},{"description":"Repair defect of arm artery","code_information":[{"code":"35045","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4127.91,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5503.89,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":10622.5,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4127.91,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5613.96,"additional_payer_notes":"APC"}]}]},{"description":"Repair artery rupture spleen","code_information":[{"code":"35112","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Repair ruptd popliteal art","code_information":[{"code":"35152","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Repair blood vessel lesion","code_information":[{"code":"35206","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2342.32,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3123.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6027.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2342.32,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3185.56,"additional_payer_notes":"APC"}]}]},{"description":"Repair blood vessel lesion","code_information":[{"code":"35241","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Repair blood vessel lesion","code_information":[{"code":"35281","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Rechanneling of artery","code_information":[{"code":"35311","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Rechanneling of artery","code_information":[{"code":"35371","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Art byp grft contral carotid","code_information":[{"code":"35509","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Art byp grft axill-brachial","code_information":[{"code":"35522","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Art byp grft aortoiliac","code_information":[{"code":"35537","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Art byp grft iliofemoral","code_information":[{"code":"35565","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Vein byp pop-tibl peroneal","code_information":[{"code":"35587","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Art byp aorsubcl/carot/innom","code_information":[{"code":"35626","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Art byp carotid-vertebral","code_information":[{"code":"35642","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Art byp ilioiliac","code_information":[{"code":"35663","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Bypass graft/av fist patency","code_information":[{"code":"35686","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Explore neck vessels","code_information":[{"code":"35800","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5503.89,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":10622.5,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4127.91,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5613.96,"additional_payer_notes":"APC"}]}]},{"description":"Revise graft w/vein","code_information":[{"code":"35881","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4127.91,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5503.89,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":10622.5,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4127.91,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5613.96,"additional_payer_notes":"APC"}]}]},{"description":"Pseudoaneurysm injection trt","code_information":[{"code":"36002","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":465.35,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":620.47,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1197.51,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":465.35,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":632.88,"additional_payer_notes":"APC"}]}]},{"description":"Establish access to artery","code_information":[{"code":"36100","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Place cath thoracic aorta","code_information":[{"code":"36221","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2342.32,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3123.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6027.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2342.32,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3185.56,"additional_payer_notes":"APC"}]}]},{"description":"Ins cath abd/l-ext art 1st","code_information":[{"code":"36245","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Insertion of infusion pump","code_information":[{"code":"36260","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4127.91,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5503.89,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":10622.5,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4127.91,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5613.96,"additional_payer_notes":"APC"}]}]},{"description":"Transfusion service fetal","code_information":[{"code":"36460","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":327.28,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":436.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":842.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":327.28,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":445.1,"additional_payer_notes":"APC"}]}]},{"description":"Insertion of catheter vein","code_information":[{"code":"36481","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Photopheresis","code_information":[{"code":"36522","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3231.05,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4308.07,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":8314.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3231.05,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4394.23,"additional_payer_notes":"APC"}]}]},{"description":"Insert tunneled cv cath","code_information":[{"code":"36565","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2342.32,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3123.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6027.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2342.32,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3185.56,"additional_payer_notes":"APC"}]}]},{"description":"Replace tunneled cv cath","code_information":[{"code":"36578","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2342.32,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3123.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6027.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2342.32,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3185.56,"additional_payer_notes":"APC"}]}]},{"description":"Removal tunneled cv cath","code_information":[{"code":"36590","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1167.76,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1557.01,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3005.03,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1167.76,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1588.15,"additional_payer_notes":"APC"}]}]},{"description":"Insertion catheter artery","code_information":[{"code":"36660","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3388.0,"maximum":4106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0}]}]},{"description":"Av fusion direct any site","code_information":[{"code":"36821","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2342.32,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3123.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6027.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2342.32,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3185.56,"additional_payer_notes":"APC"}]}]},{"description":"Dist revas ligation hemo","code_information":[{"code":"36838","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4127.91,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5503.89,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":10622.5,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4127.91,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5613.96,"additional_payer_notes":"APC"}]}]},{"description":"Insert hepatic shunt (tips)","code_information":[{"code":"37182","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":34994.75,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18131.99,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":34994.75,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13599.0,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":27583.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18494.63,"additional_payer_notes":"APC"}]}]},{"description":"Redo endovas vena cava filtr","code_information":[{"code":"37192","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2342.32,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3123.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6027.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2342.32,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3185.56,"additional_payer_notes":"APC"}]}]},{"description":"Cessj therapy cath removal","code_information":[{"code":"37214","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2342.32,"maximum":6027.57,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3123.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6027.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2342.32,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3185.56,"additional_payer_notes":"APC"}]}]},{"description":"Iliac revasc w/stent add-on","code_information":[{"code":"37223","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5512.0,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0}]}]},{"description":"Tib/per revasc stent & ather","code_information":[{"code":"37231","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8923.0,"maximum":44873.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":10765.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":8923.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":10765.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":44873.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":44873.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":44873.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":43285.0}]}]},{"description":"Open/perq place stent ea add","code_information":[{"code":"37239","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5512.0,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0}]}]},{"description":"Vascular endoscopy procedure","code_information":[{"code":"37501","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":465.35,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":620.47,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1197.51,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":465.35,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":632.88,"additional_payer_notes":"APC"}]}]},{"description":"Ligation of chest artery","code_information":[{"code":"37616","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Ligate/strip long leg vein","code_information":[{"code":"37722","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2342.32,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3123.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6027.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2342.32,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3185.56,"additional_payer_notes":"APC"}]}]},{"description":"Revascularization penis","code_information":[{"code":"37788","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Laparoscope proc spleen","code_information":[{"code":"38129","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4484.77,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5979.69,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5257.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11540.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4484.77,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6099.28,"additional_payer_notes":"APC"}]}]},{"description":"T-cell depletion of harvest","code_information":[{"code":"38210","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":327.28,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":436.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":842.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":327.28,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":445.1,"additional_payer_notes":"APC"}]}]},{"description":"Bone marrow harvest allogen","code_information":[{"code":"38230","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1155.35,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1540.47,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2973.1,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1155.35,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1571.27,"additional_payer_notes":"APC"}]}]},{"description":"Incision of lymph channels","code_information":[{"code":"38308","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2904.59,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3872.79,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7474.49,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2904.59,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3950.25,"additional_payer_notes":"APC"}]}]},{"description":"Biopsy/removal lymph nodes","code_information":[{"code":"38525","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2904.59,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3872.79,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7474.49,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2904.59,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3950.25,"additional_payer_notes":"APC"}]}]},{"description":"N block inj trigeminal","code_information":[{"code":"64400","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":227.71,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":303.61,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":585.96,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":227.71,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":309.68,"additional_payer_notes":"APC"}]}]},{"description":"N block inj intercost mlt","code_information":[{"code":"64421","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":656.13,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":874.84,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1688.44,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":656.13,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":892.34,"additional_payer_notes":"APC"}]}]},{"description":"N block inj lumbar plexus","code_information":[{"code":"64449","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":656.13,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":874.84,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1688.44,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":656.13,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":892.34,"additional_payer_notes":"APC"}]}]},{"description":"Inj foramen epidural l/s","code_information":[{"code":"64483","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":656.13,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":874.84,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1688.44,"additional_payer_notes":"APC"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1221.0},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":656.13,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":892.34,"additional_payer_notes":"APC"}]}]},{"description":"Inj paravert f jnt c/t 3 lev","code_information":[{"code":"64492","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"N block inj celiac pelus","code_information":[{"code":"64530","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":656.13,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":874.84,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1688.44,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":656.13,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":892.34,"additional_payer_notes":"APC"}]}]},{"description":"Implant neuroelectrodes","code_information":[{"code":"64575","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8266.01,"maximum":27583.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11021.34,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":10765.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":8923.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":10765.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":21271.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8266.01,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":27583.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11241.77,"additional_payer_notes":"APC"}]}]},{"description":"Injection treatment of nerve","code_information":[{"code":"64610","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1448.59,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1931.46,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3727.72,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1448.59,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1970.09,"additional_payer_notes":"APC"}]}]},{"description":"N block inj common digit","code_information":[{"code":"64632","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":227.71,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":303.61,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":585.96,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":227.71,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":309.68,"additional_payer_notes":"APC"}]}]},{"description":"Chemodenerv 1 extrem 5/> mus","code_information":[{"code":"64644","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":523.65,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":698.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1347.51,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":523.65,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":712.16,"additional_payer_notes":"APC"}]}]},{"description":"Revise finger/toe nerve","code_information":[{"code":"64702","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1448.59,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1931.46,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3727.72,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1448.59,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1970.09,"additional_payer_notes":"APC"}]}]},{"description":"Revise ulnar nerve at wrist","code_information":[{"code":"64719","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1448.59,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1931.46,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3727.72,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1448.59,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1970.09,"additional_payer_notes":"APC"}]}]},{"description":"Incision of jaw nerve","code_information":[{"code":"64738","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1448.59,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1931.46,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3727.72,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1448.59,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1970.09,"additional_payer_notes":"APC"}]}]},{"description":"Incise hip/thigh nerve","code_information":[{"code":"64766","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1448.59,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1931.46,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3727.72,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1448.59,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1970.09,"additional_payer_notes":"APC"}]}]},{"description":"Remove nerve lesion","code_information":[{"code":"64784","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1448.59,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1931.46,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3727.72,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1448.59,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1970.09,"additional_payer_notes":"APC"}]}]},{"description":"Remove sympathetic nerves","code_information":[{"code":"64804","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1448.59,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1931.46,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3727.72,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1448.59,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1970.09,"additional_payer_notes":"APC"}]}]},{"description":"Repair nerve add-on","code_information":[{"code":"64832","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Repair sciatic nerve","code_information":[{"code":"64858","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1448.59,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1931.46,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3727.72,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1448.59,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1970.09,"additional_payer_notes":"APC"}]}]},{"description":"Subsequent repair of nerve","code_information":[{"code":"64872","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Nerve graft arm/leg >4 cm","code_information":[{"code":"64893","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2534.21,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3378.94,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6521.36,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2534.21,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3446.52,"additional_payer_notes":"APC"}]}]},{"description":"Nerve pedicle transfer","code_information":[{"code":"64907","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":16752.93,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8680.28,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":16752.93,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6510.21,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8853.88,"additional_payer_notes":"APC"}]}]},{"description":"Remove eye/attach implant","code_information":[{"code":"65105","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2916.44,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3888.58,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7504.96,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2916.44,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3966.35,"additional_payer_notes":"APC"}]}]},{"description":"Revise ocular implant","code_information":[{"code":"65150","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2916.44,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3888.58,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7504.96,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2916.44,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3966.35,"additional_payer_notes":"APC"}]}]},{"description":"Remove foreign body from eye","code_information":[{"code":"65260","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1712.02,"maximum":4405.59,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2282.69,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4405.59,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1712.02,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2328.34,"additional_payer_notes":"APC"}]}]},{"description":"Repair of eye wound","code_information":[{"code":"65286","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1712.02,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2282.69,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4405.59,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1712.02,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2328.34,"additional_payer_notes":"APC"}]}]},{"description":"Curette/treat cornea","code_information":[{"code":"65436","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1763.69,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2351.59,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4538.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1763.69,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2398.62,"additional_payer_notes":"APC"}]}]},{"description":"Prep corneal endo allograft","code_information":[{"code":"65757","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Cover eye w/membrane","code_information":[{"code":"65778","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":739.52,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":986.02,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1903.02,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":739.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1005.74,"additional_payer_notes":"APC"}]}]},{"description":"Drainage of eye","code_information":[{"code":"65815","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1712.02,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2282.69,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4405.59,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1712.02,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2328.34,"additional_payer_notes":"APC"}]}]},{"description":"Incise inner eye adhesions","code_information":[{"code":"65880","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3066.31,"maximum":7890.63,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4088.41,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7890.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3066.31,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4170.17,"additional_payer_notes":"APC"}]}]},{"description":"Glaucoma surgery","code_information":[{"code":"66155","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3066.31,"maximum":7890.63,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4088.41,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7890.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3066.31,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4170.17,"additional_payer_notes":"APC"}]}]},{"description":"Insert ant drainage device","code_information":[{"code":"66183","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3066.31,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4088.41,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7890.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3066.31,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4170.17,"additional_payer_notes":"APC"}]}]},{"description":"Removal of iris","code_information":[{"code":"66605","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1712.02,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2282.69,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4405.59,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1712.02,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2328.34,"additional_payer_notes":"APC"}]}]},{"description":"Ciliary endoscopic ablation","code_information":[{"code":"66711","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1712.02,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2282.69,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4405.59,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1712.02,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2328.34,"additional_payer_notes":"APC"}]}]},{"description":"Reposition intraocular lens","code_information":[{"code":"66825","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1712.02,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2282.69,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4405.59,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1712.02,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2328.34,"additional_payer_notes":"APC"}]}]},{"description":"Cataract surgery complex","code_information":[{"code":"66982","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1712.02,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2282.69,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4405.59,"additional_payer_notes":"APC"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":4112.0},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1712.02,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2328.34,"additional_payer_notes":"APC"}]}]},{"description":"Perq vertebral augmentation","code_information":[{"code":"22514","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Neck spine fuse&remov bel c2","code_information":[{"code":"22551","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":24508.8,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12698.86,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":24508.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9524.15,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12952.84,"additional_payer_notes":"APC"}]}]},{"description":"Neck spinal fusion","code_information":[{"code":"22595","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":27583.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12698.86,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":24508.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9524.15,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":27583.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12952.84,"additional_payer_notes":"APC"}]}]},{"description":"Spine fusion extra segment","code_information":[{"code":"22634","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Kyphectomy 3 or more","code_information":[{"code":"22819","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6779.0,"maximum":33471.73,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17342.86,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":33471.73,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13007.15,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":27583.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17689.72,"additional_payer_notes":"APC"}]}]},{"description":"Insert spine fixation device","code_information":[{"code":"22846","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3388.0,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0}]}]},{"description":"Lumbar Artif Diskectomy","code_information":[{"code":"22857","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6779.0,"maximum":33471.73,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17342.86,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":33471.73,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13007.15,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":27583.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17689.72,"additional_payer_notes":"APC"}]}]},{"description":"Exc abdl tum deep 5 cm/>","code_information":[{"code":"22901","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2154.81,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2873.08,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5545.05,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2154.81,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2930.54,"additional_payer_notes":"APC"}]}]},{"description":"Drain shoulder lesion","code_information":[{"code":"23030","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2154.81,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2873.08,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5545.05,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2154.81,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2930.54,"additional_payer_notes":"APC"}]}]},{"description":"Exc shoulder tum deep 5 cm/>","code_information":[{"code":"23073","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2154.81,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2873.08,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5545.05,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2154.81,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2930.54,"additional_payer_notes":"APC"}]}]},{"description":"Incision of collarbone joint","code_information":[{"code":"23106","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Removal of humerus lesion","code_information":[{"code":"23150","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Remove humerus lesion","code_information":[{"code":"23184","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":13851.98,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Shoulder prosthesis removal","code_information":[{"code":"23334","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":13851.98,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Repair rotator cuff acute","code_information":[{"code":"23410","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Repair shoulder capsule","code_information":[{"code":"23460","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Revision of collar bone","code_information":[{"code":"23480","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Treat clavicle dislocation","code_information":[{"code":"23525","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":182.99,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":243.98,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":470.88,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":182.99,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":248.86,"additional_payer_notes":"APC"}]}]},{"description":"Treat shoulder blade fx","code_information":[{"code":"23575","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1192.86,"maximum":4106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1590.48,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3069.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1192.86,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1622.29,"additional_payer_notes":"APC"}]}]},{"description":"Treat humerus fracture","code_information":[{"code":"23630","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Fixation of shoulder","code_information":[{"code":"23700","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1192.86,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1590.48,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3069.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1192.86,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1622.29,"additional_payer_notes":"APC"}]}]},{"description":"Drainage of arm bursa","code_information":[{"code":"23931","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1225.21,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1633.61,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3152.87,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1225.21,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1666.28,"additional_payer_notes":"APC"}]}]},{"description":"Exc arm/elbow les sc < 3 cm","code_information":[{"code":"24075","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1225.21,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1633.61,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3152.87,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1225.21,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1666.28,"additional_payer_notes":"APC"}]}]},{"description":"Remove humerus lesion","code_information":[{"code":"24110","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Remove radius bone lesion","code_information":[{"code":"24136","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Removal of elbow joint","code_information":[{"code":"24155","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Arm tendon lengthening","code_information":[{"code":"24305","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Repair of ruptured tendon","code_information":[{"code":"24342","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Reconstruct elbow joint","code_information":[{"code":"24360","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Revision of humerus","code_information":[{"code":"24400","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Treat humerus fracture","code_information":[{"code":"24500","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":182.99,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":243.98,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":470.88,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":182.99,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":248.86,"additional_payer_notes":"APC"}]}]},{"description":"Treat humerus fracture","code_information":[{"code":"24546","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8923.0,"maximum":24508.8,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12698.86,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":10765.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":8923.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":10765.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":24508.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9524.15,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12952.84,"additional_payer_notes":"APC"}]}]},{"description":"Treat humerus fracture","code_information":[{"code":"24582","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":13851.98,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Treat elbow dislocation","code_information":[{"code":"24640","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":182.99,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":243.98,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":470.88,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":182.99,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":248.86,"additional_payer_notes":"APC"}]}]},{"description":"Fusion of elbow joint","code_information":[{"code":"24800","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Revision of upper arm","code_information":[{"code":"24940","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":24508.8,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12698.86,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":24508.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9524.15,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12952.84,"additional_payer_notes":"APC"}]}]},{"description":"Repair rectum-vagina fistula","code_information":[{"code":"57305","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Dilation of vagina","code_information":[{"code":"57400","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2401.4,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3201.87,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6179.61,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2401.4,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3265.91,"additional_payer_notes":"APC"}]}]},{"description":"Exam of cervix w/scope","code_information":[{"code":"57452","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":149.98,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":199.97,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":385.94,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":149.98,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":203.97,"additional_payer_notes":"APC"}]}]},{"description":"Cauterization of cervix","code_information":[{"code":"57510","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2401.4,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3201.87,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6179.61,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2401.4,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3265.91,"additional_payer_notes":"APC"}]}]},{"description":"Remove cervix/repair pelvis","code_information":[{"code":"57545","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Biopsy of uterus lining","code_information":[{"code":"58100","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":149.98,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":199.97,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":385.94,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":149.98,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":203.97,"additional_payer_notes":"APC"}]}]},{"description":"Partial hysterectomy","code_information":[{"code":"58180","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5257.0,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5257.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0}]}]},{"description":"Vag hyst w/enterocele repair","code_information":[{"code":"58270","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3710.98,"maximum":9549.58,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4947.97,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":9549.58,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3710.98,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5046.93,"additional_payer_notes":"APC"}]}]},{"description":"Insert intrauterine device","code_information":[{"code":"58300","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Reopen fallopian tube","code_information":[{"code":"58350","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3710.98,"maximum":9549.58,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4947.97,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":9549.58,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3710.98,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5046.93,"additional_payer_notes":"APC"}]}]},{"description":"Lsh w/t/o ut 250 g or less","code_information":[{"code":"58542","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":20292.15,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10514.07,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":20292.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7885.55,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10724.35,"additional_payer_notes":"APC"}]}]},{"description":"Laparo-vag hyst complex","code_information":[{"code":"58553","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":20292.15,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10514.07,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":20292.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7885.55,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10724.35,"additional_payer_notes":"APC"}]}]},{"description":"Hysteroscopy ablation","code_information":[{"code":"58563","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3710.98,"maximum":9549.58,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4947.97,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":9549.58,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3710.98,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5046.93,"additional_payer_notes":"APC"}]}]},{"description":"Division of fallopian tube","code_information":[{"code":"58600","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2401.4,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3201.87,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6179.61,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2401.4,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3265.91,"additional_payer_notes":"APC"}]}]},{"description":"Laparoscopy tubal block","code_information":[{"code":"58671","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4484.77,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5979.69,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5257.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11540.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4484.77,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6099.28,"additional_payer_notes":"APC"}]}]},{"description":"Revise ovarian tube(s)","code_information":[{"code":"58752","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0}]}]},{"description":"Biopsy of ovary(s)","code_information":[{"code":"58900","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2401.4,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3201.87,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6179.61,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2401.4,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3265.91,"additional_payer_notes":"APC"}]}]},{"description":"Tah rad dissect for debulk","code_information":[{"code":"58953","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Genital surgery procedure","code_information":[{"code":"58999","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":149.98,"maximum":13249.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":199.97,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":13249.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":10779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":13249.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":385.94,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":149.98,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":203.97,"additional_payer_notes":"APC"}]}]},{"description":"Fetal monitor w/report","code_information":[{"code":"59050","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Treat ectopic pregnancy","code_information":[{"code":"59121","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0}]}]},{"description":"Episiotomy or vaginal repair","code_information":[{"code":"59300","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2401.4,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3201.87,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6179.61,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2401.4,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3265.91,"additional_payer_notes":"APC"}]}]},{"description":"Deliver placenta","code_information":[{"code":"59414","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2401.4,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3201.87,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6179.61,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2401.4,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3265.91,"additional_payer_notes":"APC"}]}]},{"description":"Vbac delivery","code_information":[{"code":"59610","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Treatment of miscarriage","code_information":[{"code":"59821","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2401.4,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3201.87,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6179.61,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2401.4,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3265.91,"additional_payer_notes":"APC"}]}]},{"description":"Abortion","code_information":[{"code":"59856","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3388.0,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0}]}]},{"description":"Drain thyroid/tongue cyst","code_information":[{"code":"60000","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1151.01,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1534.69,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2961.94,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1151.01,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1565.38,"additional_payer_notes":"APC"}]}]},{"description":"Removal of thyroid","code_information":[{"code":"60252","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Explore parathyroid glands","code_information":[{"code":"60500","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Explore adrenal gland","code_information":[{"code":"60545","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Remove brain cavity fluid","code_information":[{"code":"61020","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":656.13,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":874.84,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1688.44,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":656.13,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":892.34,"additional_payer_notes":"APC"}]}]},{"description":"Burr hole for puncture","code_information":[{"code":"61120","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Pierce skull & explore","code_information":[{"code":"61250","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3388.0,"maximum":4106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0}]}]},{"description":"Implt cran bone flap to abdo","code_information":[{"code":"61316","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6779.0,"maximum":8333.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0}]}]},{"description":"Incise skull (press relief)","code_information":[{"code":"61343","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6779.0,"maximum":8333.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0}]}]},{"description":"Remove brain lining lesion","code_information":[{"code":"61512","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6779.0,"maximum":8333.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0}]}]},{"description":"Ercp w/specimen collection","code_information":[{"code":"43260","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2860.11,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3813.48,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7360.02,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2860.11,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3889.75,"additional_payer_notes":"APC"}]}]},{"description":"Endoscopic pancreatoscopy","code_information":[{"code":"43273","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Lap paraesophag hern repair","code_information":[{"code":"43281","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":20292.15,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10514.07,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":20292.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7885.55,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10724.35,"additional_payer_notes":"APC"}]}]},{"description":"Esophagoplasty congenital","code_information":[{"code":"43313","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Transab esoph hiat hern rpr","code_information":[{"code":"43332","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5257.0,"maximum":6462.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5257.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6462.0}]}]},{"description":"Fuse esophagus & intestine","code_information":[{"code":"43341","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Repair esophagus wound","code_information":[{"code":"43415","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Surgical opening of stomach","code_information":[{"code":"43500","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Removal of stomach","code_information":[{"code":"43620","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Vagotomy & pylorus repair","code_information":[{"code":"43640","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Laparoscopy gastrostomy","code_information":[{"code":"43653","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4484.77,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5979.69,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5257.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11540.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4484.77,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6099.28,"additional_payer_notes":"APC"}]}]},{"description":"Reposition gastrostomy tube","code_information":[{"code":"43761","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":185.35,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":247.13,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":476.96,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":185.35,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":252.07,"additional_payer_notes":"APC"}]}]},{"description":"Fusion of stomach and bowel","code_information":[{"code":"43810","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Gastroplasty w/o v-band","code_information":[{"code":"43843","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0}]}]},{"description":"Repair stomach-bowel fistula","code_information":[{"code":"43880","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Incision of small bowel","code_information":[{"code":"44010","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Excise intestine lesion(s)","code_information":[{"code":"44110","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Bowel to bowel fusion","code_information":[{"code":"44130","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Partial removal of colon","code_information":[{"code":"44141","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Removal of colon/ileostomy","code_information":[{"code":"44155","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Lap colostomy","code_information":[{"code":"44188","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5257.0,"maximum":6462.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5257.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6462.0}]}]},{"description":"Laparo total proctocolectomy","code_information":[{"code":"44210","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5257.0,"maximum":6462.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5257.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6462.0}]}]},{"description":"Revision of ileostomy","code_information":[{"code":"44312","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2628.85,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3505.13,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6764.9,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2628.85,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3575.23,"additional_payer_notes":"APC"}]}]},{"description":"Small bowel endoscopy","code_information":[{"code":"44360","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1423.51,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1898.01,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3663.16,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1423.51,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1935.97,"additional_payer_notes":"APC"}]}]},{"description":"Small bowel endoscopy","code_information":[{"code":"44372","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1423.51,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1898.01,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3663.16,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1423.51,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1935.97,"additional_payer_notes":"APC"}]}]},{"description":"Small bowel endoscopy","code_information":[{"code":"44382","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":672.83,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":897.11,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1731.42,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":672.83,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":915.05,"additional_payer_notes":"APC"}]}]},{"description":"Colonoscopy & polypectomy","code_information":[{"code":"44392","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":887.71,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1183.61,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2284.37,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":887.71,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1207.28,"additional_payer_notes":"APC"}]}]},{"description":"Colonoscopy w/ndl aspir/bx","code_information":[{"code":"44407","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":887.71,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1183.61,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2284.37,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":887.71,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1207.28,"additional_payer_notes":"APC"}]}]},{"description":"Repair bowel opening","code_information":[{"code":"44620","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Suspend bowel w/prosthesis","code_information":[{"code":"44700","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Excision of mesentery lesion","code_information":[{"code":"44820","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Laparoscope proc app","code_information":[{"code":"44979","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4484.77,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5979.69,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5257.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11540.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4484.77,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6099.28,"additional_payer_notes":"APC"}]}]},{"description":"Removal of rectum","code_information":[{"code":"45112","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Pelvic exenteration","code_information":[{"code":"45126","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Destruction rectal tumor","code_information":[{"code":"45190","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2059.07,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2745.43,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5298.68,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2059.07,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2800.34,"additional_payer_notes":"APC"}]}]},{"description":"Proctosigmoidoscopy bleed","code_information":[{"code":"45317","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":887.71,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1183.61,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2284.37,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":887.71,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1207.28,"additional_payer_notes":"APC"}]}]},{"description":"Partial removal of eye fluid","code_information":[{"code":"67010","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1712.02,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2282.69,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4405.59,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1712.02,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2328.34,"additional_payer_notes":"APC"}]}]},{"description":"Laser treatment of retina","code_information":[{"code":"67039","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3066.31,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4088.41,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7890.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3066.31,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4170.17,"additional_payer_notes":"APC"}]}]},{"description":"Repair detached retina","code_information":[{"code":"67108","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3066.31,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4088.41,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7890.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3066.31,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4170.17,"additional_payer_notes":"APC"}]}]},{"description":"Treatment of retinal lesion","code_information":[{"code":"67208","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":235.46,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":313.95,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":605.92,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":235.46,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":320.23,"additional_payer_notes":"APC"}]}]},{"description":"Tr retinal les preterm inf","code_information":[{"code":"67229","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":408.01,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":544.01,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1049.93,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":408.01,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":554.89,"additional_payer_notes":"APC"}]}]},{"description":"Revise eye muscle(s)","code_information":[{"code":"67318","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1763.69,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2351.59,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4538.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1763.69,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2398.62,"additional_payer_notes":"APC"}]}]},{"description":"Destroy nerve of eye muscle","code_information":[{"code":"67345","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":235.46,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":313.95,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":605.92,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":235.46,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":320.23,"additional_payer_notes":"APC"}]}]},{"description":"Aspiration orbital contents","code_information":[{"code":"67415","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1763.69,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2351.59,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4538.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1763.69,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2398.62,"additional_payer_notes":"APC"}]}]},{"description":"Inject/treat eye socket","code_information":[{"code":"67515","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":235.46,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":313.95,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":605.92,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":235.46,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":320.23,"additional_payer_notes":"APC"}]}]},{"description":"Remove eyelid lesion","code_information":[{"code":"67800","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":235.46,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":313.95,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":605.92,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":235.46,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":320.23,"additional_payer_notes":"APC"}]}]},{"description":"Revise eyelashes","code_information":[{"code":"67835","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1763.69,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2351.59,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4538.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1763.69,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2398.62,"additional_payer_notes":"APC"}]}]},{"description":"Repair eyelid defect","code_information":[{"code":"67902","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2916.44,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3888.58,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7504.96,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2916.44,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3966.35,"additional_payer_notes":"APC"}]}]},{"description":"Repair eyelid defect","code_information":[{"code":"67914","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1763.69,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2351.59,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4538.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1763.69,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2398.62,"additional_payer_notes":"APC"}]}]},{"description":"Repair eyelid wound","code_information":[{"code":"67930","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1763.69,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2351.59,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4538.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1763.69,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2398.62,"additional_payer_notes":"APC"}]}]},{"description":"Reconstruction of eyelid","code_information":[{"code":"67974","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2916.44,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3888.58,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7504.96,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2916.44,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3966.35,"additional_payer_notes":"APC"}]}]},{"description":"Remove eyelid lining lesion","code_information":[{"code":"68130","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1763.69,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2351.59,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4538.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1763.69,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2398.62,"additional_payer_notes":"APC"}]}]},{"description":"Revise/graft eyelid lining","code_information":[{"code":"68335","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2916.44,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3888.58,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7504.96,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2916.44,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3966.35,"additional_payer_notes":"APC"}]}]},{"description":"Incise tear duct opening","code_information":[{"code":"68440","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":235.46,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":313.95,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":605.92,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":235.46,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":320.23,"additional_payer_notes":"APC"}]}]},{"description":"Remove tear gland lesion","code_information":[{"code":"68550","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2916.44,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3888.58,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7504.96,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2916.44,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3966.35,"additional_payer_notes":"APC"}]}]},{"description":"Close tear system fistula","code_information":[{"code":"68770","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1763.69,"maximum":4538.57,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2351.59,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4538.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1763.69,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2398.62,"additional_payer_notes":"APC"}]}]},{"description":"Tear duct system surgery","code_information":[{"code":"68899","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":235.46,"maximum":13249.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":313.95,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":13249.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":10779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":13249.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":605.92,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":235.46,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":320.23,"additional_payer_notes":"APC"}]}]},{"description":"Removal of external ear","code_information":[{"code":"69120","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":11300.84,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Remove impacted ear wax uni","code_information":[{"code":"69210","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":43.76,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":58.35,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":112.62,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":43.76,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":59.52,"additional_payer_notes":"APC"}]}]},{"description":"Incision of eardrum","code_information":[{"code":"69421","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2459.51,"maximum":6329.15,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3279.35,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6329.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2459.51,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3344.94,"additional_payer_notes":"APC"}]}]},{"description":"Remove mastoid structures","code_information":[{"code":"69505","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Mastoid surgery revision","code_information":[{"code":"69601","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Rebuild eardrum structures","code_information":[{"code":"69633","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Revise middle ear & mastoid","code_information":[{"code":"69645","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Remove mastoid air cells","code_information":[{"code":"69670","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Release facial nerve","code_information":[{"code":"69725","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Remove inner ear & mastoid","code_information":[{"code":"69910","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Temporal bone surgery","code_information":[{"code":"69979","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":175.7,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":234.27,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":452.14,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":175.7,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":238.96,"additional_payer_notes":"APC"}]}]},{"description":"R hrt art/grft angio","code_information":[{"code":"93457","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2404.97,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3206.62,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6188.79,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2404.97,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3270.76,"additional_payer_notes":"APC"}]}]},{"description":"Perc drug-el cor stent sing","code_information":[{"code":"C9600","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":27583.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11418.47,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":22037.64,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8563.85,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":27583.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11646.84,"additional_payer_notes":"APC"}]}]},{"description":"Perc d-e cor revasc chro add","code_information":[{"code":"C9608","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Root surgery molar","code_information":[{"code":"D3425","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":479.59,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":639.45,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1234.13,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":479.59,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":652.24,"additional_payer_notes":"APC"}]}]},{"description":"Removal of brain abscess","code_information":[{"code":"61522","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6779.0,"maximum":8333.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0}]}]},{"description":"Removal of brain lesion","code_information":[{"code":"61536","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6779.0,"maximum":8333.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0}]}]},{"description":"Excision of brain tumor","code_information":[{"code":"61545","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6779.0,"maximum":8333.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0}]}]},{"description":"Excision of skull/sutures","code_information":[{"code":"61559","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6779.0,"maximum":8333.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0}]}]},{"description":"Skull base/brainstem surgery","code_information":[{"code":"61576","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6779.0,"maximum":8333.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0}]}]},{"description":"Infratemporal approach/skull","code_information":[{"code":"61590","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6779.0,"maximum":8333.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0}]}]},{"description":"Resect/excise cranial lesion","code_information":[{"code":"61601","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6779.0,"maximum":8333.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0}]}]},{"description":"Resect/excise lesion skull","code_information":[{"code":"61616","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6779.0,"maximum":8333.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0}]}]},{"description":"Dilate ic vasospasm init","code_information":[{"code":"61640","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6779.0,"maximum":8333.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0}]}]},{"description":"Intracranial vessel surgery","code_information":[{"code":"61684","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6779.0,"maximum":8333.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0}]}]},{"description":"Clamp neck artery","code_information":[{"code":"61703","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6779.0,"maximum":8333.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0}]}]},{"description":"Brain biopsy w/ct/mr guide","code_information":[{"code":"61751","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6779.0,"maximum":8333.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0}]}]},{"description":"Srs cranial lesion simple","code_information":[{"code":"61796","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3388.0,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0}]}]},{"description":"Implant neuroelectrde addl","code_information":[{"code":"61864","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3388.0,"maximum":4106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0}]}]},{"description":"Treat skull fracture","code_information":[{"code":"62005","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6779.0,"maximum":8333.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0}]}]},{"description":"Repair of skull defect","code_information":[{"code":"62141","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Dissect brain w/scope","code_information":[{"code":"62161","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6779.0,"maximum":8333.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0}]}]},{"description":"Establish brain cavity shunt","code_information":[{"code":"62200","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6779.0,"maximum":8333.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0}]}]},{"description":"Replace brain cavity shunt","code_information":[{"code":"62258","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Inject epidural patch","code_information":[{"code":"62273","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":523.65,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":698.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1347.51,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":523.65,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":712.16,"additional_payer_notes":"APC"}]}]},{"description":"Injection into disk lesion","code_information":[{"code":"62292","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1448.59,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1931.46,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3727.72,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1448.59,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1970.09,"additional_payer_notes":"APC"}]}]},{"description":"Remove spinal canal catheter","code_information":[{"code":"62355","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1448.59,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1931.46,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3727.72,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1448.59,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1970.09,"additional_payer_notes":"APC"}]}]},{"description":"Anl sp inf pmp w/mdreprg&fil","code_information":[{"code":"62370","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":227.84,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":303.79,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":586.32,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":227.84,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":309.87,"additional_payer_notes":"APC"}]}]},{"description":"Remove spine lamina >2 lmbr","code_information":[{"code":"63017","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Remove spine lamina 1 crvl","code_information":[{"code":"63045","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Decompress spine cord add-on","code_information":[{"code":"63057","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Remove vertebral body add-on","code_information":[{"code":"63082","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3388.0,"maximum":4106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0}]}]},{"description":"Remove vert body dcmprn lmbr","code_information":[{"code":"63102","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6779.0,"maximum":8333.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0}]}]},{"description":"Incise spine&cord 2 trx thrc","code_information":[{"code":"63197","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6779.0,"maximum":8333.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0}]}]},{"description":"Excise intrspinl lesion scrl","code_information":[{"code":"63268","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Bx/exc xdrl spine lesn scrl","code_information":[{"code":"63278","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6779.0,"maximum":8333.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0}]}]},{"description":"Bx/exc xdrl/idrl lsn any lvl","code_information":[{"code":"63290","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6779.0,"maximum":27583.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":27583.0}]}]},{"description":"Remov vert idrl bdy thrclmbr","code_information":[{"code":"63306","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6779.0,"maximum":8333.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0}]}]},{"description":"Implant neuroelectrodes","code_information":[{"code":"63655","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8923.0,"maximum":37034.45,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19188.83,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":10765.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":8923.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":10765.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":37034.45,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14391.63,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":27583.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19572.61,"additional_payer_notes":"APC"}]}]},{"description":"Repair of spinal herniation","code_information":[{"code":"63702","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Revision of spinal shunt","code_information":[{"code":"63744","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2534.21,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3378.94,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6521.36,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2534.21,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3446.52,"additional_payer_notes":"APC"}]}]},{"description":"Drainage of forearm lesion","code_information":[{"code":"25028","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Exc forearm les sc < 3 cm","code_information":[{"code":"25075","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1225.21,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1633.61,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3152.87,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1225.21,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1666.28,"additional_payer_notes":"APC"}]}]},{"description":"Remove wrist joint cartilage","code_information":[{"code":"25107","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Partial removal of ulna","code_information":[{"code":"25119","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Partial removal of ulna","code_information":[{"code":"25150","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Remove forearm foreign body","code_information":[{"code":"25248","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1192.86,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1590.48,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3069.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1192.86,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1622.29,"additional_payer_notes":"APC"}]}]},{"description":"Repair forearm tendon/muscle","code_information":[{"code":"25272","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Transplant forearm tendon","code_information":[{"code":"25310","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Revision of radius","code_information":[{"code":"25350","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Shorten radius & ulna","code_information":[{"code":"25392","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":13851.98,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Repair/graft radius & ulna","code_information":[{"code":"25426","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Reconstruct wrist joint","code_information":[{"code":"25445","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Reinforce radius and ulna","code_information":[{"code":"25492","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Treat fracture of ulna","code_information":[{"code":"25535","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":182.99,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":243.98,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":470.88,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":182.99,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":248.86,"additional_payer_notes":"APC"}]}]},{"description":"Treat Fx Distal Radial","code_information":[{"code":"25606","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Treat wrist bone fracture","code_information":[{"code":"25635","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1192.86,"maximum":4106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1590.48,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3069.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1192.86,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1622.29,"additional_payer_notes":"APC"}]}]},{"description":"Treat wrist dislocation","code_information":[{"code":"25675","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":182.99,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":243.98,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":470.88,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":182.99,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":248.86,"additional_payer_notes":"APC"}]}]},{"description":"Fusion/graft of wrist joint","code_information":[{"code":"25810","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":24508.8,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12698.86,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":24508.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9524.15,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12952.84,"additional_payer_notes":"APC"}]}]},{"description":"Amputation of forearm","code_information":[{"code":"25915","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Drainage of finger abscess","code_information":[{"code":"26010","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":148.84,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":198.45,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":383.01,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":148.84,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":202.42,"additional_payer_notes":"APC"}]}]},{"description":"Release palm contracture","code_information":[{"code":"26040","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1192.86,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1590.48,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3069.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1192.86,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1622.29,"additional_payer_notes":"APC"}]}]},{"description":"Biopsy finger joint lining","code_information":[{"code":"26105","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":6246.19,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Release palm contracture","code_information":[{"code":"26121","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Removal of palm tendon each","code_information":[{"code":"26170","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1192.86,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1590.48,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3069.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1192.86,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1622.29,"additional_payer_notes":"APC"}]}]},{"description":"Partial removal finger bone","code_information":[{"code":"26235","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1192.86,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1590.48,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3069.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1192.86,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1622.29,"additional_payer_notes":"APC"}]}]},{"description":"Repair finger/hand tendon","code_information":[{"code":"26350","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Revise hand/finger tendon","code_information":[{"code":"26390","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":13851.98,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Repair finger/hand tendon","code_information":[{"code":"26426","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Release hand/finger tendon","code_information":[{"code":"26445","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":6246.19,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Tendon shortening","code_information":[{"code":"26477","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":6246.19,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Tendon transfer with graft","code_information":[{"code":"26492","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Release thumb contracture","code_information":[{"code":"26508","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":6246.19,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Revise knuckle with implant","code_information":[{"code":"26531","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Reconstruct finger joint","code_information":[{"code":"26548","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Repair of web finger","code_information":[{"code":"26561","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Repair muscles of hand","code_information":[{"code":"26591","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Sigmoidoscopy for bleeding","code_information":[{"code":"45334","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":887.71,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1183.61,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2284.37,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":887.71,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1207.28,"additional_payer_notes":"APC"}]}]},{"description":"Sigmoidoscopy w/plcmt stent","code_information":[{"code":"45347","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3579.0,"maximum":11589.23,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6004.78,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11589.23,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4503.59,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6124.88,"additional_payer_notes":"APC"}]}]},{"description":"Colonoscopy w/lesion removal","code_information":[{"code":"45384","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":887.71,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1183.61,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2284.37,"additional_payer_notes":"APC"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1543.0},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":887.71,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1207.28,"additional_payer_notes":"APC"}]}]},{"description":"Colonoscopy w/decompression","code_information":[{"code":"45393","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":887.71,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1183.61,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2284.37,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":887.71,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1207.28,"additional_payer_notes":"APC"}]}]},{"description":"Repair of rectum","code_information":[{"code":"45500","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2059.07,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2745.43,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5298.68,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2059.07,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2800.34,"additional_payer_notes":"APC"}]}]},{"description":"Exploration/repair of rectum","code_information":[{"code":"45563","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Remove rectal obstruction","code_information":[{"code":"45915","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":887.71,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1183.61,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2284.37,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":887.71,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1207.28,"additional_payer_notes":"APC"}]}]},{"description":"Incision of rectal abscess","code_information":[{"code":"46060","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2059.07,"maximum":5298.68,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2745.43,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5298.68,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2059.07,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2800.34,"additional_payer_notes":"APC"}]}]},{"description":"Remove ext hem groups 2+","code_information":[{"code":"46250","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2059.07,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2745.43,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5298.68,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2059.07,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2800.34,"additional_payer_notes":"APC"}]}]},{"description":"Remove anal fist inter","code_information":[{"code":"46275","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2059.07,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2745.43,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5298.68,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2059.07,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2800.34,"additional_payer_notes":"APC"}]}]},{"description":"Diagnostic anoscopy","code_information":[{"code":"46601","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":331.39,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":441.86,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":852.79,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":331.39,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":450.7,"additional_payer_notes":"APC"}]}]},{"description":"Anoscopy control bleeding","code_information":[{"code":"46614","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":887.71,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1183.61,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2284.37,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":887.71,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1207.28,"additional_payer_notes":"APC"}]}]},{"description":"Rep perf anoper fistu","code_information":[{"code":"46715","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Repair of cloacal anomaly","code_information":[{"code":"46748","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Destruction anal lesion(s)","code_information":[{"code":"46910","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1530.61,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2040.81,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3938.76,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1530.61,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2081.63,"additional_payer_notes":"APC"}]}]},{"description":"Remove by ligat int hem grp","code_information":[{"code":"46945","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2059.07,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2745.43,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5298.68,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2059.07,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2800.34,"additional_payer_notes":"APC"}]}]},{"description":"Wedge biopsy of liver","code_information":[{"code":"47100","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3388.0,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0}]}]},{"description":"Partial removal donor liver","code_information":[{"code":"47141","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Repair liver wound","code_information":[{"code":"47350","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Open ablate liver tumor cryo","code_information":[{"code":"47381","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Incision of gallbladder","code_information":[{"code":"47480","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Removal biliary drg cath","code_information":[{"code":"47537","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":672.83,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":897.11,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1731.42,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":672.83,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":915.05,"additional_payer_notes":"APC"}]}]},{"description":"Bile duct endoscopy add-on","code_information":[{"code":"47550","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2334.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Laparo cholecystectomy/explr","code_information":[{"code":"47564","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5257.0,"maximum":20292.15,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10514.07,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5257.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":20292.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7885.55,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10724.35,"additional_payer_notes":"APC"}]}]},{"description":"Exploration of bile ducts","code_information":[{"code":"47700","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Fuse gallbladder & bowel","code_information":[{"code":"47741","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Bile tract surgery procedure","code_information":[{"code":"47999","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":672.83,"maximum":13249.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":897.11,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":13249.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":10779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":13249.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1731.42,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":672.83,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":915.05,"additional_payer_notes":"APC"}]}]},{"description":"Partial removal of pancreas","code_information":[{"code":"48140","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Removal of pancreas","code_information":[{"code":"48155","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Duodenal exclusion","code_information":[{"code":"48547","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Exploration of abdomen","code_information":[{"code":"49000","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0}]}]},{"description":"Abd paracentesis w/imaging","code_information":[{"code":"49083","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":672.83,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":897.11,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1731.42,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":672.83,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":915.05,"additional_payer_notes":"APC"}]}]},{"description":"Laparoscopy biopsy","code_information":[{"code":"49321","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4484.77,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5979.69,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5257.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11540.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4484.77,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6099.28,"additional_payer_notes":"APC"}]}]},{"description":"Air injection into abdomen","code_information":[{"code":"49400","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Insert tun ip cath w/port","code_information":[{"code":"49419","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4127.91,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5503.89,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":10622.5,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4127.91,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5613.96,"additional_payer_notes":"APC"}]}]},{"description":"Ligation of shunt","code_information":[{"code":"49428","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3579.0,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0}]}]},{"description":"Endodontic procedure","code_information":[{"code":"D3999","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":479.59,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":639.45,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1234.13,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":479.59,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":652.24,"additional_payer_notes":"APC"}]}]},{"description":"Apically positioned flap","code_information":[{"code":"D4245","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1151.01,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1534.69,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2961.94,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1151.01,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1565.38,"additional_payer_notes":"APC"}]}]},{"description":"Surgical revision procedure","code_information":[{"code":"D4268","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":479.59,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":639.45,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1234.13,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":479.59,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":652.24,"additional_payer_notes":"APC"}]}]},{"description":"Odontics endosteal implant","code_information":[{"code":"D6010","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5512.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0}]}]},{"description":"Bone graft time of implant","code_information":[{"code":"D6104","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5512.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0}]}]},{"description":"Tooth root removal","code_information":[{"code":"D7250","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":479.59,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":639.45,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1234.13,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":479.59,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":652.24,"additional_payer_notes":"APC"}]}]},{"description":"Place device impacted tooth","code_information":[{"code":"D7283","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5512.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0}]}]},{"description":"Temp anchorage dev w flap","code_information":[{"code":"D7293","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5512.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0}]}]},{"description":"Vestibuloplasty exten graft","code_information":[{"code":"D7350","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":11300.84,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Malig tumor > 1.25 cm","code_information":[{"code":"D7441","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2459.51,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3279.35,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6329.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2459.51,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3344.94,"additional_payer_notes":"APC"}]}]},{"description":"Remove torus mandibularis","code_information":[{"code":"D7473","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":479.59,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":639.45,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1234.13,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":479.59,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":652.24,"additional_payer_notes":"APC"}]}]},{"description":"Removal of fb reaction","code_information":[{"code":"D7540","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":479.59,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":639.45,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1234.13,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":479.59,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":652.24,"additional_payer_notes":"APC"}]}]},{"description":"Maxilla open reduct compound","code_information":[{"code":"D7710","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5512.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0}]}]},{"description":"Tmj meniscectomy","code_information":[{"code":"D7850","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5512.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0}]}]},{"description":"Lysis + lavage w catheters","code_information":[{"code":"D7871","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5512.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0}]}]},{"description":"Dental suture wound to 5 cm","code_information":[{"code":"D7911","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5512.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0}]}]},{"description":"Bone cutting body mandible","code_information":[{"code":"D7945","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5512.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0}]}]},{"description":"Bone replacement graft","code_information":[{"code":"D7953","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5512.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0}]}]},{"description":"Sialodochoplasty","code_information":[{"code":"D7982","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5512.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0}]}]},{"description":"Oral surgery procedure","code_information":[{"code":"D7999","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5512.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0}]}]},{"description":"Pild/placebo control clin tr","code_information":[{"code":"G0276","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Open tx post pelvic fxcture","code_information":[{"code":"G0415","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"transplant sm. Intest, liver, allograft","code_information":[{"code":"S2053","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5512.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0}]}]},{"description":"Breast reconstruct, DEIP","code_information":[{"code":"S2068","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5512.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0}]}]},{"description":"arthroscopy, harvest cartilage","code_information":[{"code":"S2112","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5512.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0}]}]},{"description":"Myringotomy, laser-assisted","code_information":[{"code":"S2225","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5512.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0}]}]},{"description":"Fetal surg cong cyst malf","code_information":[{"code":"S2402","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5512.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0}]}]},{"description":"Njx interlaminar crv/thrc","code_information":[{"code":"62321","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":523.65,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":698.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1347.51,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":523.65,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":712.16,"additional_payer_notes":"APC"}]}]},{"description":"Mnl prep&insj i-artic rx dev","code_information":[{"code":"20704","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Njx autol wbc concentrate","code_information":[{"code":"0481T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":331.39,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":441.86,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":852.79,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":331.39,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":450.7,"additional_payer_notes":"APC"}]}]},{"description":"Prep tum cav iort prtl mast","code_information":[{"code":"19294","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Impltj tot rplcmt hrt sys","code_information":[{"code":"33927","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8923.0,"maximum":10765.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":10765.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":8923.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":10765.0}]}]},{"description":"Laparoscopy lymphadenectomy","code_information":[{"code":"38571","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":20292.15,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10514.07,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":20292.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7885.55,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10724.35,"additional_payer_notes":"APC"}]}]},{"description":"Remove thoracic lymph nodes","code_information":[{"code":"38746","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5257.0,"maximum":6462.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5257.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6462.0}]}]},{"description":"Access thoracic lymph duct","code_information":[{"code":"38794","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Mediastinoscpy w/lmph nod bx","code_information":[{"code":"39402","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4484.77,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5979.69,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5257.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11540.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4484.77,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6099.28,"additional_payer_notes":"APC"}]}]},{"description":"Resect diaphragm complex","code_information":[{"code":"39561","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5257.0,"maximum":6462.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5257.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6462.0}]}]},{"description":"Partial removal of lip","code_information":[{"code":"40530","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2459.51,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3279.35,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6329.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2459.51,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3344.94,"additional_payer_notes":"APC"}]}]},{"description":"Repair cleft lip/nasal","code_information":[{"code":"40761","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Excision of mouth lesion","code_information":[{"code":"40810","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2459.51,"maximum":6329.15,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3279.35,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6329.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2459.51,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3344.94,"additional_payer_notes":"APC"}]}]},{"description":"Repair mouth laceration","code_information":[{"code":"40831","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":400.09,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":533.45,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1029.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":400.09,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":544.12,"additional_payer_notes":"APC"}]}]},{"description":"Drainage of mouth lesion","code_information":[{"code":"41005","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":175.7,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":234.27,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":452.14,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":175.7,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":238.96,"additional_payer_notes":"APC"}]}]},{"description":"Drainage of mouth lesion","code_information":[{"code":"41017","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2459.51,"maximum":6329.15,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3279.35,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6329.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2459.51,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3344.94,"additional_payer_notes":"APC"}]}]},{"description":"Excision of tongue lesion","code_information":[{"code":"41113","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2459.51,"maximum":6329.15,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3279.35,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6329.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2459.51,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3344.94,"additional_payer_notes":"APC"}]}]},{"description":"Tongue removal neck surgery","code_information":[{"code":"41145","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Tongue suspension","code_information":[{"code":"41512","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Excision of gum flap","code_information":[{"code":"41821","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1151.01,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1534.69,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2961.94,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1151.01,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1565.38,"additional_payer_notes":"APC"}]}]},{"description":"Treatment of gum lesion","code_information":[{"code":"41850","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1151.01,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1534.69,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2961.94,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1151.01,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1565.38,"additional_payer_notes":"APC"}]}]},{"description":"Excision lesion mouth roof","code_information":[{"code":"42106","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2459.51,"maximum":6329.15,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3279.35,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6329.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2459.51,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3344.94,"additional_payer_notes":"APC"}]}]},{"description":"Reconstruct cleft palate","code_information":[{"code":"42200","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Repair palate","code_information":[{"code":"42235","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Drainage of salivary gland","code_information":[{"code":"42320","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":400.09,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":533.45,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1029.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":400.09,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":544.12,"additional_payer_notes":"APC"}]}]},{"description":"Excise parotid gland/lesion","code_information":[{"code":"42410","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Repair salivary duct","code_information":[{"code":"42505","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Ligation of salivary duct","code_information":[{"code":"42665","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2459.51,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3279.35,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6329.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2459.51,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3344.94,"additional_payer_notes":"APC"}]}]},{"description":"Excise pharynx lesion","code_information":[{"code":"42808","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2459.51,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3279.35,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6329.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2459.51,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3344.94,"additional_payer_notes":"APC"}]}]},{"description":"Removal of adenoids","code_information":[{"code":"42830","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2459.51,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3279.35,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6329.15,"additional_payer_notes":"APC"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":4226.0},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2459.51,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3344.94,"additional_payer_notes":"APC"}]}]},{"description":"Excision of lingual tonsil","code_information":[{"code":"42870","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":11300.84,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Control throat bleeding","code_information":[{"code":"42960","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":400.09,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":533.45,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1029.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":400.09,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":544.12,"additional_payer_notes":"APC"}]}]},{"description":"Throat muscle surgery","code_information":[{"code":"43030","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Partial removal of esophagus","code_information":[{"code":"43116","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Removal of esophagus pouch","code_information":[{"code":"43135","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Esophagoscopy flex dx brush","code_information":[{"code":"43197","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":672.83,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":897.11,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1731.42,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":672.83,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":915.05,"additional_payer_notes":"APC"}]}]},{"description":"Egd esophagogastrc fndoplsty","code_information":[{"code":"43210","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":20292.15,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10514.07,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":20292.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7885.55,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10724.35,"additional_payer_notes":"APC"}]}]},{"description":"Esophagoscopy balloon <30mm","code_information":[{"code":"43220","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1423.51,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1898.01,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3663.16,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1423.51,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1935.97,"additional_payer_notes":"APC"}]}]},{"description":"Uppr gi scope w/submuc inj","code_information":[{"code":"43236","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":672.83,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":897.11,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1731.42,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":672.83,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":915.05,"additional_payer_notes":"APC"}]}]},{"description":"Egd varices ligation","code_information":[{"code":"43244","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1423.51,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1898.01,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3663.16,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1423.51,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1935.97,"additional_payer_notes":"APC"}]}]},{"description":"Egd optical endomicroscopy","code_information":[{"code":"43252","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1423.51,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1898.01,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3663.16,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1423.51,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1935.97,"additional_payer_notes":"APC"}]}]},{"description":"N block inj suprascapular","code_information":[{"code":"64418","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":523.65,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":698.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1347.51,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":523.65,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":712.16,"additional_payer_notes":"APC"}]}]},{"description":"N block inj fem single","code_information":[{"code":"64447","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":523.65,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":698.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1347.51,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":523.65,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":712.16,"additional_payer_notes":"APC"}]}]},{"description":"Inj foramen epidural c/t","code_information":[{"code":"64479","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":656.13,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":874.84,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1688.44,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":656.13,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":892.34,"additional_payer_notes":"APC"}]}]},{"description":"Inj paravert f jnt c/t 1 lev","code_information":[{"code":"64490","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":656.13,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":874.84,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1688.44,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":656.13,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":892.34,"additional_payer_notes":"APC"}]}]},{"description":"N block inj hypogas plxs","code_information":[{"code":"64517","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":656.13,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":874.84,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1688.44,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":656.13,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":892.34,"additional_payer_notes":"APC"}]}]},{"description":"Revise/repl vagus n eltrd","code_information":[{"code":"64569","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":21271.19,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11021.34,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":21271.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8266.01,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11241.77,"additional_payer_notes":"APC"}]}]},{"description":"Injection treatment of nerve","code_information":[{"code":"64600","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":656.13,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":874.84,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1688.44,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":656.13,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":892.34,"additional_payer_notes":"APC"}]}]},{"description":"Injection treatment of nerve","code_information":[{"code":"64620","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":656.13,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":874.84,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1688.44,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":656.13,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":892.34,"additional_payer_notes":"APC"}]}]},{"description":"Chemodenerv 1 extremity 1-4","code_information":[{"code":"64642","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":523.65,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":698.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1347.51,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":523.65,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":712.16,"additional_payer_notes":"APC"}]}]},{"description":"Injection treatment of nerve","code_information":[{"code":"64680","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":656.13,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":874.84,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1688.44,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":656.13,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":892.34,"additional_payer_notes":"APC"}]}]},{"description":"Revision of cranial nerve","code_information":[{"code":"64716","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1448.59,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1931.46,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3727.72,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1448.59,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1970.09,"additional_payer_notes":"APC"}]}]},{"description":"Incision of cheek nerve","code_information":[{"code":"64734","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1448.59,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1931.46,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3727.72,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1448.59,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1970.09,"additional_payer_notes":"APC"}]}]},{"description":"Incision of vagus nerve","code_information":[{"code":"64760","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3388.0,"maximum":4106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0}]}]},{"description":"Remove limb nerve lesion","code_information":[{"code":"64782","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1448.59,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1931.46,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3727.72,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1448.59,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1970.09,"additional_payer_notes":"APC"}]}]},{"description":"Biopsy of nerve","code_information":[{"code":"64795","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1448.59,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1931.46,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3727.72,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1448.59,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1970.09,"additional_payer_notes":"APC"}]}]},{"description":"Sympathectomy supfc palmar","code_information":[{"code":"64823","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Repair/transpose nerve","code_information":[{"code":"64856","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":16752.93,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8680.28,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":16752.93,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6510.21,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8853.88,"additional_payer_notes":"APC"}]}]},{"description":"Fusion of facial/other nerve","code_information":[{"code":"64866","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Nerve graft hand/foot >4 cm","code_information":[{"code":"64891","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":16752.93,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8680.28,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":16752.93,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6510.21,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8853.88,"additional_payer_notes":"APC"}]}]},{"description":"Nerve graft add-on","code_information":[{"code":"64902","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Removal of eye","code_information":[{"code":"65101","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2916.44,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3888.58,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7504.96,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2916.44,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3966.35,"additional_payer_notes":"APC"}]}]},{"description":"Insert ocular implant","code_information":[{"code":"65135","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2916.44,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3888.58,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7504.96,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2916.44,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3966.35,"additional_payer_notes":"APC"}]}]},{"description":"Remove foreign body from eye","code_information":[{"code":"65222","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":98.7,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":131.6,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":253.99,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":98.7,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":134.23,"additional_payer_notes":"APC"}]}]},{"description":"Repair of eye wound","code_information":[{"code":"65280","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3947.51,"maximum":10158.27,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5263.35,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":10158.27,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3947.51,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5368.62,"additional_payer_notes":"APC"}]}]},{"description":"Corneal smear","code_information":[{"code":"65430","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":331.39,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":441.86,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":852.79,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":331.39,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":450.7,"additional_payer_notes":"APC"}]}]},{"description":"Corneal transplant","code_information":[{"code":"65755","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3066.31,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4088.41,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7890.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3066.31,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4170.17,"additional_payer_notes":"APC"}]}]},{"description":"Correction of astigmatism","code_information":[{"code":"65772","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":739.52,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":986.02,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1903.02,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":739.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1005.74,"additional_payer_notes":"APC"}]}]},{"description":"Drainage of eye","code_information":[{"code":"65800","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1712.02,"maximum":4405.59,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2282.69,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4405.59,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1712.02,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2328.34,"additional_payer_notes":"APC"}]}]},{"description":"Incise inner eye adhesions","code_information":[{"code":"65870","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1712.02,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2282.69,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4405.59,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1712.02,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2328.34,"additional_payer_notes":"APC"}]}]},{"description":"Remove eye lesion","code_information":[{"code":"66130","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1763.69,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2351.59,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4538.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1763.69,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2398.62,"additional_payer_notes":"APC"}]}]},{"description":"Aqueous shunt eye w/o graft","code_information":[{"code":"66179","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3947.51,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5263.35,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":10158.27,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3947.51,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5368.62,"additional_payer_notes":"APC"}]}]},{"description":"Incision of iris","code_information":[{"code":"66505","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1712.02,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2282.69,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4405.59,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1712.02,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2328.34,"additional_payer_notes":"APC"}]}]},{"description":"Destruction ciliary body","code_information":[{"code":"66700","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1712.02,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2282.69,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4405.59,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1712.02,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2328.34,"additional_payer_notes":"APC"}]}]},{"description":"Incision secondary cataract","code_information":[{"code":"66820","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1712.02,"maximum":4405.59,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2282.69,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4405.59,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1712.02,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2328.34,"additional_payer_notes":"APC"}]}]},{"description":"Extraction of lens","code_information":[{"code":"66930","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3066.31,"maximum":7890.63,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4088.41,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7890.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3066.31,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4170.17,"additional_payer_notes":"APC"}]}]},{"description":"Eye surgery procedure","code_information":[{"code":"66999","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1712.02,"maximum":13249.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2282.69,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":13249.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":10779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":13249.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4405.59,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1712.02,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2328.34,"additional_payer_notes":"APC"}]}]},{"description":"Treat thumb dislocation","code_information":[{"code":"26641","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":182.99,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":243.98,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":470.88,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":182.99,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":248.86,"additional_payer_notes":"APC"}]}]},{"description":"Treat hand dislocation","code_information":[{"code":"26686","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Treat finger fracture each","code_information":[{"code":"26735","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Treat finger dislocation","code_information":[{"code":"26770","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":182.99,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":243.98,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":470.88,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":182.99,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":248.86,"additional_payer_notes":"APC"}]}]},{"description":"Fusion/graft of hand joint","code_information":[{"code":"26844","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":13851.98,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Amputation of finger/thumb","code_information":[{"code":"26951","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":6246.19,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Incision of hip tendon","code_information":[{"code":"27003","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":13851.98,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Excision of hip joint/muscle","code_information":[{"code":"27036","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Biopsy of sacroiliac joint","code_information":[{"code":"27050","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1192.86,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1590.48,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3069.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1192.86,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1622.29,"additional_payer_notes":"APC"}]}]},{"description":"Remove hip bone les deep","code_information":[{"code":"27066","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Removal of tail bone","code_information":[{"code":"27080","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Revision of hip tendon","code_information":[{"code":"27097","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Partial hip replacement","code_information":[{"code":"27125","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":24508.8,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12698.86,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":24508.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9524.15,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12952.84,"additional_payer_notes":"APC"}]}]},{"description":"Revision of hip bone","code_information":[{"code":"27147","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Treat slipped epiphysis","code_information":[{"code":"27176","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Treat tail bone fracture","code_information":[{"code":"27202","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Treat hip fracture(s)","code_information":[{"code":"27227","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Treat thigh fracture","code_information":[{"code":"27244","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Treat hip dislocation","code_information":[{"code":"27256","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":182.99,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":243.98,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":470.88,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":182.99,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":248.86,"additional_payer_notes":"APC"}]}]},{"description":"Optx thigh fx","code_information":[{"code":"27269","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3579.0,"maximum":13851.98,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Amputation of leg at hip","code_information":[{"code":"27295","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":33471.73,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17342.86,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":33471.73,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13007.15,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":27583.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17689.72,"additional_payer_notes":"APC"}]}]},{"description":"Biopsy thigh soft tissues","code_information":[{"code":"27323","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1225.21,"maximum":4106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1633.61,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3152.87,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1225.21,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1666.28,"additional_payer_notes":"APC"}]}]},{"description":"Explore/treat knee joint","code_information":[{"code":"27331","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Removal of knee cyst","code_information":[{"code":"27345","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Resect thigh/knee tum 5 cm/>","code_information":[{"code":"27364","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2154.81,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2873.08,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5545.05,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2154.81,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2930.54,"additional_payer_notes":"APC"}]}]},{"description":"Incision of thigh tendons","code_information":[{"code":"27391","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Repair of knee cartilage","code_information":[{"code":"27403","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":13851.98,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Revision of unstable kneecap","code_information":[{"code":"27420","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Incision of knee joint","code_information":[{"code":"27435","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Revision of knee joint","code_information":[{"code":"27446","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":27583.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12698.86,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":24508.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9524.15,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":27583.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12952.84,"additional_payer_notes":"APC"}]}]},{"description":"Lengthening of thigh bone","code_information":[{"code":"27466","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Revise/replace knee joint","code_information":[{"code":"27486","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6779.0,"maximum":27583.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12698.86,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":24508.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9524.15,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":27583.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12952.84,"additional_payer_notes":"APC"}]}]},{"description":"Treatment of thigh fracture","code_information":[{"code":"27500","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":182.99,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":243.98,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":470.88,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":182.99,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":248.86,"additional_payer_notes":"APC"}]}]},{"description":"Treatment of thigh fracture","code_information":[{"code":"27510","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1192.86,"maximum":4106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1590.48,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3069.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1192.86,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1622.29,"additional_payer_notes":"APC"}]}]},{"description":"Treat kneecap fracture","code_information":[{"code":"27524","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Treat knee dislocation","code_information":[{"code":"27552","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1192.86,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1590.48,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3069.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1192.86,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1622.29,"additional_payer_notes":"APC"}]}]},{"description":"Cocm by rhc/fqhc 60 min mo","code_information":[{"code":"G0512","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":142.48,"maximum":142.48,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":142.48}]}]},{"description":"Metabolic panel total ca","code_information":[{"code":"80048","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6.34,"maximum":17.11,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8.46,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":17.11},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10.58},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10.58},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10.58},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":16.33,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6.34,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14.81},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8.46},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8.63,"additional_payer_notes":"APC"}]}]},{"description":"Hepatic function panel","code_information":[{"code":"80076","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6.13,"maximum":16.54,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8.17,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":16.54},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10.21},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10.21},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10.21},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":15.77,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6.13,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14.3},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8.17},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8.33,"additional_payer_notes":"APC"}]}]},{"description":"Assay carbamazepine free","code_information":[{"code":"80157","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":9.94,"maximum":26.82,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.25,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":26.82},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16.56},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16.56},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16.56},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":25.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9.94,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23.19},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13.25},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.52,"additional_payer_notes":"APC"}]}]},{"description":"Drug assay felbamate","code_information":[{"code":"80167","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":13.98,"maximum":35.98,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18.64,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":27.71},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23.3},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23.3},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23.3},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":35.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.98,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32.62},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18.64},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19.01,"additional_payer_notes":"APC"}]}]},{"description":"Drug scrn quan levetiracetam","code_information":[{"code":"80177","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":9.94,"maximum":26.82,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.25,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":26.82},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16.56},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16.56},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16.56},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":25.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9.94,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23.19},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13.25},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.52,"additional_payer_notes":"APC"}]}]},{"description":"Assay of phenytoin free","code_information":[{"code":"80186","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":10.32,"maximum":26.56,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.76,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":23.76},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17.2},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17.2},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17.2},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":26.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10.32,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24.08},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13.76},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14.04,"additional_payer_notes":"APC"}]}]},{"description":"Assay of sirolimus","code_information":[{"code":"80195","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":10.3,"maximum":27.79,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.73,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":27.79},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17.16},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17.16},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17.16},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":26.5,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10.3,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24.03},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13.73},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14.0,"additional_payer_notes":"APC"}]}]},{"description":"Drug assay methotrexate","code_information":[{"code":"80204","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":28.93,"maximum":74.44,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":38.57,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":57.3},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":48.21},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":48.21},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":48.21},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":74.44,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":28.93,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":67.5},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38.57},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":39.34,"additional_payer_notes":"APC"}]}]},{"description":"Onc hep gene risk classifier","code_information":[{"code":"0006M","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":112.5,"maximum":289.5,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":150.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":222.82},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":187.5},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":187.5},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":187.5},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":289.5,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":112.5,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":262.5},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":153.0,"additional_payer_notes":"APC"}]}]},{"description":"Onc mrna 5 gen rsk urthl ca","code_information":[{"code":"0012M","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":570.0,"maximum":1466.8,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":760.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1128.96},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":950.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":950.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":950.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1466.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":570.0,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1330.0},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":760.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":775.2,"additional_payer_notes":"APC"}]}]},{"description":"Onc thyr 10 microrna seq alg","code_information":[{"code":"0018U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2251.57,"maximum":5794.03,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3002.09,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3752.61},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3752.61},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3752.61},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5794.03,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2251.57,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5253.66},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3002.09},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3062.13,"additional_payer_notes":"APC"}]}]},{"description":"Tenofovir liq chrom ur quan","code_information":[{"code":"0025U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":85.77,"maximum":220.85,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":114.43,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":141.56},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":143.04},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":143.04},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":143.04},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":220.85,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":85.82,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":200.25},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":85.77},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":116.72,"additional_payer_notes":"APC"}]}]},{"description":"Tpmt nudt15 genes","code_information":[{"code":"0034U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":349.63,"maximum":899.71,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":466.17,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":692.47},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":582.71},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":582.71},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":582.71},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":899.71,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":349.63,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":815.8},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":466.17},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":475.49,"additional_payer_notes":"APC"}]}]},{"description":"B brgdrferi antb 12 prtn igg","code_information":[{"code":"0042U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":12.91,"maximum":33.22,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17.21,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21.51},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21.51},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21.51},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":33.22,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.91,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30.12},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17.21},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17.55,"additional_payer_notes":"APC"}]}]},{"description":"Trgt gen seq dna 194 genes","code_information":[{"code":"0050U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2187.45,"maximum":5629.04,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2916.6,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3645.75},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3645.75},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3645.75},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5629.04,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2187.45,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5104.05},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2916.6},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2974.93,"additional_payer_notes":"APC"}]}]},{"description":"Replace g/c tube perc","code_information":[{"code":"49450","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":672.83,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":897.11,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1731.42,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":672.83,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":915.05,"additional_payer_notes":"APC"}]}]},{"description":"Rpr ing hernia baby blocked","code_information":[{"code":"49496","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2656.06,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3541.41,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6834.92,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2656.06,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3612.24,"additional_payer_notes":"APC"}]}]},{"description":"Repair lumbar hernia","code_information":[{"code":"49540","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4484.77,"maximum":11540.8,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5979.69,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5257.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11540.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4484.77,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6099.28,"additional_payer_notes":"APC"}]}]},{"description":"Repair umbilical lesion","code_information":[{"code":"49610","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Free omental flap microvasc","code_information":[{"code":"49906","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Incision of kidney","code_information":[{"code":"50070","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Renal biopsy perq","code_information":[{"code":"50200","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1225.21,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1633.61,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3152.87,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1225.21,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1666.28,"additional_payer_notes":"APC"}]}]},{"description":"Cryoablate renal mass open","code_information":[{"code":"50250","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Prep renal graft/arterial","code_information":[{"code":"50328","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Remove ureter stent percut","code_information":[{"code":"50384","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1550.71,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2067.62,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3990.5,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1550.71,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2108.97,"additional_payer_notes":"APC"}]}]},{"description":"Revision of kidney/ureter","code_information":[{"code":"50400","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0}]}]},{"description":"Repair of kidney wound","code_information":[{"code":"50500","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Laparoscopy pyeloplasty","code_information":[{"code":"50544","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":20292.15,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10514.07,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":20292.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7885.55,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10724.35,"additional_payer_notes":"APC"}]}]},{"description":"Kidney endoscopy & biopsy","code_information":[{"code":"50555","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3579.0,"maximum":18071.3,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9363.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":18071.3,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7022.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9550.63,"additional_payer_notes":"APC"}]}]},{"description":"Kidney endoscopy & treatment","code_information":[{"code":"50576","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3579.0,"maximum":18071.3,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9363.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":18071.3,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7022.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9550.63,"additional_payer_notes":"APC"}]}]},{"description":"Removal of ureter stone","code_information":[{"code":"50610","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Injection for ureter x-ray","code_information":[{"code":"50690","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Release of ureter","code_information":[{"code":"50722","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Reimplant ureter in bladder","code_information":[{"code":"50780","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0}]}]},{"description":"Construct bowel bladder","code_information":[{"code":"50825","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Release of ureter","code_information":[{"code":"50940","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Ureter endoscopy & treatment","code_information":[{"code":"50957","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3977.55,"maximum":10235.57,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5303.4,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":10235.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3977.55,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5409.47,"additional_payer_notes":"APC"}]}]},{"description":"Incise & drain bladder","code_information":[{"code":"51040","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1550.71,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2067.62,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3990.5,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1550.71,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2108.97,"additional_payer_notes":"APC"}]}]},{"description":"Drain bl w/cath insertion","code_information":[{"code":"51102","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1550.71,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2067.62,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3990.5,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1550.71,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2108.97,"additional_payer_notes":"APC"}]}]},{"description":"Revise bladder & ureter(s)","code_information":[{"code":"51565","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Removal of pelvic structures","code_information":[{"code":"51597","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Change of bladder tube","code_information":[{"code":"51705","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":185.35,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":247.13,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":476.96,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":185.35,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":252.07,"additional_payer_notes":"APC"}]}]},{"description":"Cystometrogram w/vp&up","code_information":[{"code":"51729","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":517.28,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":689.7,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1331.13,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":517.28,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":703.5,"additional_payer_notes":"APC"}]}]},{"description":"Revision of bladder/urethra","code_information":[{"code":"51800","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Repair bladder/vagina lesion","code_information":[{"code":"51900","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0}]}]},{"description":"Laparoscope proc bla","code_information":[{"code":"51999","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4484.77,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5979.69,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":13249.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":10779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":13249.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11540.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4484.77,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6099.28,"additional_payer_notes":"APC"}]}]},{"description":"Cystoscopy and treatment","code_information":[{"code":"52224","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2614.94,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3486.59,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6729.12,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2614.94,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3556.32,"additional_payer_notes":"APC"}]}]},{"description":"Cystoscopy & revise urethra","code_information":[{"code":"52275","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1550.71,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2067.62,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3990.5,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1550.71,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2108.97,"additional_payer_notes":"APC"}]}]},{"description":"Cystoscopy and treatment","code_information":[{"code":"52290","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1550.71,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2067.62,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3990.5,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1550.71,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2108.97,"additional_payer_notes":"APC"}]}]},{"description":"Cystoscopy and treatment","code_information":[{"code":"52320","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2614.94,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3486.59,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6729.12,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2614.94,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3556.32,"additional_payer_notes":"APC"}]}]},{"description":"Cysto W/Renal Stricture Tx","code_information":[{"code":"52343","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2614.94,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3486.59,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6729.12,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2614.94,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3556.32,"additional_payer_notes":"APC"}]}]},{"description":"Endo cholangiopancreatograph","code_information":[{"code":"43262","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2860.11,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3813.48,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7360.02,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2860.11,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3889.75,"additional_payer_notes":"APC"}]}]},{"description":"Ercp remove forgn body duct","code_information":[{"code":"43275","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1423.51,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1898.01,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3663.16,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1423.51,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1935.97,"additional_payer_notes":"APC"}]}]},{"description":"Lap esoph lengthening","code_information":[{"code":"43283","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":9356.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0}]}]},{"description":"Fuse esophagus & stomach","code_information":[{"code":"43320","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Transthor diaphrag hern rpr","code_information":[{"code":"43334","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5257.0,"maximum":6462.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5257.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6462.0}]}]},{"description":"Surgical opening esophagus","code_information":[{"code":"43352","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Repair esophagus opening","code_information":[{"code":"43425","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Surgical repair of stomach","code_information":[{"code":"43502","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Removal of stomach","code_information":[{"code":"43622","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Lap gastric bypass/roux-en-y","code_information":[{"code":"43644","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5257.0,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5257.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0}]}]},{"description":"Nasal/orogastric w/tube plmt","code_information":[{"code":"43752","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":331.39,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":441.86,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":852.79,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":331.39,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":450.7,"additional_payer_notes":"APC"}]}]},{"description":"Lap revise gastr adj device","code_information":[{"code":"43771","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5257.0,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5257.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0}]}]},{"description":"Fusion of stomach and bowel","code_information":[{"code":"43825","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Gastric bypass for obesity","code_information":[{"code":"43846","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Revise/remove electrd antrum","code_information":[{"code":"43882","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Explore small intestine","code_information":[{"code":"44020","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Removal of small intestine","code_information":[{"code":"44120","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Enterectomy live donor","code_information":[{"code":"44133","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Partial removal of colon","code_information":[{"code":"44144","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Colectomy w/Ileoanal Anast","code_information":[{"code":"44157","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Lap resect s/intestine addl","code_information":[{"code":"44203","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5257.0,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5257.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0}]}]},{"description":"Laparo total proctocolectomy","code_information":[{"code":"44212","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5257.0,"maximum":6462.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5257.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6462.0}]}]},{"description":"Devise bowel pouch","code_information":[{"code":"44316","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Small bowel endoscopy","code_information":[{"code":"44363","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1423.51,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1898.01,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3663.16,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1423.51,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1935.97,"additional_payer_notes":"APC"}]}]},{"description":"Small bowel endoscopy","code_information":[{"code":"44376","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1423.51,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1898.01,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3663.16,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1423.51,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1935.97,"additional_payer_notes":"APC"}]}]},{"description":"Endoscopy of bowel pouch","code_information":[{"code":"44385","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":689.87,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":919.83,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1775.27,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":689.87,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":938.23,"additional_payer_notes":"APC"}]}]},{"description":"Colonoscopy with ablation","code_information":[{"code":"44401","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":887.71,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1183.61,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2284.37,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":887.71,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1207.28,"additional_payer_notes":"APC"}]}]},{"description":"Intro gastrointestinal tube","code_information":[{"code":"44500","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":672.83,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":897.11,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1731.42,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":672.83,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":915.05,"additional_payer_notes":"APC"}]}]},{"description":"Repair bowel opening","code_information":[{"code":"44626","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Prepare fecal microbiota","code_information":[{"code":"44705","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2654.0,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0}]}]},{"description":"Bowel surgery procedure","code_information":[{"code":"44899","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":10779.0,"maximum":13249.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":13249.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":10779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":13249.0}]}]},{"description":"Drainage of rectal abscess","code_information":[{"code":"45005","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":887.71,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1183.61,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2284.37,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":887.71,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1207.28,"additional_payer_notes":"APC"}]}]},{"description":"Partial removal of rectum","code_information":[{"code":"45114","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Excision of rectal prolapse","code_information":[{"code":"45135","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Proctosigmoidoscopy dilate","code_information":[{"code":"45303","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":887.71,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1183.61,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2284.37,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":887.71,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1207.28,"additional_payer_notes":"APC"}]}]},{"description":"Proctosigmoidoscopy volvul","code_information":[{"code":"45321","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2059.07,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2745.43,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5298.68,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2059.07,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2800.34,"additional_payer_notes":"APC"}]}]},{"description":"Laser surgery eye strands","code_information":[{"code":"67031","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":408.01,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":544.01,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1049.93,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":408.01,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":554.89,"additional_payer_notes":"APC"}]}]},{"description":"Repair detached retina pc","code_information":[{"code":"67105","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":408.01,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":544.01,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1049.93,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":408.01,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":554.89,"additional_payer_notes":"APC"}]}]},{"description":"Treatment of retina","code_information":[{"code":"67141","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":235.46,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":313.95,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":605.92,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":235.46,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":320.23,"additional_payer_notes":"APC"}]}]},{"description":"Dstrj extensive retinopathy","code_information":[{"code":"67227","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2916.44,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3888.58,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7504.96,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2916.44,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3966.35,"additional_payer_notes":"APC"}]}]},{"description":"Revise eye muscle","code_information":[{"code":"67314","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1763.69,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2351.59,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4538.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1763.69,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2398.62,"additional_payer_notes":"APC"}]}]},{"description":"Revise eye muscle add-on","code_information":[{"code":"67340","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Explore/treat eye socket","code_information":[{"code":"67413","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1763.69,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2351.59,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4538.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1763.69,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2398.62,"additional_payer_notes":"APC"}]}]},{"description":"Inject/treat eye socket","code_information":[{"code":"67500","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":235.46,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":313.95,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":605.92,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":235.46,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":320.23,"additional_payer_notes":"APC"}]}]},{"description":"Incision of eyelid","code_information":[{"code":"67710","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":739.52,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":986.02,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1903.02,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":739.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1005.74,"additional_payer_notes":"APC"}]}]},{"description":"Revise eyelashes","code_information":[{"code":"67825","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":235.46,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":313.95,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":605.92,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":235.46,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":320.23,"additional_payer_notes":"APC"}]}]},{"description":"Repair brow defect","code_information":[{"code":"67900","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1763.69,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2351.59,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4538.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1763.69,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2398.62,"additional_payer_notes":"APC"}]}]},{"description":"Revise eyelid defect","code_information":[{"code":"67911","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1763.69,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2351.59,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4538.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1763.69,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2398.62,"additional_payer_notes":"APC"}]}]},{"description":"Repair eyelid defect","code_information":[{"code":"67923","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1763.69,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2351.59,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4538.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1763.69,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2398.62,"additional_payer_notes":"APC"}]}]},{"description":"Reconstruction of eyelid","code_information":[{"code":"67971","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1763.69,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2351.59,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4538.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1763.69,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2398.62,"additional_payer_notes":"APC"}]}]},{"description":"Remove eyelid lining lesion","code_information":[{"code":"68110","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1763.69,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2351.59,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4538.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1763.69,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2398.62,"additional_payer_notes":"APC"}]}]},{"description":"Revise/graft eyelid lining","code_information":[{"code":"68328","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1763.69,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2351.59,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4538.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1763.69,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2398.62,"additional_payer_notes":"APC"}]}]},{"description":"Incise/drain tear gland","code_information":[{"code":"68400","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":739.52,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":986.02,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1903.02,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":739.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1005.74,"additional_payer_notes":"APC"}]}]},{"description":"Clearance of tear duct","code_information":[{"code":"68530","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":235.46,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":313.95,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":605.92,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":235.46,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":320.23,"additional_payer_notes":"APC"}]}]},{"description":"Close tear duct opening","code_information":[{"code":"68760","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":235.46,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":313.95,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":605.92,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":235.46,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":320.23,"additional_payer_notes":"APC"}]}]},{"description":"Explore/irrigate tear ducts","code_information":[{"code":"68840","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":235.46,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":313.95,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":605.92,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":235.46,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":320.23,"additional_payer_notes":"APC"}]}]},{"description":"Biopsy of external ear canal","code_information":[{"code":"69105","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1151.01,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1534.69,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2961.94,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1151.01,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1565.38,"additional_payer_notes":"APC"}]}]},{"description":"Clear outer ear canal","code_information":[{"code":"69205","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1225.21,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1633.61,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3152.87,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1225.21,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1666.28,"additional_payer_notes":"APC"}]}]},{"description":"Outer ear surgery procedure","code_information":[{"code":"69399","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":175.7,"maximum":13249.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":234.27,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":13249.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":10779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":13249.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":452.14,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":175.7,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":238.96,"additional_payer_notes":"APC"}]}]},{"description":"Mastoidectomy","code_information":[{"code":"69501","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Remove ear lesion","code_information":[{"code":"69552","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Repair eardrum structures","code_information":[{"code":"69631","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Revise middle ear & mastoid","code_information":[{"code":"69643","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Repair middle ear structures","code_information":[{"code":"69666","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2459.51,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3279.35,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6329.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2459.51,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3344.94,"additional_payer_notes":"APC"}]}]},{"description":"Temple Bone Implant Revision","code_information":[{"code":"69717","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Explore inner ear","code_information":[{"code":"69806","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Release inner ear canal","code_information":[{"code":"69960","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Coronary art/grft angio s&i","code_information":[{"code":"93455","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2404.97,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3206.62,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6188.79,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2404.97,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3270.76,"additional_payer_notes":"APC"}]}]},{"description":"Insert/place heart catheter","code_information":[{"code":"93503","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1167.76,"maximum":4106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1557.01,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3005.03,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1167.76,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1588.15,"additional_payer_notes":"APC"}]}]},{"description":"Perc d-e cor revasc w AMI s","code_information":[{"code":"C9606","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8923.0,"maximum":10765.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":10765.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":8923.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":10765.0}]}]},{"description":"Apicoectomy - anterior","code_information":[{"code":"D3410","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":479.59,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":639.45,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1234.13,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":479.59,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":652.24,"additional_payer_notes":"APC"}]}]},{"description":"Isolation- tooth w rubb dam","code_information":[{"code":"D3910","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":479.59,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":639.45,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1234.13,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":479.59,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":652.24,"additional_payer_notes":"APC"}]}]},{"description":"Fusion of knee","code_information":[{"code":"27580","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":24508.8,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12698.86,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":24508.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9524.15,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12952.84,"additional_payer_notes":"APC"}]}]},{"description":"Decompression of lower leg","code_information":[{"code":"27600","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Explore/treat ankle joint","code_information":[{"code":"27610","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Explore/treat ankle joint","code_information":[{"code":"27620","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Remove/graft leg bone lesion","code_information":[{"code":"27638","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":13851.98,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Repair/graft achilles tendon","code_information":[{"code":"27652","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Repair lower leg tendons","code_information":[{"code":"27676","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":13851.98,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Revise additional leg tendon","code_information":[{"code":"27692","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Incision of tibia","code_information":[{"code":"27705","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Repair of lower leg","code_information":[{"code":"27725","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Reinforce tibia","code_information":[{"code":"27745","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Optx medial ankle fx","code_information":[{"code":"27766","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Treatment of ankle fracture","code_information":[{"code":"27788","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":182.99,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":243.98,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":470.88,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":182.99,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":248.86,"additional_payer_notes":"APC"}]}]},{"description":"Treatment of ankle fracture","code_information":[{"code":"27823","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Treat lower leg dislocation","code_information":[{"code":"27831","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":6246.19,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Fusion of tibiofibular joint","code_information":[{"code":"27871","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":24508.8,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12698.86,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":24508.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9524.15,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12952.84,"additional_payer_notes":"APC"}]}]},{"description":"Decompression of leg","code_information":[{"code":"27892","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Incision of foot fascia","code_information":[{"code":"28008","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Exc foot/toe tum dep 1.5cm/>","code_information":[{"code":"28041","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2154.81,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2873.08,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5545.05,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2154.81,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2930.54,"additional_payer_notes":"APC"}]}]},{"description":"Neurectomy foot","code_information":[{"code":"28055","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1448.59,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1931.46,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3727.72,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1448.59,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1970.09,"additional_payer_notes":"APC"}]}]},{"description":"Arthroscopy biceps tenodesis","code_information":[{"code":"29828","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Shoulder arthroscopy/surgery","code_information":[{"code":"29820","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Wedging of clubfoot cast","code_information":[{"code":"29750","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":207.48,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":276.65,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":533.93,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":207.48,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":282.18,"additional_payer_notes":"APC"}]}]},{"description":"Apply multlay comprs lwr leg","code_information":[{"code":"29581","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":120.55,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":160.73,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":310.21,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":120.55,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":163.95,"additional_payer_notes":"APC"}]}]},{"description":"Application of leg cast","code_information":[{"code":"29450","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":120.55,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":160.73,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":310.21,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":120.55,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":163.95,"additional_payer_notes":"APC"}]}]},{"description":"Application of long leg cast","code_information":[{"code":"29355","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":207.48,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":276.65,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":533.93,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":207.48,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":282.18,"additional_payer_notes":"APC"}]}]},{"description":"Application of finger splint","code_information":[{"code":"29131","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":43.76,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":58.35,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":112.62,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":43.76,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":59.52,"additional_payer_notes":"APC"}]}]},{"description":"Application of long arm cast","code_information":[{"code":"29065","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":207.48,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":276.65,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":533.93,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":207.48,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":282.18,"additional_payer_notes":"APC"}]}]},{"description":"Application of body cast","code_information":[{"code":"29015","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":207.48,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":276.65,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":533.93,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":207.48,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":282.18,"additional_payer_notes":"APC"}]}]},{"description":"Amputation thru metatarsal","code_information":[{"code":"28805","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Fusion of foot bones","code_information":[{"code":"28730","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":24508.8,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12698.86,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":24508.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9524.15,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12952.84,"additional_payer_notes":"APC"}]}]},{"description":"Repair toe dislocation","code_information":[{"code":"28645","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Repair foot dislocation","code_information":[{"code":"28585","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":13851.98,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Treat sesamoid bone fracture","code_information":[{"code":"28531","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":13851.98,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Treat big toe fracture","code_information":[{"code":"28490","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":182.99,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":243.98,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":470.88,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":182.99,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":248.86,"additional_payer_notes":"APC"}]}]},{"description":"Treat midfoot fracture each","code_information":[{"code":"28450","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":182.99,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":243.98,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":470.88,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":182.99,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":248.86,"additional_payer_notes":"APC"}]}]},{"description":"Gingival flap proc w/ planin","code_information":[{"code":"D4240","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2459.51,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3279.35,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6329.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2459.51,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3344.94,"additional_payer_notes":"APC"}]}]},{"description":"Guided tiss regen resorble","code_information":[{"code":"D4266","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1151.01,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1534.69,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2961.94,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1151.01,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1565.38,"additional_payer_notes":"APC"}]}]},{"description":"Soft tissue graft firsttooth","code_information":[{"code":"D4277","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1151.01,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1534.69,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2961.94,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1151.01,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1565.38,"additional_payer_notes":"APC"}]}]},{"description":"Interim abutment","code_information":[{"code":"D6051","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5512.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0}]}]},{"description":"Impact tooth remov comp bony","code_information":[{"code":"D7240","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":479.59,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":639.45,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1234.13,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":479.59,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":652.24,"additional_payer_notes":"APC"}]}]},{"description":"Exposure of unerupted tooth","code_information":[{"code":"D7280","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":479.59,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":639.45,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1234.13,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":479.59,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":652.24,"additional_payer_notes":"APC"}]}]},{"description":"Transseptal fiberotomy","code_information":[{"code":"D7291","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":479.59,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":639.45,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1234.13,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":479.59,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":652.24,"additional_payer_notes":"APC"}]}]},{"description":"Alveoloplasty not w/extracts","code_information":[{"code":"D7321","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1151.01,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1534.69,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2961.94,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1151.01,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1565.38,"additional_payer_notes":"APC"}]}]},{"description":"Excision malig les complicat","code_information":[{"code":"D7415","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1151.01,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1534.69,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2961.94,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1151.01,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1565.38,"additional_payer_notes":"APC"}]}]},{"description":"Rem exostosis any site","code_information":[{"code":"D7471","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2459.51,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3279.35,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6329.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2459.51,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3344.94,"additional_payer_notes":"APC"}]}]},{"description":"Incision/drain abscess extra","code_information":[{"code":"D7521","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":525.32,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":700.42,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1351.81,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":525.32,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":714.43,"additional_payer_notes":"APC"}]}]},{"description":"Alveolus open reduction","code_information":[{"code":"D7671","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":11300.84,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Tmj manipulation under anest","code_information":[{"code":"D7830","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5512.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0}]}]},{"description":"Tmj reshaping components","code_information":[{"code":"D7865","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5512.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0}]}]},{"description":"Tmj arthroscopy debridement","code_information":[{"code":"D7877","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5512.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0}]}]},{"description":"Cutting ramus open w/graft","code_information":[{"code":"D7943","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5512.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0}]}]},{"description":"Sinus aug w bone or bone sub","code_information":[{"code":"D7951","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5512.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0}]}]},{"description":"Sialolithotomy","code_information":[{"code":"D7980","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5512.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0}]}]},{"description":"Appliance removal","code_information":[{"code":"D7997","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5512.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0}]}]},{"description":"Removal of impacted wax md","code_information":[{"code":"G0268","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Pelvic ring fracture uni/bil","code_information":[{"code":"G0413","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":13851.98,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Photorefractive keratectomy (PRK)","code_information":[{"code":"S0810","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5512.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0}]}]},{"description":"Breast reconstruct, GAP","code_information":[{"code":"S2066","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5512.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0}]}]},{"description":"Iselt cell transplant, allogeneic","code_information":[{"code":"S2102","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5512.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0}]}]},{"description":"Minimally invasive direct co","code_information":[{"code":"S2208","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5512.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0}]}]},{"description":"Fetal surg congen hernia","code_information":[{"code":"S2400","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5512.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0}]}]},{"description":"Corrj halux rigdus w/implt","code_information":[{"code":"28291","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Njx interlaminar lmbr/sac","code_information":[{"code":"62327","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":656.13,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":874.84,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1688.44,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":656.13,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":892.34,"additional_payer_notes":"APC"}]}]},{"description":"Fxjl abl lsr 1st 100 sq cm","code_information":[{"code":"0479T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":548.27,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":731.02,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1410.87,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":548.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":745.64,"additional_payer_notes":"APC"}]}]},{"description":"Mdfc flap w/prsrv vasc pedcl","code_information":[{"code":"15730","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2628.85,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3505.13,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6764.9,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2628.85,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3575.23,"additional_payer_notes":"APC"}]}]},{"description":"Nsl/sins ndsc w/sins dilat","code_information":[{"code":"31298","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5235.45,"maximum":13472.56,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6980.6,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":7398.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6019.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":7398.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13472.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5235.45,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7120.21,"additional_payer_notes":"APC"}]}]},{"description":"Treatment of heel fracture","code_information":[{"code":"28406","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":13851.98,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Repair of metatarsals","code_information":[{"code":"28322","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":13851.98,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Incision of metatarsal","code_information":[{"code":"28307","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":13851.98,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Correction hallux valgus","code_information":[{"code":"28297","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6779.0,"maximum":24508.8,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12698.86,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":24508.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9524.15,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12952.84,"additional_payer_notes":"APC"}]}]},{"description":"Release of toe joint each","code_information":[{"code":"28272","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1192.86,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1590.48,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3069.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1192.86,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1622.29,"additional_payer_notes":"APC"}]}]},{"description":"Revision of foot tendon","code_information":[{"code":"28238","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Repair/graft of foot tendon","code_information":[{"code":"28210","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Resect metatarsal tumor","code_information":[{"code":"28173","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Partial removal of toe","code_information":[{"code":"28124","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Part removal of metatarsal","code_information":[{"code":"28112","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Remove/graft foot lesion","code_information":[{"code":"28102","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Ins mark thor for rt perq","code_information":[{"code":"32553","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1026.79,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1369.06,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2642.28,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1026.79,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1396.44,"additional_payer_notes":"APC"}]}]},{"description":"Thoracoscopy diagnostic","code_information":[{"code":"32601","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4484.77,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5979.69,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5257.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11540.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4484.77,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6099.28,"additional_payer_notes":"APC"}]}]},{"description":"Thoracoscopy rem totl cortex","code_information":[{"code":"32652","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5257.0,"maximum":27583.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5257.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":27583.0}]}]},{"description":"Thoracoscopy w/mediast exc","code_information":[{"code":"32662","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5257.0,"maximum":6462.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5257.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6462.0}]}]},{"description":"Reconstruction of nose","code_information":[{"code":"30420","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Injection treatment of nose","code_information":[{"code":"30200","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":400.09,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":533.45,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1029.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":400.09,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":544.12,"additional_payer_notes":"APC"}]}]},{"description":"Removal of intranasal lesion","code_information":[{"code":"30118","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2459.51,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3279.35,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6329.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2459.51,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3344.94,"additional_payer_notes":"APC"}]}]},{"description":"Hip arthro w/labral repair","code_information":[{"code":"29916","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Mcp joint arthroscopy surg","code_information":[{"code":"29901","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Ankle arthroscopy/surgery","code_information":[{"code":"29892","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Knee arthroscopy/surgery","code_information":[{"code":"29883","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Knee arthroscopy/surgery","code_information":[{"code":"29874","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Hip arthr0 w/debridement","code_information":[{"code":"29862","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Wrist arthroscopy/surgery","code_information":[{"code":"29847","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Elbow arthroscopy/surgery","code_information":[{"code":"29836","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Repair nasal defect","code_information":[{"code":"30545","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Control of nosebleed","code_information":[{"code":"30901","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":98.7,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":131.6,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":253.99,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":98.7,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":134.23,"additional_payer_notes":"APC"}]}]},{"description":"Irrigation maxillary sinus","code_information":[{"code":"31000","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":175.7,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":234.27,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":452.14,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":175.7,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":238.96,"additional_payer_notes":"APC"}]}]},{"description":"Exploration of frontal sinus","code_information":[{"code":"31070","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":11300.84,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Exploration of sinuses","code_information":[{"code":"31090","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Nasal/sinus endoscopy dx","code_information":[{"code":"31235","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1320.39,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1760.51,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3397.79,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1320.39,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1795.72,"additional_payer_notes":"APC"}]}]},{"description":"Endoscopy maxillary sinus","code_information":[{"code":"31267","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4956.0,"maximum":13472.56,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6980.6,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":7398.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6019.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":7398.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13472.56,"additional_payer_notes":"APC"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":4956.0},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5235.45,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7120.21,"additional_payer_notes":"APC"}]}]},{"description":"Nasal/sinus endoscopy surg","code_information":[{"code":"31294","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5235.45,"maximum":13472.56,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6980.6,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":7398.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6019.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":7398.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13472.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5235.45,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7120.21,"additional_payer_notes":"APC"}]}]},{"description":"Partial removal of larynx","code_information":[{"code":"31367","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Revision of larynx","code_information":[{"code":"31400","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Injection into vocal cord","code_information":[{"code":"31513","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":290.14,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":386.86,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":746.64,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":290.14,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":394.6,"additional_payer_notes":"APC"}]}]},{"description":"Laryngoscopy w/fb removal","code_information":[{"code":"31530","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1320.39,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1760.51,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3397.79,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1320.39,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1795.72,"additional_payer_notes":"APC"}]}]},{"description":"Laryngoscop w/arytenoidectom","code_information":[{"code":"31560","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5235.45,"maximum":13472.56,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6980.6,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":7398.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6019.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":7398.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13472.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5235.45,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7120.21,"additional_payer_notes":"APC"}]}]},{"description":"Laryngoscopy telescopic","code_information":[{"code":"31579","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":290.14,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":386.86,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":746.64,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":290.14,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":394.6,"additional_payer_notes":"APC"}]}]},{"description":"Incision of windpipe","code_information":[{"code":"31603","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1151.01,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1534.69,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2961.94,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1151.01,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1565.38,"additional_payer_notes":"APC"}]}]},{"description":"Dx bronchoscope/wash","code_information":[{"code":"31622","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1320.39,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1760.51,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3397.79,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1320.39,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1795.72,"additional_payer_notes":"APC"}]}]},{"description":"Bronchoscopy dilate/fx repr","code_information":[{"code":"31630","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2765.81,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3687.74,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7117.34,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2765.81,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3761.5,"additional_payer_notes":"APC"}]}]},{"description":"Bronchoscopy revise stent","code_information":[{"code":"31638","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5235.45,"maximum":13472.56,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6980.6,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":7398.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6019.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":7398.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13472.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5235.45,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7120.21,"additional_payer_notes":"APC"}]}]},{"description":"Bronchial valve remov addl","code_information":[{"code":"31649","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1320.39,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1760.51,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3397.79,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1320.39,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1795.72,"additional_payer_notes":"APC"}]}]},{"description":"Clearance of airways","code_information":[{"code":"31720","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":162.44,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":216.59,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":418.02,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":162.44,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":220.92,"additional_payer_notes":"APC"}]}]},{"description":"Reconstruct bronchus","code_information":[{"code":"31775","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Repair of windpipe defect","code_information":[{"code":"31825","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2459.51,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3279.35,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6329.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2459.51,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3344.94,"additional_payer_notes":"APC"}]}]},{"description":"Exploration of chest","code_information":[{"code":"32100","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6019.0,"maximum":7398.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":7398.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6019.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":7398.0}]}]},{"description":"Open chest heart massage","code_information":[{"code":"32160","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6019.0,"maximum":7398.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":7398.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6019.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":7398.0}]}]},{"description":"Remove lung pneumonectomy","code_information":[{"code":"32440","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":9356.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0}]}]},{"description":"Lung volume reduction","code_information":[{"code":"32491","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":9356.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0}]}]},{"description":"Insert pleural cath","code_information":[{"code":"32550","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2656.06,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3541.41,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6834.92,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2656.06,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3612.24,"additional_payer_notes":"APC"}]}]},{"description":"Thorax stereo rad targetw/tx","code_information":[{"code":"32701","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2654.0,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0}]}]},{"description":"Lung transplant double","code_information":[{"code":"32853","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8923.0,"maximum":10765.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":10765.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":8923.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":10765.0}]}]},{"description":"Therapeutic pneumothorax","code_information":[{"code":"32960","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":465.35,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":620.47,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1197.51,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":465.35,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":632.88,"additional_payer_notes":"APC"}]}]},{"description":"Resect heart sac lesion","code_information":[{"code":"33050","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6019.0,"maximum":7398.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":7398.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6019.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":7398.0}]}]},{"description":"Insert heart pm ventricular","code_information":[{"code":"33207","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":27583.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10338.17,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":19952.66,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7753.63,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":27583.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10544.93,"additional_payer_notes":"APC"}]}]},{"description":"Insert 1 electrode pm-defib","code_information":[{"code":"33216","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6138.95,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8185.27,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":15797.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6138.95,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8348.97,"additional_payer_notes":"APC"}]}]},{"description":"L ventric pacing lead add-on","code_information":[{"code":"33225","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5512.0,"maximum":43643.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43643.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43643.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43643.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":41120.0}]}]},{"description":"Removal of pacemaker system","code_information":[{"code":"33234","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2772.2,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3696.26,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7133.79,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2772.2,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3770.19,"additional_payer_notes":"APC"}]}]},{"description":"Remove elctrd transvenously","code_information":[{"code":"33244","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2772.2,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3696.26,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7133.79,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2772.2,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3770.19,"additional_payer_notes":"APC"}]}]},{"description":"Ablate atria x10sv add-on","code_information":[{"code":"33258","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6019.0,"maximum":7398.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":7398.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6019.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":7398.0}]}]},{"description":"Ins/rep subq defibrillator","code_information":[{"code":"33270","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8923.0,"maximum":59920.75,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":31047.02,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":10765.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":8923.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":10765.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":54996.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":54996.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":54996.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":59920.75,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23285.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":51942.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":31667.96,"additional_payer_notes":"APC"}]}]},{"description":"Repair major blood vessel(s)","code_information":[{"code":"33320","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6019.0,"maximum":7398.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":7398.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6019.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":7398.0}]}]},{"description":"Replace aortic valve open","code_information":[{"code":"33364","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":9356.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0}]}]},{"description":"Replacement aortic valve opn","code_information":[{"code":"33406","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":9356.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0}]}]},{"description":"Repair of aortic valve","code_information":[{"code":"33417","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":9356.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0}]}]},{"description":"Replacement of mitral valve","code_information":[{"code":"33430","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":9356.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0}]}]},{"description":"Revision of heart chamber","code_information":[{"code":"33476","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":9356.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0}]}]},{"description":"Coronary artery graft","code_information":[{"code":"33504","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":9356.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0}]}]},{"description":"Cabg vein four","code_information":[{"code":"33513","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":9356.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0}]}]},{"description":"Tc meas 5 bmrk sfdi m-s alys","code_information":[{"code":"0061U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":18.82,"maximum":48.44,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25.1,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":31.38},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":31.38},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":31.38},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":48.44,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18.82,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":43.93},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25.1},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25.6,"additional_payer_notes":"APC"}]}]},{"description":"Onc clrct microrna mir-31-3p","code_information":[{"code":"0069U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":285.0,"maximum":733.4,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":380.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":564.48},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":475.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":475.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":475.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":733.4,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":285.0,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":665.0},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":380.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":387.6,"additional_payer_notes":"APC"}]}]},{"description":"Ig paraprotein qual bld/ur","code_information":[{"code":"0077U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":32.57,"maximum":83.82,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":43.43,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":54.29},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":54.29},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":54.29},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":83.82,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":32.57,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":76.0},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":43.43},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":44.3,"additional_payer_notes":"APC"}]}]},{"description":"Trnsplj kdn algrft rej 1494","code_information":[{"code":"0088U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2369.56,"maximum":6097.68,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3159.42,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3949.28},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3949.28},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3949.28},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6097.68,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2369.56,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5528.99},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3159.42},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3222.61,"additional_payer_notes":"APC"}]}]},{"description":"Hered colon ca do 15 genes","code_information":[{"code":"0101U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1169.8,"maximum":3365.82,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1743.95,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2590.58},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2179.94},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2179.94},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2179.94},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3365.82,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1307.96,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3051.91},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1169.8},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1778.83,"additional_payer_notes":"APC"}]}]},{"description":"Rx mntr 1+oral onc rx&sbsts","code_information":[{"code":"0110U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":20.33,"maximum":52.32,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27.11,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":40.27},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":33.89},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":33.89},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":33.89},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":52.32,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20.33,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":47.44},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27.11},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27.65,"additional_payer_notes":"APC"}]}]},{"description":"Trnsplj don-drv cll-fr dna","code_information":[{"code":"0118U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2064.94,"maximum":5313.77,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2753.25,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3441.56},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3441.56},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3441.56},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5313.77,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2064.94,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":4818.19},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2753.25},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2808.32,"additional_payer_notes":"APC"}]}]},{"description":"Hered brst ca rltd do pnl 13","code_information":[{"code":"0131U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":710.0,"maximum":1242.5,"payers_information":[{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":887.5},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":887.5},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":887.5},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1242.5},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":710.0}]}]},{"description":"Nfct ds fungi dna 15 trgt","code_information":[{"code":"0140U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":117.56,"maximum":302.53,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":156.75,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":232.84},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":195.94},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":195.94},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":195.94},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":302.53,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":117.56,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":274.31},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":156.75},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":159.88,"additional_payer_notes":"APC"}]}]},{"description":"Apc mrna seq alys","code_information":[{"code":"0157U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":212.16,"maximum":545.96,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":282.88,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":420.22},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":353.6},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":353.6},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":353.6},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":545.96,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":212.16,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":495.04},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":282.88},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":288.54,"additional_payer_notes":"APC"}]}]},{"description":"Peanut allg spec asmt 64 epi","code_information":[{"code":"0165U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":347.82,"maximum":895.06,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":463.76,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":688.91},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":579.7},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":579.7},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":579.7},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":895.06,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":347.82,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":811.58},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":463.76},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":473.04,"additional_payer_notes":"APC"}]}]},{"description":"Psyc gen alys panel 15 genes","code_information":[{"code":"0175U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1002.07,"maximum":2578.65,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1336.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1984.72},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1670.11},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1670.11},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1670.11},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2578.65,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1002.07,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2338.16},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1336.09},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1362.81,"additional_payer_notes":"APC"}]}]},{"description":"Di gnotyp slc4a1 exon 19","code_information":[{"code":"0183U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":138.9,"maximum":357.44,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":185.2,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":275.11},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":231.5},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":231.5},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":231.5},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":357.44,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":138.9,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":324.1},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":185.2},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":188.9,"additional_payer_notes":"APC"}]}]},{"description":"In gnotyp cd44 exons 2 3 6","code_information":[{"code":"0191U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":206.12,"maximum":530.42,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":274.83,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":408.24},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":343.54},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":343.54},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":343.54},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":530.42,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":206.12,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":480.95},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":274.83},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":280.33,"additional_payer_notes":"APC"}]}]},{"description":"Sc gnotyp ermap exons 4 12","code_information":[{"code":"0199U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":206.12,"maximum":530.42,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":274.83,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":408.24},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":343.54},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":343.54},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":343.54},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":530.42,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":206.12,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":480.95},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":274.83},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":280.33,"additional_payer_notes":"APC"}]}]},{"description":"Cytog const alys interrog","code_information":[{"code":"0209U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":590.36,"maximum":1519.2,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":787.15,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1169.3},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":983.94},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":983.94},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":983.94},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1519.2,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":590.36,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1377.51},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":787.15},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":802.89,"additional_payer_notes":"APC"}]}]},{"description":"Neuro inh ataxia dna 51 gene","code_information":[{"code":"0217U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1648.76,"maximum":4242.82,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2198.35,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3265.58},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2747.94},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2747.94},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2747.94},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4242.82,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1648.76,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3847.11},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2198.35},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2242.32,"additional_payer_notes":"APC"}]}]},{"description":"Nfct ds dna&rna 21 sarscov2","code_information":[{"code":"0225U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":312.58,"maximum":804.39,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":416.78,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":619.1},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":520.98},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":520.98},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":520.98},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":804.39,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":312.58,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":729.37},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":416.77},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":425.12,"additional_payer_notes":"APC"}]}]},{"description":"Fxn gene analysis","code_information":[{"code":"0233U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":206.12,"maximum":530.42,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":274.83,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":408.24},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":343.54},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":343.54},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":343.54},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":530.42,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":206.12,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":480.95},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":274.83},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":280.33,"additional_payer_notes":"APC"}]}]},{"description":"Nfct ds vir resp rna 4 trgt","code_information":[{"code":"0241U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":142.6,"maximum":249.6,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":211.87},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":178.29},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":178.29},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":178.29},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":249.6},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":142.6}]}]},{"description":"Onc brst alys 32 phsprtn alg","code_information":[{"code":"0249U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1664.35,"maximum":4282.92,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2219.13,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3285.98},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2773.91},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2773.91},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2773.91},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4282.92,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1664.35,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3883.48},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2219.13},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2263.51,"additional_payer_notes":"APC"}]}]},{"description":"Vlcad leuk nzm actv whl bld","code_information":[{"code":"0257U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":534.35,"maximum":1375.07,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":712.47,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1054.98},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":890.59},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":890.59},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":890.59},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1375.07,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":534.35,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1246.82},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":712.47},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":726.72,"additional_payer_notes":"APC"}]}]},{"description":"Rar do whl gn&mtcdrl dna als","code_information":[{"code":"0265U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4106.85,"maximum":10568.29,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5475.8,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":8108.29},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":6844.75},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":6844.75},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":6844.75},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":10568.29,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4106.85,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9582.65},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5475.8},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5585.32,"additional_payer_notes":"APC"}]}]},{"description":"Hem gen hyprfibrnlysis 8 gen","code_information":[{"code":"0273U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":456.13,"maximum":1173.77,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":608.17,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":900.54},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":760.21},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":760.21},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":760.21},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1173.77,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":456.13,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1064.3},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":608.17},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":620.33,"additional_payer_notes":"APC"}]}]},{"description":"Hem vwd propeptide ag lvl","code_information":[{"code":"0281U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":12.95,"maximum":33.33,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17.27,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":25.66},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21.59},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21.59},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21.59},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":33.33,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.95,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30.22},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17.27},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17.62,"additional_payer_notes":"APC"}]}]},{"description":"Neuro alzheimer mrna 24 gen","code_information":[{"code":"0289U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":570.0,"maximum":1466.8,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":760.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1125.37},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":950.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":950.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":950.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1466.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":570.0,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1330.0},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":760.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":775.2,"additional_payer_notes":"APC"}]}]},{"description":"Onc pan tum whl gen seq dna","code_information":[{"code":"0297U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2189.7,"maximum":5634.83,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2919.6,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4372.39},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3649.5},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3649.5},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3649.5},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5634.83,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2189.7,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5109.3},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2919.6},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2977.99,"additional_payer_notes":"APC"}]}]},{"description":"Hem rbc fnclty&dfrm shr strs","code_information":[{"code":"0305U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":496.94,"maximum":1278.78,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":662.58,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":992.28},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":828.23},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":828.23},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":828.23},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1278.78,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":496.94,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1159.52},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":662.58},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":675.83,"additional_payer_notes":"APC"}]}]},{"description":"Onc pncrs dna&mrna seq 74","code_information":[{"code":"0313U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2700.0,"maximum":6948.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3600.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5330.71},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4500.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4500.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4500.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6948.0,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2700.0,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6300.0},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3600.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3672.0,"additional_payer_notes":"APC"}]}]},{"description":"Iadna gu pthgn 20bct&fng org","code_information":[{"code":"0321U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":476.13,"maximum":1225.24,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":634.84,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":940.04},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":793.55},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":793.55},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":793.55},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1225.24,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":476.13,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1110.97},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":634.84},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":647.54,"additional_payer_notes":"APC"}]}]},{"description":"Onc hl neo opt gen mapping","code_information":[{"code":"0331U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1397.42,"maximum":3596.01,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1863.22,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2790.35},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2329.03},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2329.03},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2329.03},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3596.01,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1397.42,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3260.64},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1863.22},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1900.48,"additional_payer_notes":"APC"}]}]},{"description":"Onc prst8 mrna hoxc6 & dlx1","code_information":[{"code":"0339U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":570.0,"maximum":1466.8,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":760.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1125.37},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":950.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":950.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":950.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1466.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":570.0,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1330.0},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":760.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":775.2,"additional_payer_notes":"APC"}]}]},{"description":"Rx metab/pcx dna 25 gen alys","code_information":[{"code":"0348U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":556.7,"maximum":1432.58,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":742.27,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1099.13},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":927.84},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":927.84},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":927.84},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1432.58,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":556.7,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1298.97},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":742.27},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":757.12,"additional_payer_notes":"APC"}]}]},{"description":"Onc lung elisa 7 autoant alg","code_information":[{"code":"0360U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":630.49,"maximum":1622.45,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":840.65,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1258.96},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":978.66},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":978.66},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":978.66},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1622.45,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":630.49,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1370.13},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":840.65},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":857.46,"additional_payer_notes":"APC"}]}]},{"description":"Onc clrct ca mut&mthyltn mrk","code_information":[{"code":"0368U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":416.78,"maximum":729.37,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":600.17},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":520.98},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":520.98},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":520.98},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":729.37},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":416.78}]}]},{"description":"Drug test prsmv dir opt obs","code_information":[{"code":"80305","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":9.45,"maximum":24.32,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.6,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":22.22},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15.75},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15.75},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15.75},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":24.32,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9.45,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22.05},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12.6},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.85,"additional_payer_notes":"APC"}]}]},{"description":"Antidepressants class 1 or 2","code_information":[{"code":"80332","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":35.06,"maximum":35.06,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":35.06}]}]},{"description":"Drug screening cocaine","code_information":[{"code":"80353","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":35.06,"maximum":35.06,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":35.06}]}]},{"description":"Opiates 1 or more","code_information":[{"code":"80361","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":35.06,"maximum":35.06,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":35.06}]}]},{"description":"Drug screening tapentadol","code_information":[{"code":"80372","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":35.06,"maximum":35.06,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":35.06}]}]},{"description":"Acth stimulation panel","code_information":[{"code":"80406","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":58.7,"maximum":158.35,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":78.26,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":158.35},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":97.83},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":97.83},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":97.83},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":151.04,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":58.7,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":136.96},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":78.26},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":79.83,"additional_payer_notes":"APC"}]}]},{"description":"Pituitary evaluation panel","code_information":[{"code":"80418","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":434.61,"maximum":1172.82,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":579.48,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1172.82},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":724.35},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":724.35},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":724.35},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1118.4,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":434.61,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1014.09},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":579.48},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":591.07,"additional_payer_notes":"APC"}]}]},{"description":"Insulin tolerance panel","code_information":[{"code":"80434","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":204.72,"maximum":550.11,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":285.03,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":204.72},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":356.29},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":356.29},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":356.29},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":550.11,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":213.77,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":498.8},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":285.03},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":290.73,"additional_payer_notes":"APC"}]}]},{"description":"Path clin consltj prolng svc","code_information":[{"code":"80506","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":43.26,"maximum":66.35,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":66.35},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":43.26}]}]},{"description":"Urinalysis glass test","code_information":[{"code":"81020","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3.52,"maximum":9.07,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4.7,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7.45},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5.88},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5.88},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5.88},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":9.07,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3.52,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8.23},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":4.7},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4.79,"additional_payer_notes":"APC"}]}]},{"description":"Hpa-6 genotyping","code_information":[{"code":"81110","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":91.66,"maximum":235.88,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":122.22,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":224.14},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":152.78},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":152.78},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":152.78},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":235.88,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":91.66,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":213.89},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":122.22},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":124.66,"additional_payer_notes":"APC"}]}]},{"description":"Brca1&2 gen ful dup/del alys","code_information":[{"code":"81164","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":438.17,"maximum":1127.56,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":584.23,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":867.85},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":730.29},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":730.29},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":730.29},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1127.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":438.17,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1022.4},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":584.23},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":595.91,"additional_payer_notes":"APC"}]}]},{"description":"Ar gene full gene sequence","code_information":[{"code":"81173","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":226.01,"maximum":581.61,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":301.35,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":447.65},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":376.69},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":376.69},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":376.69},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":581.61,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":226.01,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":527.36},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":301.35},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":307.38,"additional_payer_notes":"APC"}]}]},{"description":"Atxn7 gene detc abnor allele","code_information":[{"code":"81181","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":102.75,"maximum":264.41,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":137.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":203.51},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":171.25},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":171.25},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":171.25},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":264.41,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":102.75,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":239.75},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":137.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":139.74,"additional_payer_notes":"APC"}]}]},{"description":"Cstb gene full gene sequence","code_information":[{"code":"81189","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":206.12,"maximum":530.42,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":274.83,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":408.24},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":343.54},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":343.54},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":343.54},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":530.42,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":206.12,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":480.95},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":274.83},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":280.33,"additional_payer_notes":"APC"}]}]},{"description":"Apc gene full sequence","code_information":[{"code":"81201","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":585.0,"maximum":1505.4,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":780.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1158.67},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":975.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":975.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":975.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1505.4,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":585.0,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1365.0},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":780.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":795.6,"additional_payer_notes":"APC"}]}]},{"description":"Blm gene","code_information":[{"code":"81209","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":29.48,"maximum":75.87,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":39.31,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":58.39},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":49.14},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":49.14},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":49.14},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":75.87,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":29.48,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":68.79},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":39.31},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":40.1,"additional_payer_notes":"APC"}]}]},{"description":"Cftr gene com variants","code_information":[{"code":"81220","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":417.45,"maximum":1074.24,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":556.6,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":826.81},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":695.75},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":695.75},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":695.75},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1074.24,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":417.45,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":974.05},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":556.6},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":567.73,"additional_payer_notes":"APC"}]}]},{"description":"Cytogen micrarray copy nmbr","code_information":[{"code":"81228","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":675.0,"maximum":1737.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":900.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1336.92},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1125.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1125.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1125.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1737.0,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":675.0,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1575.0},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":900.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":918.0,"additional_payer_notes":"APC"}]}]},{"description":"Ezh2 gene full gene sequence","code_information":[{"code":"81236","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":212.16,"maximum":545.96,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":282.88,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":420.22},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":353.6},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":353.6},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":353.6},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":545.96,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":212.16,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":495.04},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":282.88},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":288.54,"additional_payer_notes":"APC"}]}]},{"description":"Fmr1 gene characterization","code_information":[{"code":"81244","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":33.67,"maximum":86.64,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":44.89,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":66.68},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":56.11},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":56.11},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":56.11},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":86.64,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":33.67,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":78.56},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":44.89},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":45.79,"additional_payer_notes":"APC"}]}]},{"description":"Gjb2 gene full sequence","code_information":[{"code":"81252","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":75.84,"maximum":195.16,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":101.12,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":150.19},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":126.4},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":126.4},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":126.4},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":195.16,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":75.84,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":176.96},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":101.12},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":103.14,"additional_payer_notes":"APC"}]}]},{"description":"Ikbkap gene","code_information":[{"code":"81260","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":29.48,"maximum":75.87,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":39.31,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":58.39},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":49.14},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":49.14},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":49.14},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":75.87,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":29.48,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":68.79},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":39.31},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":40.1,"additional_payer_notes":"APC"}]}]},{"description":"Chimerism anal w/cell select","code_information":[{"code":"81268","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":195.59,"maximum":527.7,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":260.79,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":527.7},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":325.99},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":325.99},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":325.99},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":503.32,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":195.59,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":456.38},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":260.79},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":266.01,"additional_payer_notes":"APC"}]}]},{"description":"Kras gene addl variants","code_information":[{"code":"81276","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":144.94,"maximum":372.97,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":193.25,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":292.93},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":241.56},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":241.56},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":241.56},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":372.97,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":144.94,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":338.19},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":193.25},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":197.12,"additional_payer_notes":"APC"}]}]},{"description":"Mgmt gene methylation anal","code_information":[{"code":"81287","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":93.48,"maximum":240.56,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":124.64,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":123.43},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":155.8},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":155.8},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":155.8},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":240.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":93.48,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":218.12},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":124.64},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":127.13,"additional_payer_notes":"APC"}]}]},{"description":"Msh2 gene full seq","code_information":[{"code":"81295","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":225.02,"maximum":736.68,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":381.7,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":225.02},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":477.13},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":477.13},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":477.13},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":736.68,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":286.28,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":667.98},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":381.7},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":389.33,"additional_payer_notes":"APC"}]}]},{"description":"Mecp2 gene known variant","code_information":[{"code":"81303","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":90.0,"maximum":231.6,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":120.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":178.25},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":150.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":150.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":150.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":231.6,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":90.0,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":210.0},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":120.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":122.4,"additional_payer_notes":"APC"}]}]},{"description":"Nras gene variants exon 2&3","code_information":[{"code":"81311","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":221.84,"maximum":570.87,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":295.79,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":439.39},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":369.74},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":369.74},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":369.74},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":570.87,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":221.84,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":517.63},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":295.79},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":301.71,"additional_payer_notes":"APC"}]}]},{"description":"Pms2 gene dup/delet variants","code_information":[{"code":"81319","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":152.62,"maximum":392.76,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":203.5,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":328.79},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":254.38},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":254.38},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":254.38},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":392.76,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":152.62,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":356.13},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":203.5},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":207.57,"additional_payer_notes":"APC"}]}]},{"description":"Sept9 methylation analysis","code_information":[{"code":"81327","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":124.28,"maximum":370.56,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":192.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":124.28},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":240.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":240.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":240.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":370.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":144.0,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":336.0},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":192.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":195.84,"additional_payer_notes":"APC"}]}]},{"description":"Abltj perc lxtr/perph nrv","code_information":[{"code":"0441T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1448.59,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1931.46,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3727.72,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1448.59,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1970.09,"additional_payer_notes":"APC"}]}]},{"description":"Insj aqueous drain dev 1st","code_information":[{"code":"0449T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3947.51,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5263.35,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":10158.27,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3947.51,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5368.62,"additional_payer_notes":"APC"}]}]},{"description":"Sigmoidoscopy & decompress","code_information":[{"code":"45337","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":689.87,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":919.83,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1775.27,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":689.87,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":938.23,"additional_payer_notes":"APC"}]}]},{"description":"Sgmdsc w/band ligation","code_information":[{"code":"45350","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":887.71,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1183.61,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2284.37,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":887.71,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1207.28,"additional_payer_notes":"APC"}]}]},{"description":"Colonoscopy w/balloon dilat","code_information":[{"code":"45386","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":887.71,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1183.61,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2284.37,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":887.71,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1207.28,"additional_payer_notes":"APC"}]}]},{"description":"Lap remove rectum w/pouch","code_information":[{"code":"45397","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Treatment of rectal prolapse","code_information":[{"code":"45520","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":689.87,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":919.83,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1775.27,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":689.87,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":938.23,"additional_payer_notes":"APC"}]}]},{"description":"Repair fistula w/colostomy","code_information":[{"code":"45805","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Rectum surgery procedure","code_information":[{"code":"45999","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":689.87,"maximum":13249.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":919.83,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":13249.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":10779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":13249.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1775.27,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":689.87,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":938.23,"additional_payer_notes":"APC"}]}]},{"description":"Incision of anal sphincter","code_information":[{"code":"46080","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2059.07,"maximum":5298.68,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2745.43,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5298.68,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2059.07,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2800.34,"additional_payer_notes":"APC"}]}]},{"description":"Remove in/ex hem grp & fiss","code_information":[{"code":"46257","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2059.07,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2745.43,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5298.68,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2059.07,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2800.34,"additional_payer_notes":"APC"}]}]},{"description":"Remove anal fist 2 stage","code_information":[{"code":"46285","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2059.07,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2745.43,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5298.68,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2059.07,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2800.34,"additional_payer_notes":"APC"}]}]},{"description":"Anoscopy and biopsy","code_information":[{"code":"46606","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":887.71,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1183.61,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2284.37,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":887.71,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1207.28,"additional_payer_notes":"APC"}]}]},{"description":"Repair of anal stricture","code_information":[{"code":"46700","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2059.07,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2745.43,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5298.68,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2059.07,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2800.34,"additional_payer_notes":"APC"}]}]},{"description":"Construction of absent anus","code_information":[{"code":"46730","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Repair of anal sphincter","code_information":[{"code":"46751","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Laser surgery anal lesions","code_information":[{"code":"46917","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2059.07,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2745.43,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5298.68,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2059.07,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2800.34,"additional_payer_notes":"APC"}]}]},{"description":"Hemorrhoidopexy by stapling","code_information":[{"code":"46947","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2059.07,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2745.43,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5298.68,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2059.07,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2800.34,"additional_payer_notes":"APC"}]}]},{"description":"Extensive removal of liver","code_information":[{"code":"47122","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Prep donor liver whole","code_information":[{"code":"47143","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Repair liver wound","code_information":[{"code":"47361","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Perq abltj lvr cryoablation","code_information":[{"code":"47383","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5257.0,"maximum":20292.15,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10514.07,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5257.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":20292.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7885.55,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10724.35,"additional_payer_notes":"APC"}]}]},{"description":"Injection for cholangiogram","code_information":[{"code":"47531","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2656.06,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3541.41,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6834.92,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2656.06,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3612.24,"additional_payer_notes":"APC"}]}]},{"description":"Perq plmt bile duct stent","code_information":[{"code":"47539","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4484.77,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5979.69,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5257.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11540.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4484.77,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6099.28,"additional_payer_notes":"APC"}]}]},{"description":"Biliary endoscopy thru skin","code_information":[{"code":"47553","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6403.32,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":12358.4,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4802.49,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6531.38,"additional_payer_notes":"APC"}]}]},{"description":"Laparoscope proc biliary","code_information":[{"code":"47579","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4484.77,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5979.69,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5257.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11540.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4484.77,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6099.28,"additional_payer_notes":"APC"}]}]},{"description":"Excision of bile duct tumor","code_information":[{"code":"47711","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Fuse liver ducts & bowel","code_information":[{"code":"47765","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Placement of drain pancreas","code_information":[{"code":"48001","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Pancreatectomy","code_information":[{"code":"48146","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Injection intraop add-on","code_information":[{"code":"48400","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2654.0,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0}]}]},{"description":"Donor pancreatectomy","code_information":[{"code":"48550","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Exploration behind abdomen","code_information":[{"code":"49010","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":12358.4,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6403.32,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":12358.4,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4802.49,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6531.38,"additional_payer_notes":"APC"}]}]},{"description":"Biopsy abdominal mass","code_information":[{"code":"49180","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1225.21,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1633.61,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3152.87,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1225.21,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1666.28,"additional_payer_notes":"APC"}]}]},{"description":"Laparo drain lymphocele","code_information":[{"code":"49323","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4484.77,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5979.69,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5257.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11540.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4484.77,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6099.28,"additional_payer_notes":"APC"}]}]},{"description":"Image cath fluid colxn visc","code_information":[{"code":"49405","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1225.21,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1633.61,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3152.87,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1225.21,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1666.28,"additional_payer_notes":"APC"}]}]},{"description":"Remove tunneled ip cath","code_information":[{"code":"49422","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2342.32,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3123.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6027.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2342.32,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3185.56,"additional_payer_notes":"APC"}]}]},{"description":"Insert Subq Exten to IP Cath","code_information":[{"code":"49435","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3579.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0}]}]},{"description":"Cabg art-vein six or more","code_information":[{"code":"33523","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":9356.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0}]}]},{"description":"Restore/remodel ventricle","code_information":[{"code":"33548","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":9356.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0}]}]},{"description":"Repair double ventricle","code_information":[{"code":"33612","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":9356.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0}]}]},{"description":"Revision of heart veins","code_information":[{"code":"33645","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6019.0,"maximum":7398.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":7398.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6019.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":7398.0}]}]},{"description":"Repair heart septum defect","code_information":[{"code":"33681","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":9356.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0}]}]},{"description":"Repair of heart defects","code_information":[{"code":"33710","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":9356.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0}]}]},{"description":"Major vessel shunt","code_information":[{"code":"33750","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6019.0,"maximum":7398.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":7398.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6019.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":7398.0}]}]},{"description":"Repair great vessels defect","code_information":[{"code":"33771","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6019.0,"maximum":7398.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":7398.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6019.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":7398.0}]}]},{"description":"Repair great vessels defect","code_information":[{"code":"33781","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6019.0,"maximum":7398.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":7398.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6019.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":7398.0}]}]},{"description":"Repair septal defect","code_information":[{"code":"33814","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":9356.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0}]}]},{"description":"Repair septal defect","code_information":[{"code":"33853","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":9356.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0}]}]},{"description":"Endovasc prosth taa add-on","code_information":[{"code":"33884","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":9356.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0}]}]},{"description":"Repair pulmonary atresia","code_information":[{"code":"33920","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6019.0,"maximum":7398.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":7398.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6019.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":7398.0}]}]},{"description":"Removal of donor heart","code_information":[{"code":"33940","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5257.0,"maximum":6462.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5257.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6462.0}]}]},{"description":"Ecmo/ecls insj prph cannula","code_information":[{"code":"33952","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3388.0,"maximum":4106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0}]}]},{"description":"Ecmo/ecls repos perph cnula","code_information":[{"code":"33962","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3388.0,"maximum":4106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0}]}]},{"description":"Aortic circulation assist","code_information":[{"code":"33970","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Insert intracorporeal device","code_information":[{"code":"33979","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":9356.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0}]}]},{"description":"Artery expos/graft artery","code_information":[{"code":"33987","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Removal of artery clot","code_information":[{"code":"34001","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Removal of vein clot","code_information":[{"code":"34421","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2342.32,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3123.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6027.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2342.32,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3185.56,"additional_payer_notes":"APC"}]}]},{"description":"Leg vein fusion","code_information":[{"code":"34530","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2342.32,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3123.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6027.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2342.32,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3185.56,"additional_payer_notes":"APC"}]}]},{"description":"Xpose for endoprosth iliac","code_information":[{"code":"34833","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Visc & infraren abd 2 prosth","code_information":[{"code":"34846","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6019.0,"maximum":7398.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":7398.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6019.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":7398.0}]}]},{"description":"Repair defect of artery","code_information":[{"code":"35021","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Repair artery rupture aorta","code_information":[{"code":"35103","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Repair artery rupture thigh","code_information":[{"code":"35142","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Repair blood vessel lesion","code_information":[{"code":"35190","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4127.91,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5503.89,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":10622.5,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4127.91,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5613.96,"additional_payer_notes":"APC"}]}]},{"description":"Repair blood vessel lesion","code_information":[{"code":"35231","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2342.32,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3123.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6027.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2342.32,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3185.56,"additional_payer_notes":"APC"}]}]},{"description":"Repair blood vessel lesion","code_information":[{"code":"35271","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Rechanneling of Artery","code_information":[{"code":"35305","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Rechanneling of artery","code_information":[{"code":"35361","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Art byp grft subclav-carotid","code_information":[{"code":"35506","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Art byp grft axillary-axilry","code_information":[{"code":"35518","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Art byp grft hepatorenal","code_information":[{"code":"35535","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Art byp grft aortorenal","code_information":[{"code":"35560","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Rmvl sinus tarsi implant","code_information":[{"code":"0510T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Removal iims electrode only","code_information":[{"code":"0531T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2772.2,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3696.26,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7133.79,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2772.2,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3770.19,"additional_payer_notes":"APC"}]}]},{"description":"Repos prev ss impl dfb eltrd","code_information":[{"code":"0574T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2772.2,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3696.26,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7133.79,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2772.2,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3770.19,"additional_payer_notes":"APC"}]}]},{"description":"Perq njx algc fluor lmbr 1st","code_information":[{"code":"0627T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":9524.15,"maximum":24508.8,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12698.86,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":24508.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9524.15,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12952.84,"additional_payer_notes":"APC"}]}]},{"description":"Tprnl lsr ablt b9 prst8 hypr","code_information":[{"code":"0714T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3977.55,"maximum":10235.57,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5303.4,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":10235.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3977.55,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5409.47,"additional_payer_notes":"APC"}]}]},{"description":"Onc prst8 ca img alys 128","code_information":[{"code":"0376U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":529.69,"maximum":1363.06,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":706.25,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1057.68},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":882.81},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":882.81},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":882.81},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1363.06,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":529.69,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1235.94},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":706.25},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":720.38,"additional_payer_notes":"APC"}]}]},{"description":"Neph ckd alg rsk dbtc kdn ds","code_information":[{"code":"0385U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":293.06,"maximum":754.15,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":390.75,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":585.19},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":488.44},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":488.44},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":488.44},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":754.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":293.06,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":683.81},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":390.75},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":398.56,"additional_payer_notes":"APC"}]}]},{"description":"Pfas 16 pfas compnd lc ms/ms","code_information":[{"code":"0394U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":149.06,"maximum":383.57,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":198.74,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":297.64},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":248.43},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":248.43},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":248.43},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":383.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":149.06,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":347.8},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":198.74},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":202.71,"additional_payer_notes":"APC"}]}]},{"description":"Onc brst semiq meas thym kn","code_information":[{"code":"0404U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":242.22,"maximum":623.31,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":322.96,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":483.66},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":403.7},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":403.7},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":403.7},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":623.31,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":242.22,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":565.18},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":322.96},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":329.42,"additional_payer_notes":"APC"}]}]},{"description":"Beta amyloid a?42/40 imprcip","code_information":[{"code":"0412U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":562.5,"maximum":1447.5,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":750.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1080.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":937.5},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":937.5},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":937.5},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1447.5,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":562.5,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1312.5},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":750.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":765.0,"additional_payer_notes":"APC"}]}]},{"description":"Onc clrct scr sgl amp 8 rna","code_information":[{"code":"0421U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":508.87,"maximum":890.52,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":732.77},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":636.09},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":636.09},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":636.09},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":890.52},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":508.87}]}]},{"description":"Gi malabs aat calpro pncrtc","code_information":[{"code":"0430U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":46.16,"maximum":118.77,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":61.54,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":88.62},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":76.93},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":76.93},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":76.93},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":118.77,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":46.16,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":107.7},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":61.54},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":62.77,"additional_payer_notes":"APC"}]}]},{"description":"Rx metab advrs vrnt alys 33","code_information":[{"code":"0438U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":312.58,"maximum":804.39,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":416.78,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":600.17},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":520.98},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":520.98},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":520.98},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":804.39,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":312.58,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":729.37},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":416.78},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":425.12,"additional_payer_notes":"APC"}]}]},{"description":"Ai ds sle alys 10 cytokine","code_information":[{"code":"0446U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":630.49,"maximum":1622.45,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":840.65,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1210.54},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1050.81},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1050.81},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1050.81},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1622.45,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":630.49,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1471.14},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":840.65},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":857.46,"additional_payer_notes":"APC"}]}]},{"description":"Nfct agt sti mult amp prb ur","code_information":[{"code":"0455U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":106.97,"maximum":275.28,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":142.63,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":205.39},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":178.29},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":178.29},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":178.29},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":275.28,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":106.97,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":249.6},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":142.63},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":145.48,"additional_payer_notes":"APC"}]}]},{"description":"Onc clrct scr qrtsa dna mrk","code_information":[{"code":"0464U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":443.94,"maximum":1142.41,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":591.92,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":852.36},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":739.9},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":739.9},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":739.9},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1142.41,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":443.94,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1035.86},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":591.92},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":603.76,"additional_payer_notes":"APC"}]}]},{"description":"Nfct ds csf metag ngs alys","code_information":[{"code":"0480U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1594.65,"maximum":4103.57,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2126.2,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3061.73},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2657.75},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2657.75},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2657.75},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4103.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1594.65,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3720.85},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2126.2},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2168.72,"additional_payer_notes":"APC"}]}]},{"description":"Ob fetal ag nipt cfdna alys","code_information":[{"code":"0488U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":759.05,"maximum":1328.34,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1093.03},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":948.81},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":948.81},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":948.81},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1328.34},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":759.05}]}]},{"description":"Nfct ds uti id 17 path orgs","code_information":[{"code":"0504U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":312.58,"maximum":804.39,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":416.78,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":600.17},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":520.98},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":520.98},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":520.98},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":804.39,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":312.58,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":729.37},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":416.78},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":425.12,"additional_payer_notes":"APC"}]}]},{"description":"Onc prst8 alys dgtz img msi","code_information":[{"code":"0512U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":529.69,"maximum":1363.06,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":706.25,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1017.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":882.81},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":882.81},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":882.81},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1363.06,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":529.69,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1235.94},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":706.25},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":720.38,"additional_payer_notes":"APC"}]}]},{"description":"Ther rx mntr 200+ rx/sbsts","code_information":[{"code":"0520U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":185.19,"maximum":476.56,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":246.92,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":355.56},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":308.65},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":308.65},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":308.65},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":476.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":185.19,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":432.11},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":246.92},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":251.86,"additional_payer_notes":"APC"}]}]},{"description":"Obstetric panel","code_information":[{"code":"80055","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":35.86,"maximum":96.72,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":47.81,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":96.72},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":59.76},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":59.76},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":59.76},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":92.27,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":35.86,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":83.67},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":47.81},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":48.77,"additional_payer_notes":"APC"}]}]},{"description":"Assay of amikacin","code_information":[{"code":"80150","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":11.31,"maximum":30.5,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15.08,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":30.5},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18.85},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18.85},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18.85},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":29.1,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11.31,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26.39},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15.08},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15.38,"additional_payer_notes":"APC"}]}]},{"description":"Assay of digoxin total","code_information":[{"code":"80162","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":9.96,"maximum":26.87,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.28,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":26.87},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16.6},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16.6},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16.6},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":25.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9.96,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23.24},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13.28},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.55,"additional_payer_notes":"APC"}]}]},{"description":"Drug screen quant gabapentin","code_information":[{"code":"80171","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":16.25,"maximum":41.82,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21.67,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":26.82},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27.09},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27.09},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27.09},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":41.82,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16.25,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37.92},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21.67},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22.1,"additional_payer_notes":"APC"}]}]},{"description":"Drug assay flecainide","code_information":[{"code":"80181","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":13.98,"maximum":35.98,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18.64,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":27.71},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23.3},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23.3},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23.3},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":35.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.98,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32.62},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18.64},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19.01,"additional_payer_notes":"APC"}]}]},{"description":"Assay of procainamide","code_information":[{"code":"80190","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":33.9,"maximum":115.8,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":60.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":33.9},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":75.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":75.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":75.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":115.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":45.0,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":105.0},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":60.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":61.2,"additional_payer_notes":"APC"}]}]},{"description":"Assay of tobramycin","code_information":[{"code":"80200","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":12.1,"maximum":32.64,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16.13,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":32.64},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20.16},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20.16},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20.16},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":31.13,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.1,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28.23},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16.13},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16.45,"additional_payer_notes":"APC"}]}]},{"description":"Drug assay lacosamide","code_information":[{"code":"80235","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":20.33,"maximum":52.32,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27.11,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":40.27},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":33.89},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":33.89},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":33.89},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":52.32,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20.33,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":47.44},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27.11},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27.65,"additional_payer_notes":"APC"}]}]},{"description":"Acth stimulation panel","code_information":[{"code":"80402","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":65.22,"maximum":175.96,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":86.96,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":175.96},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":108.7},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":108.7},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":108.7},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":167.83,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":65.22,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":152.18},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":86.96},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":88.7,"additional_payer_notes":"APC"}]}]},{"description":"Renin stimulation panel","code_information":[{"code":"80417","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":32.99,"maximum":89.02,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":43.99,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":89.02},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":54.99},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":54.99},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":54.99},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":84.9,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":32.99,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":76.98},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":43.99},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":44.87,"additional_payer_notes":"APC"}]}]},{"description":"Insulin suppression panel","code_information":[{"code":"80432","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":115.64,"maximum":319.63,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":165.61,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":115.64},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":207.01},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":207.01},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":207.01},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":319.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":124.21,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":289.82},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":165.61},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":168.92,"additional_payer_notes":"APC"}]}]},{"description":"Urinalysis nonauto w/o scope","code_information":[{"code":"81002","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2.61,"maximum":6.72,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3.48,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5.18},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4.35},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4.35},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4.35},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6.72,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2.61,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6.09},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3.48},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3.55,"additional_payer_notes":"APC"}]}]},{"description":"Hpa-1 genotyping","code_information":[{"code":"81105","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":91.66,"maximum":235.88,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":122.22,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":224.14},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":152.78},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":152.78},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":152.78},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":235.88,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":91.66,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":213.89},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":122.22},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":124.66,"additional_payer_notes":"APC"}]}]},{"description":"Idh1 common variants","code_information":[{"code":"81120","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":144.94,"maximum":372.97,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":193.25,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":287.06},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":241.56},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":241.56},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":241.56},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":372.97,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":144.94,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":338.19},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":193.25},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":197.12,"additional_payer_notes":"APC"}]}]},{"description":"Brca2 gene full dup/del alys","code_information":[{"code":"81167","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":212.16,"maximum":545.96,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":282.88,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":420.22},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":353.6},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":353.6},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":353.6},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":545.96,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":212.16,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":495.04},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":282.88},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":288.54,"additional_payer_notes":"APC"}]}]},{"description":"Asxl1 gene target seq alys","code_information":[{"code":"81176","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":181.42,"maximum":466.87,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":241.9,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":443.63},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":302.38},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":302.38},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":302.38},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":466.87,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":181.42,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":423.33},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":241.9},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":246.74,"additional_payer_notes":"APC"}]}]},{"description":"Cacna1a gen detc abnor allel","code_information":[{"code":"81184","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":102.75,"maximum":264.41,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":137.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":203.51},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":171.25},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":171.25},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":171.25},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":264.41,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":102.75,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":239.75},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":137.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":139.74,"additional_payer_notes":"APC"}]}]},{"description":"Replace g-j tube perc","code_information":[{"code":"49452","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":672.83,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":897.11,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1731.42,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":672.83,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":915.05,"additional_payer_notes":"APC"}]}]},{"description":"Rpr ing hernia init blocked","code_information":[{"code":"49501","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2656.06,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3541.41,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6834.92,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2656.06,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3612.24,"additional_payer_notes":"APC"}]}]},{"description":"Rpr fem hernia init blocked","code_information":[{"code":"49553","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2656.06,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3541.41,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6834.92,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2656.06,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3612.24,"additional_payer_notes":"APC"}]}]},{"description":"Lap ing hernia repair init","code_information":[{"code":"49650","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4484.77,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5979.69,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5257.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11540.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4484.77,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6099.28,"additional_payer_notes":"APC"}]}]},{"description":"Exploration of kidney","code_information":[{"code":"50010","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Removal of kidney stone","code_information":[{"code":"50080","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7022.52,"maximum":18071.3,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9363.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":18071.3,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7022.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9550.63,"additional_payer_notes":"APC"}]}]},{"description":"Remove kidney open","code_information":[{"code":"50220","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Removal of kidney lesion","code_information":[{"code":"50290","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Removal of kidney","code_information":[{"code":"50340","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Remove stent via transureth","code_information":[{"code":"50386","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1550.71,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2067.62,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3990.5,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1550.71,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2108.97,"additional_payer_notes":"APC"}]}]},{"description":"Njx px nfrosgrm &/urtrgrm","code_information":[{"code":"50430","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":517.28,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":689.7,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1331.13,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":517.28,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":703.5,"additional_payer_notes":"APC"}]}]},{"description":"Close nephrovisceral fistula","code_information":[{"code":"50525","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Laparoscopic nephrectomy","code_information":[{"code":"50546","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5257.0,"maximum":6462.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5257.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6462.0}]}]},{"description":"Kidney endoscopy & treatment","code_information":[{"code":"50561","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3977.55,"maximum":10235.57,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5303.4,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":10235.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3977.55,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5409.47,"additional_payer_notes":"APC"}]}]},{"description":"Fragmenting of kidney stone","code_information":[{"code":"50590","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2614.94,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3486.59,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6729.12,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2614.94,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3556.32,"additional_payer_notes":"APC"}]}]},{"description":"Removal of ureter stone","code_information":[{"code":"50630","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Plmt ureteral stent prq","code_information":[{"code":"50694","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2614.94,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3486.59,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6729.12,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2614.94,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3556.32,"additional_payer_notes":"APC"}]}]},{"description":"Revise ureter","code_information":[{"code":"50727","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2614.94,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3486.59,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6729.12,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2614.94,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3556.32,"additional_payer_notes":"APC"}]}]},{"description":"Reimplant ureter in bladder","code_information":[{"code":"50783","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Replace ureter by bowel","code_information":[{"code":"50840","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Laparo New Ureter/Bladder","code_information":[{"code":"50947","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5257.0,"maximum":20292.15,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10514.07,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5257.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":20292.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7885.55,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10724.35,"additional_payer_notes":"APC"}]}]},{"description":"Ureter endoscopy","code_information":[{"code":"50970","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2614.94,"maximum":6729.12,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3486.59,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6729.12,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2614.94,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3556.32,"additional_payer_notes":"APC"}]}]},{"description":"Removal of bladder stone","code_information":[{"code":"51050","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3977.55,"maximum":10235.57,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5303.4,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":10235.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3977.55,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5409.47,"additional_payer_notes":"APC"}]}]},{"description":"Removal of bladder lesion","code_information":[{"code":"51520","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2614.94,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3486.59,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6729.12,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2614.94,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3556.32,"additional_payer_notes":"APC"}]}]},{"description":"Removal of bladder & nodes","code_information":[{"code":"51575","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Preparation for bladder xray","code_information":[{"code":"51605","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Endoscopic injection/implant","code_information":[{"code":"51715","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2614.94,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3486.59,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6729.12,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2614.94,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3556.32,"additional_payer_notes":"APC"}]}]},{"description":"Electro-uroflowmetry first","code_information":[{"code":"51741","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":160.18,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":213.57,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":412.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":160.18,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":217.84,"additional_payer_notes":"APC"}]}]},{"description":"Attach bladder/urethra","code_information":[{"code":"51840","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3710.98,"maximum":9549.58,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4947.97,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":9549.58,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3710.98,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5046.93,"additional_payer_notes":"APC"}]}]},{"description":"Hysterectomy/bladder repair","code_information":[{"code":"51925","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5257.0,"maximum":6462.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5257.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6462.0}]}]},{"description":"Cystoscopy removal of clots","code_information":[{"code":"52001","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2614.94,"maximum":6729.12,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3486.59,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6729.12,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2614.94,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3556.32,"additional_payer_notes":"APC"}]}]},{"description":"Cystoscopy and treatment","code_information":[{"code":"52235","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2614.94,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3486.59,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6729.12,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2614.94,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3556.32,"additional_payer_notes":"APC"}]}]},{"description":"Cystoscopy and treatment","code_information":[{"code":"52277","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2614.94,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3486.59,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6729.12,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2614.94,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3556.32,"additional_payer_notes":"APC"}]}]},{"description":"Cystoscopy and treatment","code_information":[{"code":"52301","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2614.94,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3486.59,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6729.12,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2614.94,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3556.32,"additional_payer_notes":"APC"}]}]},{"description":"Cystoscopy inject material","code_information":[{"code":"52327","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3977.55,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5303.4,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":10235.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3977.55,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5409.47,"additional_payer_notes":"APC"}]}]},{"description":"Cysto/Uretero W/Up Stricture","code_information":[{"code":"52345","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2614.94,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3486.59,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6729.12,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2614.94,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3556.32,"additional_payer_notes":"APC"}]}]},{"description":"Ntrk2 translocation analysis","code_information":[{"code":"81192","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":155.48,"maximum":400.11,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":207.31,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":307.94},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":259.14},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":259.14},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":259.14},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":400.11,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":155.48,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":362.79},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":207.31},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":211.46,"additional_payer_notes":"APC"}]}]},{"description":"Ar gene charac alleles","code_information":[{"code":"81204","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":102.75,"maximum":264.41,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":137.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":203.51},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":171.25},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":171.25},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":171.25},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":264.41,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":102.75,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":239.75},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":137.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":139.74,"additional_payer_notes":"APC"}]}]},{"description":"Brca1 gene known fam variant","code_information":[{"code":"81215","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":138.29,"maximum":724.23,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":375.25,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":138.29},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":469.06},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":469.06},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":469.06},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":724.23,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":281.44,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":656.69},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":375.25},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":382.76,"additional_payer_notes":"APC"}]}]},{"description":"Cftr gene full sequence","code_information":[{"code":"81223","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":374.25,"maximum":963.07,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":499.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":741.25},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":623.75},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":623.75},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":623.75},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":963.07,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":374.25,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":873.25},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":499.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":508.98,"additional_payer_notes":"APC"}]}]},{"description":"Cyp3a5 gene common variants","code_information":[{"code":"81231","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":131.11,"maximum":337.38,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":174.81,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":259.67},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":218.51},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":218.51},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":218.51},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":337.38,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":131.11,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":305.92},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":174.81},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":178.31,"additional_payer_notes":"APC"}]}]},{"description":"Dmpk gene charac alleles","code_information":[{"code":"81239","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":206.12,"maximum":530.42,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":274.83,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":408.24},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":343.54},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":343.54},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":343.54},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":530.42,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":206.12,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":480.95},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":274.83},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":280.33,"additional_payer_notes":"APC"}]}]},{"description":"G6pd gene alys cmn variant","code_information":[{"code":"81247","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":131.11,"maximum":337.38,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":174.81,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":259.67},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":218.51},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":218.51},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":218.51},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":337.38,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":131.11,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":305.92},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":174.81},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":178.31,"additional_payer_notes":"APC"}]}]},{"description":"Hexa gene","code_information":[{"code":"81255","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":38.59,"maximum":99.3,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":51.45,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":76.44},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":64.31},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":64.31},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":64.31},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":99.3,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":38.59,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":90.04},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":51.45},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":52.48,"additional_payer_notes":"APC"}]}]},{"description":"Igh vari regional mutation","code_information":[{"code":"81263","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":220.89,"maximum":595.96,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":294.52,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":595.96},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":368.15},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":368.15},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":368.15},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":568.42,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":220.89,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":515.41},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":294.52},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":300.41,"additional_payer_notes":"APC"}]}]},{"description":"Htt gene detc abnor alleles","code_information":[{"code":"81271","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":102.75,"maximum":264.41,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":137.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":203.51},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":171.25},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":171.25},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":171.25},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":264.41,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":102.75,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":239.75},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":137.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":139.74,"additional_payer_notes":"APC"}]}]},{"description":"Jak2 gene trgt sequence alys","code_information":[{"code":"81279","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":138.9,"maximum":357.44,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":185.2,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":275.11},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":231.5},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":231.5},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":231.5},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":357.44,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":138.9,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":324.1},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":185.2},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":188.9,"additional_payer_notes":"APC"}]}]},{"description":"Mcoln1 gene","code_information":[{"code":"81290","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":29.48,"maximum":75.87,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":39.31,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":58.39},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":49.14},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":49.14},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":49.14},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":75.87,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":29.48,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":68.79},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":39.31},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":40.1,"additional_payer_notes":"APC"}]}]},{"description":"Msh6 gene full seq","code_information":[{"code":"81298","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":426.92,"maximum":1238.77,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":641.85,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":426.92},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":802.31},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":802.31},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":802.31},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1238.77,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":481.39,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1123.24},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":641.85},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":654.69,"additional_payer_notes":"APC"}]}]},{"description":"Nudt15 gene common variants","code_information":[{"code":"81306","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":218.52,"maximum":562.32,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":291.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":432.79},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":364.2},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":364.2},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":364.2},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":562.32,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":218.52,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":509.88},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":291.36},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":297.19,"additional_payer_notes":"APC"}]}]},{"description":"Pdgfra gene","code_information":[{"code":"81314","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":247.13,"maximum":635.95,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":329.51,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":489.48},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":411.89},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":411.89},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":411.89},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":635.95,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":247.13,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":576.64},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":329.51},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":336.1,"additional_payer_notes":"APC"}]}]},{"description":"Pten gene known fam variant","code_information":[{"code":"81322","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":34.95,"maximum":89.94,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":46.6,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":86.63},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":58.25},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":58.25},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":58.25},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":89.94,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":34.95,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":81.55},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":46.6},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":47.53,"additional_payer_notes":"APC"}]}]},{"description":"Smpd1 gene common variants","code_information":[{"code":"81330","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":35.25,"maximum":90.71,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":47.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":69.82},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":58.75},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":58.75},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":58.75},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":90.71,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":35.25,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":82.25},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":47.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":47.94,"additional_payer_notes":"APC"}]}]},{"description":"Mpl gene common variants","code_information":[{"code":"81338","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":112.75,"maximum":290.14,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":150.33,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":223.31},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":187.91},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":187.91},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":187.91},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":290.14,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":112.75,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":263.08},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":150.33},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":153.34,"additional_payer_notes":"APC"}]}]},{"description":"Tyms gene com variants","code_information":[{"code":"81346","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":131.11,"maximum":337.38,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":174.81,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":259.67},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":218.51},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":218.51},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":218.51},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":337.38,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":131.11,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":305.92},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":174.81},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":178.31,"additional_payer_notes":"APC"}]}]},{"description":"Vkorc1 gene","code_information":[{"code":"81355","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":66.15,"maximum":170.23,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":88.2,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":131.03},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":110.25},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":110.25},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":110.25},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":170.23,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":66.15,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":154.35},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":88.2},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":89.96,"additional_payer_notes":"APC"}]}]},{"description":"Hla i & ii type verify lr","code_information":[{"code":"81371","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":303.39,"maximum":780.72,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":404.52,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":487.03},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":505.65},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":505.65},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":505.65},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":780.72,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":303.39,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":707.91},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":404.52},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":412.61,"additional_payer_notes":"APC"}]}]},{"description":"Hla i typing complete hr","code_information":[{"code":"81379","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":251.54,"maximum":678.64,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":335.38,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":678.64},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":419.23},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":419.23},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":419.23},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":647.28,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":251.54,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":586.92},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":335.38},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":342.09,"additional_payer_notes":"APC"}]}]},{"description":"Mopath procedure level 4","code_information":[{"code":"81403","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":138.9,"maximum":357.44,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":185.2,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":275.11},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":231.5},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":231.5},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":231.5},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":357.44,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":138.9,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":324.1},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":185.2},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":188.9,"additional_payer_notes":"APC"}]}]},{"description":"Ashkenazi jewish assoc dis","code_information":[{"code":"81412","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":894.41,"maximum":4725.72,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2448.56,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":894.41},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3060.7},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3060.7},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3060.7},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4725.72,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1836.42,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":4284.98},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2448.56},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2497.53,"additional_payer_notes":"APC"}]}]},{"description":"Fetal chrmoml aneuploidy","code_information":[{"code":"81420","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":569.29,"maximum":1464.97,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":759.05,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1191.84},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":948.81},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":948.81},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":948.81},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1464.97,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":569.29,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1328.34},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":759.05},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":774.23,"additional_payer_notes":"APC"}]}]},{"description":"Hrdtry brst ca-rlatd dsordrs","code_information":[{"code":"81433","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":548.66,"maximum":894.41,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":894.41},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":548.66},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":548.66},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":548.66},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":768.13}]}]},{"description":"Ibmfs seq alys pnl 30 genes","code_information":[{"code":"81441","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1836.42,"maximum":4725.72,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2448.56,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3625.7},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3060.7},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3060.7},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3060.7},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4725.72,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1836.42,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":4284.98},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2448.56},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2497.53,"additional_payer_notes":"APC"}]}]},{"description":"Targeted genomic seq analys","code_information":[{"code":"81455","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2189.7,"maximum":5634.83,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2919.6,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4336.97},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3649.5},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3649.5},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3649.5},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5634.83,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2189.7,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5109.3},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2919.6},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2977.99,"additional_payer_notes":"APC"}]}]},{"description":"So gsap cll fr mcrstl ins","code_information":[{"code":"81464","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2466.38,"maximum":6346.82,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3288.51,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4735.45},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4110.64},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4110.64},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4110.64},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6346.82,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2466.38,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5754.89},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3288.51},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3354.28,"additional_payer_notes":"APC"}]}]},{"description":"Oncology tissue of origin","code_information":[{"code":"81504","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":390.0,"maximum":1003.6,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":520.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":772.44},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":650.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":650.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":650.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1003.6,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":390.0,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":910.0},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":520.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":530.4,"additional_payer_notes":"APC"}]}]},{"description":"Nfct ds bv rna vag flu alg","code_information":[{"code":"81513","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":106.97,"maximum":275.28,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":142.63,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":211.87},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":178.29},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":178.29},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":178.29},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":275.28,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":106.97,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":249.6},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":142.63},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":145.48,"additional_payer_notes":"APC"}]}]},{"description":"Onc breast mrna 12 genes","code_information":[{"code":"81522","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2904.75,"maximum":7474.89,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3873.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5753.22},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4841.25},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4841.25},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4841.25},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7474.89,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2904.75,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6777.75},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3873.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3950.46,"additional_payer_notes":"APC"}]}]},{"description":"Oncology prostate prob score","code_information":[{"code":"81539","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":570.0,"maximum":1466.8,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":760.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":894.41},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":950.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":950.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":950.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1466.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":570.0,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1330.0},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":760.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":775.2,"additional_payer_notes":"APC"}]}]},{"description":"Trnspl rej kdn mrna qpcr 139","code_information":[{"code":"81558","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2430.0,"maximum":6253.2,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3240.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4665.6},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4050.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4050.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4050.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6253.2,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2430.0,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5670.0},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3240.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3304.8,"additional_payer_notes":"APC"}]}]},{"description":"Acylcarnitines quant","code_information":[{"code":"82017","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":12.65,"maximum":32.56,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16.87,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":29.16},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21.09},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21.09},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21.09},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":32.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.65,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29.52},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16.87},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17.21,"additional_payer_notes":"APC"}]}]},{"description":"Assay of breath ethanol","code_information":[{"code":"82075","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":22.5,"maximum":57.9,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":30.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":24.38},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":37.5},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":37.5},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":37.5},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":57.9,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22.5,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":52.5},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":30.6,"additional_payer_notes":"APC"}]}]},{"description":"Alpha-Fetoprotein L3","code_information":[{"code":"82107","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":48.31,"maximum":130.33,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":64.41,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":130.33},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":80.51},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":80.51},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":80.51},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":124.31,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":48.31,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":112.72},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":64.41},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":65.7,"additional_payer_notes":"APC"}]}]},{"description":"Amino acids quan 6 or more","code_information":[{"code":"82139","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":12.65,"maximum":32.56,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16.87,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":29.16},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21.09},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21.09},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21.09},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":32.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.65,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29.52},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16.87},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17.21,"additional_payer_notes":"APC"}]}]},{"description":"Angiotensin I enzyme test","code_information":[{"code":"82164","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":10.95,"maximum":29.56,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14.6,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":29.56},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18.25},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18.25},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18.25},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":28.18,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10.95,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25.55},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14.6},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14.89,"additional_payer_notes":"APC"}]}]},{"description":"Occult blood other sources","code_information":[{"code":"82271","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3.99,"maximum":10.27,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5.32,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6.58},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":6.65},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":6.65},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":6.65},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":10.27,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3.99,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9.31},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5.32},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5.43,"additional_payer_notes":"APC"}]}]},{"description":"Assay of calcium","code_information":[{"code":"82330","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":10.26,"maximum":27.68,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.68,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":27.68},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17.1},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17.1},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17.1},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":26.4,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10.26,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23.94},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13.68},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.95,"additional_payer_notes":"APC"}]}]},{"description":"Assay blood carbon dioxide","code_information":[{"code":"82374","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3.66,"maximum":9.9,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4.88,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":9.9},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":6.1},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":6.1},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":6.1},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":9.42,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3.66,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8.54},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":4.88},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4.98,"additional_payer_notes":"APC"}]}]},{"description":"Assay three catecholamines","code_information":[{"code":"82384","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":18.94,"maximum":51.11,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25.25,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":51.11},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":31.56},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":31.56},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":31.56},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":48.73,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18.94,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":44.19},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25.25},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25.76,"additional_payer_notes":"APC"}]}]},{"description":"Test for chlorohydrocarbons","code_information":[{"code":"82441","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4.51,"maximum":12.16,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6.01,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":12.16},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7.51},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7.51},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7.51},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11.6,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4.51,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10.52},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6.01},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6.13,"additional_payer_notes":"APC"}]}]},{"description":"Assay of copper","code_information":[{"code":"82525","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":9.31,"maximum":23.95,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.41,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":20.77},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15.51},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15.51},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15.51},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":23.95,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9.31,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21.72},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12.41},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.66,"additional_payer_notes":"APC"}]}]},{"description":"Creatine mb fraction","code_information":[{"code":"82553","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8.66,"maximum":22.29,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11.55,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":12.48},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14.44},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14.44},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14.44},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":22.29,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8.66,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20.21},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11.55},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11.78,"additional_payer_notes":"APC"}]}]},{"description":"Vitamin B-12","code_information":[{"code":"82607","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":11.31,"maximum":30.5,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15.08,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":30.5},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18.85},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18.85},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18.85},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":29.1,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11.31,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26.39},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15.08},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15.38,"additional_payer_notes":"APC"}]}]},{"description":"Assay of dibucaine number","code_information":[{"code":"82638","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":9.19,"maximum":24.78,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.25,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":24.78},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15.31},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15.31},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15.31},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":23.64,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9.19,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21.44},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12.25},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.5,"additional_payer_notes":"APC"}]}]},{"description":"Assay of erythropoietin","code_information":[{"code":"82668","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":14.09,"maximum":38.03,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18.79,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":38.03},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23.49},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23.49},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23.49},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":36.26,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14.09,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32.88},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18.79},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19.17,"additional_payer_notes":"APC"}]}]},{"description":"Assay of etiocholanolone","code_information":[{"code":"82696","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":19.68,"maximum":50.64,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26.24,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":47.71},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":32.8},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":32.8},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":32.8},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":50.64,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19.68,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":45.92},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26.24},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26.76,"additional_payer_notes":"APC"}]}]},{"description":"Assay of fluoride","code_information":[{"code":"82735","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":13.9,"maximum":37.5,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18.54,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":37.5},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23.18},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23.18},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23.18},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":35.78,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.9,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32.45},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18.54},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18.91,"additional_payer_notes":"APC"}]}]},{"description":"Galectin-3","code_information":[{"code":"82777","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":33.19,"maximum":85.4,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":44.25,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":44.51},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":55.31},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":55.31},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":55.31},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":85.4,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":33.19,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":77.44},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":44.25},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":45.14,"additional_payer_notes":"APC"}]}]},{"description":"Hemoglobin-oxygen affinity","code_information":[{"code":"82820","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":10.0,"maximum":25.75,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.34,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":20.21},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16.68},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16.68},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16.68},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":25.75,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10.0,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23.35},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13.34},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.61,"additional_payer_notes":"APC"}]}]},{"description":"Reagent strip/blood glucose","code_information":[{"code":"82948","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3.78,"maximum":9.73,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5.04,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6.41},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":6.3},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":6.3},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":6.3},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":9.73,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3.78,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8.82},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5.04},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5.14,"additional_payer_notes":"APC"}]}]},{"description":"Assay of gdh enzyme","code_information":[{"code":"82965","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":9.86,"maximum":25.38,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.15,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":15.62},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16.44},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16.44},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16.44},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":25.38,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9.86,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23.01},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13.15},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.41,"additional_payer_notes":"APC"}]}]},{"description":"Growth stimulation gene 2","code_information":[{"code":"83006","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":44.51,"maximum":145.91,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":75.6,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":44.51},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":94.5},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":94.5},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":94.5},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":145.91,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":56.7,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":132.3},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":75.6},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":77.11,"additional_payer_notes":"APC"}]}]},{"description":"Hemoglobin electrophoresis","code_information":[{"code":"83020","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":9.23,"maximum":24.84,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.87,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":9.23},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16.09},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16.09},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16.09},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":24.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9.65,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22.52},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12.87},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.13,"additional_payer_notes":"APC"}]}]},{"description":"Blood methemoglobin assay","code_information":[{"code":"83050","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5.93,"maximum":15.83,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8.2,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5.93},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10.25},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10.25},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10.25},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":15.83,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6.15,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14.35},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8.2},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8.36,"additional_payer_notes":"APC"}]}]},{"description":"Assay of histamine","code_information":[{"code":"83088","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":22.15,"maximum":59.77,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":29.53,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":59.77},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":36.91},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":36.91},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":36.91},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":56.99,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22.15,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":51.68},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29.53},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":30.12,"additional_payer_notes":"APC"}]}]},{"description":"Immunoassay nonantibody","code_information":[{"code":"83516","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8.65,"maximum":23.34,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11.53,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":23.34},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14.41},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14.41},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14.41},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":22.25,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8.65,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20.18},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11.53},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11.76,"additional_payer_notes":"APC"}]}]},{"description":"Asay of interleukin-6 (il-6)","code_information":[{"code":"83529","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":12.95,"maximum":33.33,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17.27,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":25.66},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21.59},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21.59},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21.59},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":33.33,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.95,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30.22},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17.27},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17.62,"additional_payer_notes":"APC"}]}]},{"description":"Lactate (LD) (LDH) enzyme","code_information":[{"code":"83615","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4.53,"maximum":12.22,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6.04,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":12.22},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7.55},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7.55},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7.55},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11.66,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4.53,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10.57},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6.04},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6.16,"additional_payer_notes":"APC"}]}]},{"description":"Foam stability fetal lung","code_information":[{"code":"83662","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":14.18,"maximum":38.27,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18.91,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":38.27},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23.64},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23.64},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23.64},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":36.5,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14.18,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33.09},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18.91},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19.29,"additional_payer_notes":"APC"}]}]},{"description":"Lipoprotein bld hr fraction","code_information":[{"code":"83701","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":25.4,"maximum":65.35,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":33.86,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":50.24},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":42.33},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":42.33},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":42.33},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":65.35,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25.4,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":59.26},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33.86},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":34.54,"additional_payer_notes":"APC"}]}]},{"description":"Assay malate dehydrogenase","code_information":[{"code":"83775","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5.53,"maximum":14.92,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":14.92},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":9.21},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":9.21},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":9.21},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":14.22,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5.53,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12.9},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7.37},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7.52,"additional_payer_notes":"APC"}]}]},{"description":"Assay synovial fluid mucin","code_information":[{"code":"83872","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4.4,"maximum":11.86,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5.86,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":11.86},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7.33},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7.33},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7.33},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11.31,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4.4,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10.26},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5.86},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5.98,"additional_payer_notes":"APC"}]}]},{"description":"Assay of nucleotidase","code_information":[{"code":"83915","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8.36,"maximum":22.56,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11.15,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":22.56},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13.94},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13.94},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13.94},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":21.52,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8.36,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19.51},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11.15},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11.37,"additional_payer_notes":"APC"}]}]},{"description":"Assay of oxalate","code_information":[{"code":"83945","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":10.84,"maximum":27.89,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14.45,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":26.03},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18.06},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18.06},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18.06},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":27.89,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10.84,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25.29},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14.45},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14.74,"additional_payer_notes":"APC"}]}]},{"description":"Assay of phenylketones","code_information":[{"code":"84035","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2.98,"maximum":7.68,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3.98,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7.42},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4.98},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4.98},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4.98},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7.68,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2.98,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6.97},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3.98},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4.06,"additional_payer_notes":"APC"}]}]},{"description":"Cystouretero W/Congen Repr","code_information":[{"code":"52400","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2614.94,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3486.59,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6729.12,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2614.94,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3556.32,"additional_payer_notes":"APC"}]}]},{"description":"Relieve bladder contracture","code_information":[{"code":"52640","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2614.94,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3486.59,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6729.12,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2614.94,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3556.32,"additional_payer_notes":"APC"}]}]},{"description":"Incision of urethra","code_information":[{"code":"53025","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1550.71,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2067.62,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3990.5,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1550.71,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2108.97,"additional_payer_notes":"APC"}]}]},{"description":"Treatment of urethra lesion","code_information":[{"code":"53220","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2614.94,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3486.59,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6729.12,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2614.94,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3556.32,"additional_payer_notes":"APC"}]}]},{"description":"Repair of urethra defect","code_information":[{"code":"53275","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2614.94,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3486.59,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6729.12,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2614.94,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3556.32,"additional_payer_notes":"APC"}]}]},{"description":"Reconstruct urethra/bladder","code_information":[{"code":"53431","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3977.55,"maximum":10235.57,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5303.4,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":10235.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3977.55,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5409.47,"additional_payer_notes":"APC"}]}]},{"description":"Repair uro sphincter","code_information":[{"code":"53449","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":18071.3,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9363.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":18071.3,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7022.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9550.63,"additional_payer_notes":"APC"}]}]},{"description":"Repair of urethra defect","code_information":[{"code":"53520","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3977.55,"maximum":10235.57,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5303.4,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":10235.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3977.55,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5409.47,"additional_payer_notes":"APC"}]}]},{"description":"Dilation of urethra","code_information":[{"code":"53665","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1550.71,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2067.62,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3990.5,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1550.71,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2108.97,"additional_payer_notes":"APC"}]}]},{"description":"Drain penis lesion","code_information":[{"code":"54015","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1225.21,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1633.61,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3152.87,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1225.21,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1666.28,"additional_payer_notes":"APC"}]}]},{"description":"Biopsy of penis","code_information":[{"code":"54105","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2154.81,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2873.08,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5545.05,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2154.81,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2930.54,"additional_payer_notes":"APC"}]}]},{"description":"Remove penis & nodes","code_information":[{"code":"54135","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Treatment of penis lesion","code_information":[{"code":"54205","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3977.55,"maximum":10235.57,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5303.4,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":10235.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3977.55,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5409.47,"additional_payer_notes":"APC"}]}]},{"description":"Revision of penis","code_information":[{"code":"54304","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2614.94,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3486.59,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6729.12,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2614.94,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3556.32,"additional_payer_notes":"APC"}]}]},{"description":"Revise penis/urethra","code_information":[{"code":"54328","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2614.94,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3486.59,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6729.12,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2614.94,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3556.32,"additional_payer_notes":"APC"}]}]},{"description":"Repair penis","code_information":[{"code":"54380","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1550.71,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2067.62,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3990.5,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1550.71,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2108.97,"additional_payer_notes":"APC"}]}]},{"description":"Remove/replace penis prosth","code_information":[{"code":"54410","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8923.0,"maximum":43643.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20500.4,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":10765.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":8923.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":10765.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43643.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43643.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43643.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":39565.78,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15375.3,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":41120.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20910.41,"additional_payer_notes":"APC"}]}]},{"description":"Repair corporeal tear","code_information":[{"code":"54437","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2614.94,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3486.59,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6729.12,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2614.94,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3556.32,"additional_payer_notes":"APC"}]}]},{"description":"Removal of testis","code_information":[{"code":"54530","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2656.06,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3541.41,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6834.92,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2656.06,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3612.24,"additional_payer_notes":"APC"}]}]},{"description":"Revision of testis","code_information":[{"code":"54660","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3977.55,"maximum":10235.57,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5303.4,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":10235.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3977.55,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5409.47,"additional_payer_notes":"APC"}]}]},{"description":"Remove epididymis lesion","code_information":[{"code":"54830","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2614.94,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3486.59,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6729.12,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2614.94,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3556.32,"additional_payer_notes":"APC"}]}]},{"description":"Removal of hydrocele","code_information":[{"code":"55040","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2656.06,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3541.41,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6834.92,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2656.06,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3612.24,"additional_payer_notes":"APC"}]}]},{"description":"Revision of scrotum","code_information":[{"code":"55180","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3977.55,"maximum":10235.57,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5303.4,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":10235.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3977.55,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5409.47,"additional_payer_notes":"APC"}]}]},{"description":"Revise spermatic cord veins","code_information":[{"code":"55535","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":12358.4,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6403.32,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":12358.4,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4802.49,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6531.38,"additional_payer_notes":"APC"}]}]},{"description":"Biopsy of prostate","code_information":[{"code":"55700","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3388.0,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0}]}]},{"description":"Extensive prostate surgery","code_information":[{"code":"55815","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Extensive prostate surgery","code_information":[{"code":"55865","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Sex transformation m to f","code_information":[{"code":"55970","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3388.0,"maximum":9549.58,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4947.97,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":9549.58,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3710.98,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5046.93,"additional_payer_notes":"APC"}]}]},{"description":"Destroy vulva lesion/s compl","code_information":[{"code":"56515","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1530.61,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2040.81,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3938.76,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1530.61,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2081.63,"additional_payer_notes":"APC"}]}]},{"description":"Extensive vulva surgery","code_information":[{"code":"56633","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":27583.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":27583.0}]}]},{"description":"Repair of perineum","code_information":[{"code":"56810","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2401.4,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3201.87,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6179.61,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2401.4,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3265.91,"additional_payer_notes":"APC"}]}]},{"description":"Destroy vag lesions simple","code_information":[{"code":"57061","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2401.4,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3201.87,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6179.61,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2401.4,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3265.91,"additional_payer_notes":"APC"}]}]},{"description":"Remove vagina tissue compl","code_information":[{"code":"57111","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0}]}]},{"description":"Fitting of diaphragm/cap","code_information":[{"code":"57170","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":149.98,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":199.97,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":385.94,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":149.98,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":203.97,"additional_payer_notes":"APC"}]}]},{"description":"Repair of vagina","code_information":[{"code":"57260","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3710.98,"maximum":9549.58,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4947.97,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":9549.58,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3710.98,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5046.93,"additional_payer_notes":"APC"}]}]},{"description":"Repair paravag defect open","code_information":[{"code":"57284","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3710.98,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4947.97,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":9549.58,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3710.98,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5046.93,"additional_payer_notes":"APC"}]}]},{"description":"Assay phosphohexose enzymes","code_information":[{"code":"84087","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8.05,"maximum":20.9,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10.73,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":20.9},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13.41},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13.41},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13.41},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":20.71,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8.05,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18.78},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10.73},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10.94,"additional_payer_notes":"APC"}]}]},{"description":"Assay of feces porphyrins","code_information":[{"code":"84126","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":29.33,"maximum":75.48,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":39.11,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":51.55},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":48.89},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":48.89},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":48.89},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":75.48,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":29.33,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":68.44},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":39.11},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":39.89,"additional_payer_notes":"APC"}]}]},{"description":"Assay of progesterone","code_information":[{"code":"84144","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":15.64,"maximum":40.26,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20.86,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":37.66},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26.08},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26.08},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26.08},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":40.26,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15.64,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36.51},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20.86},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21.28,"additional_payer_notes":"APC"}]}]},{"description":"Assay of protein urine","code_information":[{"code":"84156","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2.75,"maximum":7.43,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3.67,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7.43},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4.59},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4.59},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4.59},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7.08,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2.75,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6.42},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3.67},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3.74,"additional_payer_notes":"APC"}]}]},{"description":"Assay RBC protoporphyrin","code_information":[{"code":"84202","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":10.76,"maximum":29.03,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14.35,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":29.03},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17.94},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17.94},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17.94},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":27.7,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10.76,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25.11},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14.35},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14.64,"additional_payer_notes":"APC"}]}]},{"description":"Assay of progesterone","code_information":[{"code":"84234","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":48.66,"maximum":131.29,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":64.88,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":131.29},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":81.1},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":81.1},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":81.1},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":125.22,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":48.66,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":113.54},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":64.88},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":66.18,"additional_payer_notes":"APC"}]}]},{"description":"Assay of sialic acid","code_information":[{"code":"84275","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":10.08,"maximum":27.18,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.44,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":27.18},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16.8},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16.8},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16.8},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":25.94,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10.08,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23.52},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13.44},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.71,"additional_payer_notes":"APC"}]}]},{"description":"Body fluid specific gravity","code_information":[{"code":"84315","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2.46,"maximum":6.33,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3.28,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5.08},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4.1},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4.1},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4.1},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6.33,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2.46,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5.74},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3.28},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3.35,"additional_payer_notes":"APC"}]}]},{"description":"Asy thiopurin s-mthyltrnsfrs","code_information":[{"code":"84433","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":16.63,"maximum":42.79,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22.17,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":32.82},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27.71},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27.71},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27.71},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":42.79,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16.63,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38.8},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22.17},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22.61,"additional_payer_notes":"APC"}]}]},{"description":"Assay of transcortin","code_information":[{"code":"84449","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":13.5,"maximum":36.43,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":36.43},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22.5},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22.5},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22.5},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":34.74,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.5,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31.5},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18.36,"additional_payer_notes":"APC"}]}]},{"description":"T3 reverse","code_information":[{"code":"84482","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":11.82,"maximum":30.42,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15.76,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":15.56},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19.7},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19.7},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19.7},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":30.42,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11.82,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27.58},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15.76},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16.08,"additional_payer_notes":"APC"}]}]},{"description":"Urea nitrogen semi-quant","code_information":[{"code":"84525","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3.85,"maximum":9.9,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5.13,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7.62},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":6.41},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":6.41},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":6.41},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":9.9,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3.85,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8.98},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5.13},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5.23,"additional_payer_notes":"APC"}]}]},{"description":"Assay of urine urobilinogen","code_information":[{"code":"84583","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4.54,"maximum":11.68,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6.05,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":10.18},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7.56},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7.56},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7.56},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11.68,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4.54,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10.59},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6.05},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6.17,"additional_payer_notes":"APC"}]}]},{"description":"Xylose tolerance test","code_information":[{"code":"84620","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":9.68,"maximum":24.92,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.91,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":23.99},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16.14},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16.14},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16.14},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":24.92,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9.68,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22.59},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12.91},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.17,"additional_payer_notes":"APC"}]}]},{"description":"Automated diff wbc count","code_information":[{"code":"85004","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4.85,"maximum":13.08,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6.47,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":13.08},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8.09},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8.09},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8.09},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":12.49,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4.85,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11.32},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6.47},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6.6,"additional_payer_notes":"APC"}]}]},{"description":"Complete cbc automated","code_information":[{"code":"85027","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4.85,"maximum":13.08,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6.47,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":13.08},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8.09},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8.09},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8.09},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":12.49,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4.85,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11.32},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6.47},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6.6,"additional_payer_notes":"APC"}]}]},{"description":"Reticulated platelet assay","code_information":[{"code":"85055","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":26.8,"maximum":68.98,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":35.74,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":54.18},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":44.68},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":44.68},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":44.68},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":68.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26.8,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":62.55},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35.74},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":36.45,"additional_payer_notes":"APC"}]}]},{"description":"Clot factor viii reltd antgn","code_information":[{"code":"85244","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":15.32,"maximum":41.32,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20.42,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":41.32},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25.53},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25.53},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25.53},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":39.41,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15.32,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35.74},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20.42},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20.83,"additional_payer_notes":"APC"}]}]},{"description":"Clot factor xiii fibrin stab","code_information":[{"code":"85290","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":12.26,"maximum":33.06,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16.34,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":33.06},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20.43},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20.43},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20.43},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":31.54,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.26,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28.6},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16.34},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16.67,"additional_payer_notes":"APC"}]}]},{"description":"Clot inhibit prot s total","code_information":[{"code":"85305","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8.71,"maximum":23.48,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11.61,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":23.48},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14.51},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14.51},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14.51},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":22.41,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8.71,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20.32},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11.61},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11.84,"additional_payer_notes":"APC"}]}]},{"description":"Euglobulin lysis","code_information":[{"code":"85360","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6.31,"maximum":17.02,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8.41,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":17.02},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10.51},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10.51},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10.51},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":16.23,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6.31,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14.72},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8.41},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8.58,"additional_payer_notes":"APC"}]}]},{"description":"Fibrinogen antigen","code_information":[{"code":"85385","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":10.84,"maximum":27.91,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14.46,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":17.18},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18.08},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18.08},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18.08},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":27.91,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10.84,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25.31},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14.46},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14.75,"additional_payer_notes":"APC"}]}]},{"description":"Heinz bodies direct","code_information":[{"code":"85441","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3.15,"maximum":8.52,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4.2,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":8.52},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5.25},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5.25},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5.25},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":8.11,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3.15,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7.35},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":4.2},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4.28,"additional_payer_notes":"APC"}]}]},{"description":"Iron Stain Peripheral Blood","code_information":[{"code":"85536","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5.16,"maximum":13.28,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6.88,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":13.08},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8.6},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8.6},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8.6},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13.28,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5.16,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12.04},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6.88},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7.02,"additional_payer_notes":"APC"}]}]},{"description":"Hexagnal phosph pltlt neutrl","code_information":[{"code":"85598","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":13.48,"maximum":36.38,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17.98,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":36.38},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22.48},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22.48},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22.48},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":34.7,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.48,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31.47},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17.98},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18.34,"additional_payer_notes":"APC"}]}]},{"description":"RBC sickle cell test","code_information":[{"code":"85660","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4.13,"maximum":11.16,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5.51,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":11.16},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":6.89},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":6.89},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":6.89},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":10.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4.13,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9.64},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5.51},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5.62,"additional_payer_notes":"APC"}]}]},{"description":"Allergen Specific Igg","code_information":[{"code":"86001","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5.86,"maximum":15.09,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7.82,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6.56},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":9.78},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":9.78},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":9.78},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":15.09,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5.86,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13.69},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7.82},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7.98,"additional_payer_notes":"APC"}]}]},{"description":"Anca screen each antibody","code_information":[{"code":"86036","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":9.04,"maximum":23.26,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.05,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":17.89},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15.06},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15.06},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15.06},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":23.26,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9.04,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21.09},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12.05},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.29,"additional_payer_notes":"APC"}]}]},{"description":"Aquaporin-4 antb cba each","code_information":[{"code":"86052","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":9.04,"maximum":23.26,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.05,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":17.89},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15.06},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15.06},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15.06},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":23.26,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9.04,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21.09},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12.05},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.29,"additional_payer_notes":"APC"}]}]},{"description":"Anti-phospholipid antibody","code_information":[{"code":"86148","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":11.77,"maximum":31.02,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16.07,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":11.77},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20.09},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20.09},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20.09},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":31.02,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.05,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28.12},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16.07},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16.39,"additional_payer_notes":"APC"}]}]},{"description":"Complement fixation each","code_information":[{"code":"86171","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7.51,"maximum":20.27,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10.01,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":20.27},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12.51},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12.51},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12.51},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":19.32,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7.51,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17.52},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10.01},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10.21,"additional_payer_notes":"APC"}]}]},{"description":"Fluorescent antibody titer","code_information":[{"code":"86256","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":9.04,"maximum":24.38,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.05,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":24.38},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15.06},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15.06},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15.06},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":23.26,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9.04,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21.09},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12.05},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.29,"additional_payer_notes":"APC"}]}]},{"description":"Human epididymis protein 4","code_information":[{"code":"86305","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":15.61,"maximum":42.11,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20.81,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":42.11},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26.01},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26.01},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26.01},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":40.16,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15.61,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36.42},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20.81},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21.23,"additional_payer_notes":"APC"}]}]},{"description":"Other immunoelectrophoresis","code_information":[{"code":"86325","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":17.35,"maximum":45.26,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23.13,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":45.26},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28.91},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28.91},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28.91},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":44.64,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17.35,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":40.48},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23.13},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23.59,"additional_payer_notes":"APC"}]}]},{"description":"Extensive sternum surgery","code_information":[{"code":"21632","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":17314.0,"maximum":18364.0,"payers_information":[{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0}]}]},{"description":"Cystouretero W/Excise Tumor","code_information":[{"code":"52355","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3977.55,"maximum":10235.57,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5303.4,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":10235.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3977.55,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5409.47,"additional_payer_notes":"APC"}]}]},{"description":"Prostatectomy (TURP)","code_information":[{"code":"52601","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3977.55,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5303.4,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":10235.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3977.55,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5409.47,"additional_payer_notes":"APC"}]}]},{"description":"Incision of urethra","code_information":[{"code":"53010","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3977.55,"maximum":10235.57,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5303.4,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":10235.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3977.55,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5409.47,"additional_payer_notes":"APC"}]}]},{"description":"Removal of urethra","code_information":[{"code":"53210","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2614.94,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3486.59,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6729.12,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2614.94,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3556.32,"additional_payer_notes":"APC"}]}]},{"description":"Treatment of urethra lesion","code_information":[{"code":"53265","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1550.71,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2067.62,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3990.5,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1550.71,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2108.97,"additional_payer_notes":"APC"}]}]},{"description":"Reconstruct urethra stage 2","code_information":[{"code":"53425","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3977.55,"maximum":10235.57,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5303.4,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":10235.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3977.55,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5409.47,"additional_payer_notes":"APC"}]}]},{"description":"Remove/replace ur sphincter","code_information":[{"code":"53447","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8923.0,"maximum":43643.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20500.4,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":10765.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":8923.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":10765.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43643.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43643.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43643.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":39565.78,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15375.3,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":41120.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20910.41,"additional_payer_notes":"APC"}]}]},{"description":"Repair of urethra injury","code_information":[{"code":"53510","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3977.55,"maximum":10235.57,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5303.4,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":10235.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3977.55,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5409.47,"additional_payer_notes":"APC"}]}]},{"description":"Dilation of urethra","code_information":[{"code":"53660","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":95.45,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":127.27,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":245.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":95.45,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":129.82,"additional_payer_notes":"APC"}]}]},{"description":"Slitting of prepuce","code_information":[{"code":"54000","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2614.94,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3486.59,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6729.12,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2614.94,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3556.32,"additional_payer_notes":"APC"}]}]},{"description":"Destruction penis lesion(s)","code_information":[{"code":"54065","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1530.61,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2040.81,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3938.76,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1530.61,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2081.63,"additional_payer_notes":"APC"}]}]},{"description":"Removal of penis","code_information":[{"code":"54125","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3579.0,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0}]}]},{"description":"Frenulotomy of penis","code_information":[{"code":"54164","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1550.71,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2067.62,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3990.5,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1550.71,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2108.97,"additional_payer_notes":"APC"}]}]},{"description":"Penis study","code_information":[{"code":"54250","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":185.35,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":247.13,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":476.96,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":185.35,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":252.07,"additional_payer_notes":"APC"}]}]},{"description":"Reconstruction of urethra","code_information":[{"code":"54324","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2614.94,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3486.59,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6729.12,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2614.94,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3556.32,"additional_payer_notes":"APC"}]}]},{"description":"Reconstruct urethra/penis","code_information":[{"code":"54352","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3977.55,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5303.4,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":10235.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3977.55,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5409.47,"additional_payer_notes":"APC"}]}]},{"description":"Remove muti-comp penis pros","code_information":[{"code":"54406","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2614.94,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3486.59,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6729.12,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2614.94,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3556.32,"additional_payer_notes":"APC"}]}]},{"description":"Revision of penis","code_information":[{"code":"54430","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Removal of testis","code_information":[{"code":"54520","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2614.94,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3486.59,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6729.12,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2614.94,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3556.32,"additional_payer_notes":"APC"}]}]},{"description":"Suspension of testis","code_information":[{"code":"54640","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2656.06,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3541.41,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6834.92,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2656.06,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3612.24,"additional_payer_notes":"APC"}]}]},{"description":"Drainage of scrotum","code_information":[{"code":"54700","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1550.71,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2067.62,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3990.5,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1550.71,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2108.97,"additional_payer_notes":"APC"}]}]},{"description":"Fusion of spermatic ducts","code_information":[{"code":"54901","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2614.94,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3486.59,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6729.12,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2614.94,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3556.32,"additional_payer_notes":"APC"}]}]},{"description":"Removal of scrotum","code_information":[{"code":"55150","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2614.94,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3486.59,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6729.12,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2614.94,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3556.32,"additional_payer_notes":"APC"}]}]},{"description":"Removal of sperm cord lesion","code_information":[{"code":"55520","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2614.94,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3486.59,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6729.12,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2614.94,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3556.32,"additional_payer_notes":"APC"}]}]},{"description":"Remove sperm duct pouch","code_information":[{"code":"55650","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2959.0,"maximum":4106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0}]}]},{"description":"Extensive prostate surgery","code_information":[{"code":"55810","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Surgical exposure prostate","code_information":[{"code":"55860","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3977.55,"maximum":10235.57,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5303.4,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":10235.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3977.55,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5409.47,"additional_payer_notes":"APC"}]}]},{"description":"Genital surgery procedure","code_information":[{"code":"55899","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":185.35,"maximum":13249.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":247.13,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":13249.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":10779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":13249.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":476.96,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":185.35,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":252.07,"additional_payer_notes":"APC"}]}]},{"description":"Hymenotomy","code_information":[{"code":"56442","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2401.4,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3201.87,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6179.61,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2401.4,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3265.91,"additional_payer_notes":"APC"}]}]},{"description":"Extensive vulva surgery","code_information":[{"code":"56631","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":27583.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":27583.0}]}]},{"description":"Repair of vagina","code_information":[{"code":"56800","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2401.4,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3201.87,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6179.61,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2401.4,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3265.91,"additional_payer_notes":"APC"}]}]},{"description":"I & d vaginal hematoma pp","code_information":[{"code":"57022","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2154.81,"maximum":5545.05,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2873.08,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5545.05,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2154.81,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2930.54,"additional_payer_notes":"APC"}]}]},{"description":"Vaginectomy partial w/nodes","code_information":[{"code":"57109","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2401.4,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3201.87,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6179.61,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2401.4,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3265.91,"additional_payer_notes":"APC"}]}]},{"description":"Ins vag brachytx device","code_information":[{"code":"57156","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":226.06,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":301.41,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":581.72,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":226.06,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":307.44,"additional_payer_notes":"APC"}]}]},{"description":"Repair bladder & vagina","code_information":[{"code":"57240","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3710.98,"maximum":9549.58,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4947.97,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":9549.58,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3710.98,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5046.93,"additional_payer_notes":"APC"}]}]},{"description":"Colpopexy extraperitoneal","code_information":[{"code":"57282","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5501.01,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7334.68,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":14155.93,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5501.01,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7481.37,"additional_payer_notes":"APC"}]}]},{"description":"Inhibin A","code_information":[{"code":"86336","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":11.69,"maximum":31.54,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15.59,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":31.54},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19.49},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19.49},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19.49},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":30.09,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11.69,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27.28},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15.59},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15.9,"additional_payer_notes":"APC"}]}]},{"description":"B cells total count","code_information":[{"code":"86355","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":28.3,"maximum":76.34,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":37.73,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":76.34},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":47.16},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":47.16},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":47.16},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":72.82,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":28.3,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":66.03},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37.73},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":38.48,"additional_payer_notes":"APC"}]}]},{"description":"Tiss trnsgltmnase ea ig clas","code_information":[{"code":"86364","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8.65,"maximum":22.25,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11.53,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":17.12},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14.41},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14.41},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14.41},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":22.25,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8.65,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20.18},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11.53},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11.76,"additional_payer_notes":"APC"}]}]},{"description":"Particle agglut antbdy scrn","code_information":[{"code":"86403","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8.66,"maximum":22.27,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11.54,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":20.63},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14.43},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14.43},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14.43},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":22.27,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8.66,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20.2},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11.54},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11.77,"additional_payer_notes":"APC"}]}]},{"description":"Tb ag response t-cell susp","code_information":[{"code":"86481","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":75.0,"maximum":193.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":100.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":151.62},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":125.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":125.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":125.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":193.0,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":75.0,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":175.0},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":100.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":102.0,"additional_payer_notes":"APC"}]}]},{"description":"Aspergillus antibody","code_information":[{"code":"86606","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":11.29,"maximum":29.05,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15.05,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":11.77},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18.81},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18.81},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18.81},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":29.05,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11.29,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26.34},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15.05},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15.35,"additional_payer_notes":"APC"}]}]},{"description":"Brucella antibody","code_information":[{"code":"86622","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6.7,"maximum":17.23,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8.93,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":11.77},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11.16},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11.16},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11.16},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":17.23,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6.7,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15.63},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8.93},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9.11,"additional_payer_notes":"APC"}]}]},{"description":"CMV antibody","code_information":[{"code":"86644","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":10.79,"maximum":29.12,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14.39,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":29.12},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17.99},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17.99},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17.99},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":27.77,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10.79,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25.18},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14.39},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14.68,"additional_payer_notes":"APC"}]}]},{"description":"Epstein-barr antibody","code_information":[{"code":"86663","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":9.84,"maximum":26.53,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.12,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":26.53},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16.4},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16.4},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16.4},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":25.32,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9.84,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22.96},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13.12},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.38,"additional_payer_notes":"APC"}]}]},{"description":"Helminth antibody","code_information":[{"code":"86682","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":9.76,"maximum":25.11,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.01,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":11.77},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16.26},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16.26},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16.26},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":25.11,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9.76,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22.77},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13.01},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.27,"additional_payer_notes":"APC"}]}]},{"description":"Herpes simplex type 2 test","code_information":[{"code":"86696","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":14.51,"maximum":39.17,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19.35,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":39.17},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24.19},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24.19},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24.19},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":37.35,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14.51,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33.86},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19.35},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19.74,"additional_payer_notes":"APC"}]}]},{"description":"Hepatitis be antibody","code_information":[{"code":"86707","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8.68,"maximum":23.41,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11.57,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":23.41},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14.46},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14.46},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14.46},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":22.33,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8.68,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20.25},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11.57},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11.8,"additional_payer_notes":"APC"}]}]},{"description":"Listeria monocytogenes","code_information":[{"code":"86723","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":9.89,"maximum":25.46,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":11.77},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16.49},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16.49},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16.49},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":25.46,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9.89,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23.08},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13.19},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.45,"additional_payer_notes":"APC"}]}]},{"description":"Malaria antibody","code_information":[{"code":"86750","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":9.89,"maximum":26.7,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":26.7},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16.49},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16.49},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16.49},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":25.46,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9.89,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23.08},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13.19},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.45,"additional_payer_notes":"APC"}]}]},{"description":"Sars-cov-2 covid-19 antibody","code_information":[{"code":"86769","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":31.6,"maximum":81.31,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":42.13,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":62.59},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":52.66},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":52.66},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":52.66},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":81.31,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":31.6,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":73.73},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":42.13},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":42.97,"additional_payer_notes":"APC"}]}]},{"description":"West nile virus ab igm","code_information":[{"code":"86788","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":11.77,"maximum":32.52,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16.85,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":11.77},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21.06},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21.06},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21.06},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":32.52,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.64,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29.49},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16.85},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17.19,"additional_payer_notes":"APC"}]}]},{"description":"Lymphocytotoxicity assay","code_information":[{"code":"86805","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":105.82,"maximum":365.75,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":189.51,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":105.82},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":236.89},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":236.89},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":236.89},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":365.75,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":142.13,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":331.64},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":189.51},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":193.3,"additional_payer_notes":"APC"}]}]},{"description":"Lymphocyte culture mixed","code_information":[{"code":"86821","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":27.42,"maximum":114.25,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":36.56,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":114.25},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":45.7},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":45.7},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":45.7},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":70.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27.42,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":63.98},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36.56},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":37.29,"additional_payer_notes":"APC"}]}]},{"description":"Hla class ii high defin qual","code_information":[{"code":"86833","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":233.4,"maximum":628.79,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":325.8,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":233.4},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":407.25},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":407.25},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":407.25},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":628.79,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":244.35,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":570.15},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":325.8},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":332.32,"additional_payer_notes":"APC"}]}]},{"description":"Blood typing serologic rh(d)","code_information":[{"code":"86901","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2.99,"maximum":71.3,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":36.94,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5.54},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3.74},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3.74},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3.74},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":71.3,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27.71,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5.23},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2.99},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":37.68,"additional_payer_notes":"APC"}]}]},{"description":"Specimen infect agnt concntj","code_information":[{"code":"87015","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5.01,"maximum":12.89,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6.68,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7.56},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8.35},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8.35},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8.35},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":12.89,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5.01,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11.69},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6.68},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6.81,"additional_payer_notes":"APC"}]}]},{"description":"Culture anaerobe ident each","code_information":[{"code":"87076","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6.06,"maximum":16.33,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8.08,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":16.33},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10.1},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10.1},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10.1},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":15.59,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6.06,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14.14},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8.08},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8.24,"additional_payer_notes":"APC"}]}]},{"description":"Blood fungus culture","code_information":[{"code":"87103","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":15.34,"maximum":39.49,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20.46,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":18.24},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25.58},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25.58},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25.58},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":39.49,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15.34,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35.81},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20.46},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20.87,"additional_payer_notes":"APC"}]}]},{"description":"Culture typing glc/hplc","code_information":[{"code":"87143","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":9.39,"maximum":25.34,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.52,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":25.34},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15.65},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15.65},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15.65},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":24.16,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9.39,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21.91},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12.52},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.77,"additional_payer_notes":"APC"}]}]},{"description":"Dark field examination","code_information":[{"code":"87164","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8.06,"maximum":20.73,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10.74,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":18.07},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13.43},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13.43},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13.43},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":20.73,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8.06,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18.8},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10.74},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10.95,"additional_payer_notes":"APC"}]}]},{"description":"Microbe susceptible disk","code_information":[{"code":"87184","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5.61,"maximum":14.44,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7.48,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":13.96},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":9.35},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":9.35},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":9.35},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":14.44,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5.61,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13.09},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7.48},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7.63,"additional_payer_notes":"APC"}]}]},{"description":"Smear fluorescent/acid stai","code_information":[{"code":"87206","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4.04,"maximum":10.9,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5.39,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":10.9},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":6.74},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":6.74},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":6.74},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":10.4,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4.04,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9.43},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5.39},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5.5,"additional_payer_notes":"APC"}]}]},{"description":"Virus inoculate tissue addl","code_information":[{"code":"87253","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":15.15,"maximum":38.99,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20.2,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":28.22},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25.25},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25.25},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25.25},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":38.99,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15.15,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35.35},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20.2},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20.6,"additional_payer_notes":"APC"}]}]},{"description":"Cytomegalovirus dfa","code_information":[{"code":"87271","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":10.06,"maximum":25.9,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.42,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":24.26},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16.78},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16.78},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16.78},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":25.9,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10.06,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23.49},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13.42},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.69,"additional_payer_notes":"APC"}]}]},{"description":"Respiratory syncytial ag if","code_information":[{"code":"87280","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":10.06,"maximum":25.9,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.42,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":24.26},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16.78},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16.78},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16.78},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":25.9,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10.06,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23.49},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13.42},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.69,"additional_payer_notes":"APC"}]}]},{"description":"Aspergillus ag ia","code_information":[{"code":"87305","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8.98,"maximum":24.26,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11.98,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":24.26},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14.98},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14.98},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14.98},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":23.12,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8.98,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20.97},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11.98},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.22,"additional_payer_notes":"APC"}]}]},{"description":"Entamoeb hist dispr ag ia","code_information":[{"code":"87336","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":12.0,"maximum":30.88,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":24.26},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":30.88,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.0,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28.0},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16.32,"additional_payer_notes":"APC"}]}]},{"description":"Histoplasma capsul ag ia","code_information":[{"code":"87385","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":9.94,"maximum":25.57,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.25,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":24.26},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16.56},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16.56},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16.56},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":25.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9.94,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23.19},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13.25},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.52,"additional_payer_notes":"APC"}]}]},{"description":"Shiga-like toxin ag ia","code_information":[{"code":"87427","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8.98,"maximum":24.26,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11.98,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":24.26},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14.98},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14.98},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14.98},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":23.12,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8.98,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20.97},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11.98},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.22,"additional_payer_notes":"APC"}]}]},{"description":"Bartonella dna amp probe","code_information":[{"code":"87471","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":26.32,"maximum":71.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":35.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":71.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43.86},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43.86},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43.86},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":67.72,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26.32,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":61.41},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35.09},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":35.79,"additional_payer_notes":"APC"}]}]},{"description":"Insj biomechanical device","code_information":[{"code":"22853","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":2334.0,"payers_information":[{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Onc ovar 5 prtn ser alg scor","code_information":[{"code":"0003U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":712.5,"maximum":1833.5,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":950.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1411.2},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1187.5},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1187.5},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1187.5},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1833.5,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":712.5,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1662.5},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":950.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":969.0,"additional_payer_notes":"APC"}]}]},{"description":"Nfct ds strn typ whl gen seq","code_information":[{"code":"0010U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":320.44,"maximum":824.61,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":427.26,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":634.68},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":534.08},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":534.08},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":534.08},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":824.61,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":320.44,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":747.71},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":427.26},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":435.81,"additional_payer_notes":"APC"}]}]},{"description":"Onc dlbcl mrna 20 genes alg","code_information":[{"code":"0017M","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1882.66,"maximum":4844.71,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2510.21,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3728.84},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3137.76},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3137.76},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3137.76},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4844.71,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1882.66,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":4392.87},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2510.21},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2560.41,"additional_payer_notes":"APC"}]}]},{"description":"Trgt gen seq dna&rna 23 gene","code_information":[{"code":"0022U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1462.5,"maximum":3763.5,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1950.0,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2437.5},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2437.5},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2437.5},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3763.5,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1462.5,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3412.5},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1950.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1989.0,"additional_payer_notes":"APC"}]}]},{"description":"Cyp1a2 gene","code_information":[{"code":"0031U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":174.81,"maximum":305.92,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":259.67},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":218.51},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":218.51},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":218.51},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":305.92},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":174.81}]}]},{"description":"Dna antb 2strand hi avidity","code_information":[{"code":"0039U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":10.3,"maximum":26.52,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.74,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":22.69},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17.18},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17.18},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17.18},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":26.52,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10.3,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24.05},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13.74},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14.01,"additional_payer_notes":"APC"}]}]},{"description":"Onc prst8 mrna 17 gene alg","code_information":[{"code":"0047U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2904.75,"maximum":7474.89,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3873.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5753.22},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4841.25},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4841.25},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4841.25},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7474.89,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2904.75,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6777.75},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3873.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3950.46,"additional_payer_notes":"APC"}]}]},{"description":"Onc merkel cll carc srm quan","code_information":[{"code":"0058U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":242.22,"maximum":623.31,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":322.96,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":533.06},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":403.7},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":403.7},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":403.7},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":623.31,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":242.22,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":565.18},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":322.96},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":329.42,"additional_payer_notes":"APC"}]}]},{"description":"Clsd tx pelvic ring fx","code_information":[{"code":"27197","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":182.99,"maximum":2334.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":243.98,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":470.88,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":182.99,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":248.86,"additional_payer_notes":"APC"}]}]},{"description":"Pamg-1 ia cervico-vag fluid","code_information":[{"code":"0066U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":19.11,"maximum":26.76,"payers_information":[{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19.11},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19.11},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19.11},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26.76}]}]},{"description":"Cyp2d6 nonduplicated gene","code_information":[{"code":"0074U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":338.18,"maximum":870.26,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":450.91,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":669.83},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":563.64},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":563.64},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":563.64},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":870.26,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":338.18,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":789.09},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":450.91},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":459.93,"additional_payer_notes":"APC"}]}]},{"description":"Rbc dna gnotyp 10 bld groups","code_information":[{"code":"0084U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":540.0,"maximum":1389.6,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":720.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1069.54},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":900.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":900.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":900.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1389.6,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":540.0,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1260.0},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":720.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":734.4,"additional_payer_notes":"APC"}]}]},{"description":"Genome rapid sequence alys","code_information":[{"code":"0094U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5686.65,"maximum":14633.65,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7582.2,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":9477.75},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":9477.75},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":9477.75},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":14633.65,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5686.65,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13268.85},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7582.2},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7733.84,"additional_payer_notes":"APC"}]}]},{"description":"C diff tox ag detcj ia stool","code_information":[{"code":"0107U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":12.0,"maximum":30.88,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":23.77},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":30.88,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.0,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28.0},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16.32,"additional_payer_notes":"APC"}]}]},{"description":"Respir iadna 18 viral&2 bact","code_information":[{"code":"0115U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":206.51,"maximum":531.43,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":275.35,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":344.19},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":344.19},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":344.19},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":531.43,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":206.51,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":481.86},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":275.35},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":280.86,"additional_payer_notes":"APC"}]}]},{"description":"Mchnl fragility rbc prflg","code_information":[{"code":"0123U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":268.22,"maximum":690.23,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":357.63,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":447.04},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":447.04},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":447.04},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":690.23,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":268.22,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":625.85},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":357.63},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":364.78,"additional_payer_notes":"APC"}]}]},{"description":"Atm mrna seq alys","code_information":[{"code":"0136U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":305.57,"maximum":786.34,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":407.43,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":509.29},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":509.29},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":509.29},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":786.34,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":305.57,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":713.0},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":407.43},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":415.58,"additional_payer_notes":"APC"}]}]},{"description":"Fgfr3 gene analysis","code_information":[{"code":"0154U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":207.31,"maximum":930.53,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":482.14,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":602.68},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":602.68},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":602.68},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":930.53,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":361.6,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":843.75},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":207.31},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":491.78,"additional_payer_notes":"APC"}]}]},{"description":"Hered colon ca trgt mrna pnl","code_information":[{"code":"0162U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":364.9,"maximum":939.02,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":486.54,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":722.74},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":608.18},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":608.18},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":608.18},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":939.02,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":364.9,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":851.45},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":486.54},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":496.27,"additional_payer_notes":"APC"}]}]},{"description":"Onc sld tum alys brca1 brca2","code_information":[{"code":"0172U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2272.5,"maximum":5847.9,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3030.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4500.97},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3787.5},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3787.5},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3787.5},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5847.9,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2272.5,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5302.5},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3090.6,"additional_payer_notes":"APC"}]}]},{"description":"Abo gnotyp abo 7 exons","code_information":[{"code":"0180U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":206.12,"maximum":530.42,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":274.83,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":408.24},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":343.54},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":343.54},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":343.54},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":530.42,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":206.12,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":480.95},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":274.83},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":280.33,"additional_payer_notes":"APC"}]}]},{"description":"Ge gnotyp gypc exons 1-4","code_information":[{"code":"0188U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":206.12,"maximum":530.42,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":274.83,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":408.24},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":343.54},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":343.54},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":343.54},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":530.42,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":206.12,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":480.95},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":274.83},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":280.33,"additional_payer_notes":"APC"}]}]},{"description":"Lu gnotyp bcam exon 3","code_information":[{"code":"0196U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":138.9,"maximum":357.44,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":185.2,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":275.11},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":231.5},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":231.5},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":231.5},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":357.44,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":138.9,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":324.1},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":185.2},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":188.9,"additional_payer_notes":"APC"}]}]},{"description":"Oph amd alys 3 gene variants","code_information":[{"code":"0205U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":35.25,"maximum":90.71,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":47.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":69.82},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":58.75},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":58.75},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":58.75},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":90.71,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":35.25,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":82.25},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":47.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":47.94,"additional_payer_notes":"APC"}]}]},{"description":"Rare ds xom dna alys proband","code_information":[{"code":"0214U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3918.45,"maximum":10083.48,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5224.6,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7760.98},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":6530.75},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":6530.75},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":6530.75},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":10083.48,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3918.45,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9143.05},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5224.6},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5329.09,"additional_payer_notes":"APC"}]}]},{"description":"Rhd&rhce gntyp next gnrj seq","code_information":[{"code":"0222U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":212.16,"maximum":545.96,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":282.88,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":420.22},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":353.6},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":353.6},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":353.6},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":545.96,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":212.16,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":495.04},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":282.88},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":288.54,"additional_payer_notes":"APC"}]}]},{"description":"Ar full sequence analysis","code_information":[{"code":"0230U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":226.01,"maximum":581.61,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":301.35,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":447.65},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":376.69},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":376.69},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":376.69},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":581.61,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":226.01,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":527.36},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":301.35},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":307.38,"additional_payer_notes":"APC"}]}]},{"description":"Onc lnch syn gen dna seq aly","code_information":[{"code":"0238U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":438.68,"maximum":1128.86,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":584.9,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":868.86},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":731.13},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":731.13},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":731.13},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1128.86,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":438.68,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1023.58},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":584.9},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":596.6,"additional_payer_notes":"APC"}]}]},{"description":"Rbc dna gnotyp 16 bld groups","code_information":[{"code":"0246U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":540.0,"maximum":1389.6,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":720.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1069.54},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":900.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":900.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":900.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1389.6,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":540.0,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1260.0},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":720.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":734.4,"additional_payer_notes":"APC"}]}]},{"description":"Reprdtve med alys 24 chrmsm","code_information":[{"code":"0254U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":569.29,"maximum":1464.97,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":759.05,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1123.97},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":948.81},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":948.81},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":948.81},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1464.97,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":569.29,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1328.34},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":759.05},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":774.23,"additional_payer_notes":"APC"}]}]},{"description":"Onc sld tum rt-pcr 7 gen","code_information":[{"code":"0262U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2400.0,"maximum":6176.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3200.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4738.4},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4000.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4000.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4000.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6176.0,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2400.0,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5600.0},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3200.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3264.0,"additional_payer_notes":"APC"}]}]},{"description":"Hem cgen coagj do 20 genes","code_information":[{"code":"0270U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":456.13,"maximum":1173.77,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":608.17,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":900.54},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":760.21},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":760.21},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":760.21},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1173.77,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":456.13,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1064.3},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":608.17},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":620.33,"additional_payer_notes":"APC"}]}]},{"description":"Hem gen thrombosis 12 genes","code_information":[{"code":"0278U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":456.13,"maximum":1173.77,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":608.17,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":900.54},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":760.21},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":760.21},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":760.21},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1173.77,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":456.13,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1064.3},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":608.17},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":620.33,"additional_payer_notes":"APC"}]}]},{"description":"Cep72 nudt15&tpmt gene alys","code_information":[{"code":"0286U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":100.6,"maximum":258.87,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":134.13,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":198.62},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":167.66},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":167.66},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":167.66},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":258.87,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":100.6,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":234.73},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":134.13},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":136.81,"additional_payer_notes":"APC"}]}]},{"description":"Lngvty&mrtlty rsk mrna 18gen","code_information":[{"code":"0294U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":760.0,"maximum":1330.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1125.37},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":950.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":950.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":950.0},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1330.0},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":760.0}]}]},{"description":"Iadna brtnla ddpcr flwg liq","code_information":[{"code":"0302U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":271.03,"maximum":697.44,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":361.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":541.19},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":451.71},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":451.71},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":451.71},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":697.44,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":271.03,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":632.4},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":361.37},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":368.6,"additional_payer_notes":"APC"}]}]},{"description":"Ped vsclts kd alys 3 bmrks","code_information":[{"code":"0310U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":293.06,"maximum":754.15,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":390.75,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":578.62},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":488.44},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":488.44},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":488.44},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":754.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":293.06,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":683.81},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":390.75},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":398.56,"additional_payer_notes":"APC"}]}]},{"description":"Ped whl gen mthyltn alys 50+","code_information":[{"code":"0318U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1327.86,"maximum":3417.03,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1770.48,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2651.47},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2213.1},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2213.1},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2213.1},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3417.03,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1327.86,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3098.34},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1770.48},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1805.89,"additional_payer_notes":"APC"}]}]},{"description":"Drug assay 120+ rx&metablt","code_information":[{"code":"0328U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":85.82,"maximum":220.85,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":114.43,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":169.45},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":143.04},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":143.04},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":143.04},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":220.85,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":85.82,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":200.25},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":114.43},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":116.72,"additional_payer_notes":"APC"}]}]},{"description":"Rare ds whl gen seq bld/slv","code_information":[{"code":"0336U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1930.99,"maximum":4969.07,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2574.65,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3812.41},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3218.31},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3218.31},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3218.31},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4969.07,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1930.99,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":4505.64},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2574.65},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2626.14,"additional_payer_notes":"APC"}]}]},{"description":"Hep nafld semiq evl 28 lipid","code_information":[{"code":"0344U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":594.13,"maximum":1528.89,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":792.17,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1186.34},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":990.21},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":990.21},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":990.21},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1528.89,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":594.13,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1386.3},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":792.17},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":808.01,"additional_payer_notes":"APC"}]}]},{"description":"Onc orop 17 dna ddpcr alg","code_information":[{"code":"0356U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1350.0,"maximum":3474.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1800.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2592.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2250.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2250.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2250.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3474.0,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1350.0,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3150.0},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1800.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1836.0,"additional_payer_notes":"APC"}]}]},{"description":"Onc bldr 10 prb bldr ca","code_information":[{"code":"0365U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":672.75,"maximum":1731.21,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":897.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1343.35},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1121.25},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1121.25},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1121.25},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1731.21,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":672.75,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1569.75},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":897.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":914.94,"additional_payer_notes":"APC"}]}]},{"description":"Iadna rsp tr nfct 17 8 13&16","code_information":[{"code":"0373U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":416.78,"maximum":729.37,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":624.18},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":520.98},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":520.98},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":520.98},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":729.37},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":416.78}]}]},{"description":"Cns dna amp probe type 12-25","code_information":[{"code":"87483","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":312.58,"maximum":849.28,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":416.78,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":849.28},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":520.98},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":520.98},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":520.98},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":804.39,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":312.58,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":729.37},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":416.78},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":425.12,"additional_payer_notes":"APC"}]}]},{"description":"C diff amplified probe","code_information":[{"code":"87493","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":27.95,"maximum":71.93,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":37.27,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":71.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":46.59},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":46.59},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":46.59},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":71.93,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27.95,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":65.22},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37.27},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":38.02,"additional_payer_notes":"APC"}]}]},{"description":"Influenza dna amp prob addl","code_information":[{"code":"87503","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":21.92,"maximum":56.39,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":29.22,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":42.02},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":36.53},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":36.53},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":36.53},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":56.39,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21.92,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":51.14},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29.22},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":29.8,"additional_payer_notes":"APC"}]}]},{"description":"Hepatitis b dna amp probe","code_information":[{"code":"87516","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":26.32,"maximum":71.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":35.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":71.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43.86},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43.86},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43.86},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":67.72,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26.32,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":61.41},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35.09},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":35.79,"additional_payer_notes":"APC"}]}]},{"description":"Hepatitis g dna quant","code_information":[{"code":"87527","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":31.32,"maximum":84.49,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":41.76,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":84.49},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":52.2},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":52.2},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":52.2},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":80.6,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":31.32,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":73.08},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":41.76},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":42.6,"additional_payer_notes":"APC"}]}]},{"description":"Hiv-1 probe&reverse trnscrpj","code_information":[{"code":"87535","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":26.32,"maximum":71.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":35.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":71.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43.86},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43.86},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43.86},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":67.72,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26.32,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":61.41},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35.09},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":35.79,"additional_payer_notes":"APC"}]}]},{"description":"Mycobacteria dna dir probe","code_information":[{"code":"87550","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":15.04,"maximum":40.58,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20.05,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":40.58},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25.06},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25.06},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25.06},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":38.7,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15.04,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35.09},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20.05},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20.45,"additional_payer_notes":"APC"}]}]},{"description":"M.avium-intra dna quant","code_information":[{"code":"87562","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":32.13,"maximum":86.68,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":42.84,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":86.68},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":53.55},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":53.55},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":53.55},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":82.68,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":32.13,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":74.97},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":42.84},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":43.7,"additional_payer_notes":"APC"}]}]},{"description":"N.gonorrhoeae dna quant","code_information":[{"code":"87592","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":32.13,"maximum":86.68,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":42.84,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":86.68},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":53.55},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":53.55},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":53.55},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":82.68,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":32.13,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":74.97},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":42.84},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":43.7,"additional_payer_notes":"APC"}]}]},{"description":"Resp virus 6-11 targets","code_information":[{"code":"87632","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":163.54,"maximum":431.88,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":218.06,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":431.88},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":272.58},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":272.58},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":272.58},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":420.86,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":163.54,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":381.61},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":218.06},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":222.42,"additional_payer_notes":"APC"}]}]},{"description":"Strep a dna dir probe","code_information":[{"code":"87650","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":15.04,"maximum":40.58,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20.05,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":40.58},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25.06},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25.06},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25.06},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":38.7,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15.04,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35.09},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20.05},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20.45,"additional_payer_notes":"APC"}]}]},{"description":"Detect agent nos dna amp","code_information":[{"code":"87798","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":26.32,"maximum":71.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":35.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":71.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43.86},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43.86},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43.86},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":67.72,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26.32,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":61.41},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35.09},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":35.79,"additional_payer_notes":"APC"}]}]},{"description":"Rsv assay w/optic","code_information":[{"code":"87807","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":9.82,"maximum":25.28,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.1,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":24.26},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16.38},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16.38},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16.38},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":25.28,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9.82,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22.93},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13.1},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.36,"additional_payer_notes":"APC"}]}]},{"description":"Phenotype infect agent drug","code_information":[{"code":"87900","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":97.76,"maximum":263.75,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":130.35,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":263.75},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":162.94},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":162.94},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":162.94},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":251.58,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":97.76,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":228.11},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":130.35},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":132.96,"additional_payer_notes":"APC"}]}]},{"description":"Genotype dna hepatitis b","code_information":[{"code":"87912","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":193.09,"maximum":520.94,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":257.45,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":520.94},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":321.81},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":321.81},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":321.81},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":496.88,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":193.09,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":450.54},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":257.45},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":262.6,"additional_payer_notes":"APC"}]}]},{"description":"Cytopath c/v manual","code_information":[{"code":"88150","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":13.9,"maximum":35.78,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18.54,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":21.4},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22.74},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22.74},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22.74},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":35.78,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.9,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31.83},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15.12},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18.91,"additional_payer_notes":"APC"}]}]},{"description":"Cytopath c/v auto in fluid","code_information":[{"code":"88174","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":19.03,"maximum":48.96,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":43.24},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":31.71},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":31.71},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":31.71},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":48.96,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19.03,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":44.4},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25.37},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25.88,"additional_payer_notes":"APC"}]}]},{"description":"Frozen cell preparation","code_information":[{"code":"88241","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":9.07,"maximum":23.33,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":14.14},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15.11},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15.11},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15.11},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":23.33,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9.07,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21.16},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12.09},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.33,"additional_payer_notes":"APC"}]}]},{"description":"Chromosome analys placenta","code_information":[{"code":"88267","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":141.43,"maximum":363.94,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":188.57,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":363.78},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":235.71},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":235.71},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":235.71},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":363.94,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":141.43,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":330.0},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":188.57},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":192.34,"additional_payer_notes":"APC"}]}]},{"description":"Chromosome banding study","code_information":[{"code":"88283","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":51.45,"maximum":138.83,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":68.6,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":138.83},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":85.75},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":85.75},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":85.75},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":132.4,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":51.45,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":120.05},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":68.6},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":69.97,"additional_payer_notes":"APC"}]}]},{"description":"Transcutaneous methb","code_information":[{"code":"88741","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7.03,"maximum":18.08,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":10.15},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11.71},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11.71},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11.71},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":18.08,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7.03,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16.4},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9.37},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9.56,"additional_payer_notes":"APC"}]}]},{"description":"Semen analysis w/huhner","code_information":[{"code":"89300","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7.38,"maximum":18.99,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9.84,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":18.07},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12.3},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12.3},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12.3},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":18.99,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7.38,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17.22},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9.84},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10.04,"additional_payer_notes":"APC"}]}]},{"description":"Retrograde ejaculation anal","code_information":[{"code":"89331","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":14.69,"maximum":37.81,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19.59,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":36.92},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24.49},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24.49},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24.49},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":37.81,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14.69,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34.28},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19.59},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19.98,"additional_payer_notes":"APC"}]}]},{"description":"Scr c/v cyto, autosys, rescr","code_information":[{"code":"G0148","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":21.4,"maximum":61.64,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":31.94,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":21.4},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":39.93},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":39.93},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":39.93},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":61.64,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23.96,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":55.9},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31.94},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":32.58,"additional_payer_notes":"APC"}]}]},{"description":"Ven blood coll snf/hha","code_information":[{"code":"G0471","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7.43,"maximum":21.89,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11.34,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7.43},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13.86},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13.86},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13.86},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":21.89,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8.5,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19.41},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11.57,"additional_payer_notes":"APC"}]}]},{"description":"Hepb screen high risk indiv","code_information":[{"code":"G0499","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":21.2,"maximum":54.56,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":28.27,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":51.85},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":35.34},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":35.34},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":35.34},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":54.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21.2,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":49.47},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28.27},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":28.84,"additional_payer_notes":"APC"}]}]},{"description":"Screen pap by tech w md supv","code_information":[{"code":"P3000","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":13.9,"maximum":35.78,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18.54,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":21.4},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22.74},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22.74},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22.74},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":35.78,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.9,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31.83},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15.12},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18.91,"additional_payer_notes":"APC"}]}]},{"description":"2019 nCoV diagnostic P","code_information":[{"code":"U0001","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":26.94,"maximum":69.33,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":35.92,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":53.36},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":44.9},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":44.9},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":44.9},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":69.33,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26.94,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":62.86},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35.92},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":36.64,"additional_payer_notes":"APC"}]}]},{"description":"Extracorp shockwv tx anesth","code_information":[{"code":"0102T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Njx paravert w/us cer/thor","code_information":[{"code":"0213T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":656.13,"maximum":3030.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":874.84,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1688.44,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":656.13,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":892.34,"additional_payer_notes":"APC"}]}]},{"description":"Plmt post facet implt lumb","code_information":[{"code":"0221T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":13851.98,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Im b1 mrw cel ther cmpl","code_information":[{"code":"0263T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3231.05,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4308.07,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":8314.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3231.05,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4394.23,"additional_payer_notes":"APC"}]}]},{"description":"Rev/remvl crtd sns dev gen","code_information":[{"code":"0271T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8657.0,"maximum":8770.0,"payers_information":[{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0}]}]},{"description":"Thxp apheresis w/hdl delip","code_information":[{"code":"0342T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3231.05,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4308.07,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":8314.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3231.05,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4394.23,"additional_payer_notes":"APC"}]}]},{"description":"Insj/rplc car modulj atr elt","code_information":[{"code":"0410T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6138.95,"maximum":27583.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8185.27,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":15797.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6138.95,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":27583.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8348.97,"additional_payer_notes":"APC"}]}]},{"description":"Revise vag graft open abd","code_information":[{"code":"57296","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Repair bladder-vagina lesion","code_information":[{"code":"57330","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5501.01,"maximum":14155.93,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7334.68,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":14155.93,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5501.01,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7481.37,"additional_payer_notes":"APC"}]}]},{"description":"Laparoscopy surg colpopexy","code_information":[{"code":"57425","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":20292.15,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10514.07,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":20292.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7885.55,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10724.35,"additional_payer_notes":"APC"}]}]},{"description":"Biopsy of cervix","code_information":[{"code":"57500","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":683.26,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":911.02,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1758.27,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":683.26,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":929.24,"additional_payer_notes":"APC"}]}]},{"description":"Removal of cervix radical","code_information":[{"code":"57531","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Revision of cervix","code_information":[{"code":"57720","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2401.4,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3201.87,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6179.61,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2401.4,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3265.91,"additional_payer_notes":"APC"}]}]},{"description":"Total hysterectomy","code_information":[{"code":"58150","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5257.0,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5257.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0}]}]},{"description":"Vag hyst w/t/o & vag repair","code_information":[{"code":"58263","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3710.98,"maximum":9549.58,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4947.97,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":9549.58,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3710.98,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5046.93,"additional_payer_notes":"APC"}]}]},{"description":"Vag hyst t/o & repair compl","code_information":[{"code":"58292","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5501.01,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7334.68,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":14155.93,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5501.01,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7481.37,"additional_payer_notes":"APC"}]}]},{"description":"Reopen fallopian tube","code_information":[{"code":"58345","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2401.4,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3201.87,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6179.61,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2401.4,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3265.91,"additional_payer_notes":"APC"}]}]},{"description":"Revision of uterus","code_information":[{"code":"58540","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Laparo-asst vag hysterectomy","code_information":[{"code":"58550","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4484.77,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5979.69,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5257.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11540.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4484.77,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6099.28,"additional_payer_notes":"APC"}]}]},{"description":"Hysteroscopy remove myoma","code_information":[{"code":"58561","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3710.98,"maximum":9549.58,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4947.97,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":9549.58,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3710.98,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5046.93,"additional_payer_notes":"APC"}]}]},{"description":"Laparo proc uterus","code_information":[{"code":"58578","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4484.77,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5979.69,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5257.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11540.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4484.77,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6099.28,"additional_payer_notes":"APC"}]}]},{"description":"Laparoscopy excise lesions","code_information":[{"code":"58662","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4484.77,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5979.69,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5257.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11540.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4484.77,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6099.28,"additional_payer_notes":"APC"}]}]},{"description":"Adhesiolysis tube ovary","code_information":[{"code":"58740","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0}]}]},{"description":"Drain ovary abscess percut","code_information":[{"code":"58822","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0}]}]},{"description":"Resect ovarian malignancy","code_information":[{"code":"58951","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Transfer of embryo","code_information":[{"code":"58974","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":683.26,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":911.02,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1758.27,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":683.26,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":929.24,"additional_payer_notes":"APC"}]}]},{"description":"Fetal non-stress test","code_information":[{"code":"59025","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":149.98,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":199.97,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":385.94,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":149.98,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":203.97,"additional_payer_notes":"APC"}]}]},{"description":"Remove uterus lesion","code_information":[{"code":"59100","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3388.0,"maximum":9549.58,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4947.97,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":9549.58,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3710.98,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5046.93,"additional_payer_notes":"APC"}]}]},{"description":"D & c after delivery","code_information":[{"code":"59160","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2401.4,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3201.87,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6179.61,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2401.4,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3265.91,"additional_payer_notes":"APC"}]}]},{"description":"Obstetrical care","code_information":[{"code":"59410","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Cesarean delivery","code_information":[{"code":"59515","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Treatment of miscarriage","code_information":[{"code":"59812","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2401.4,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3201.87,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6179.61,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2401.4,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3265.91,"additional_payer_notes":"APC"}]}]},{"description":"Abortion","code_information":[{"code":"59852","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3388.0,"maximum":4106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0}]}]},{"description":"Laparo proc ob care/deliver","code_information":[{"code":"59898","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4484.77,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5979.69,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5257.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11540.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4484.77,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6099.28,"additional_payer_notes":"APC"}]}]},{"description":"Partial removal of thyroid","code_information":[{"code":"60225","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4484.77,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5979.69,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5257.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11540.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4484.77,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6099.28,"additional_payer_notes":"APC"}]}]},{"description":"Remove thyroid duct lesion","code_information":[{"code":"60281","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4484.77,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5979.69,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5257.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11540.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4484.77,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6099.28,"additional_payer_notes":"APC"}]}]},{"description":"Removal of thymus gland","code_information":[{"code":"60522","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Remove cranial cavity fluid","code_information":[{"code":"61000","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":523.65,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":698.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1347.51,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":523.65,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":712.16,"additional_payer_notes":"APC"}]}]},{"description":"Drill skull for implantation","code_information":[{"code":"61107","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3388.0,"maximum":4106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0}]}]},{"description":"Pierce skull implant device","code_information":[{"code":"61210","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3388.0,"maximum":4106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0}]}]},{"description":"Open skull for drainage","code_information":[{"code":"61314","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6779.0,"maximum":8333.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0}]}]},{"description":"Explore orbit/remove lesion","code_information":[{"code":"61333","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Remove infected skull bone","code_information":[{"code":"61501","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6779.0,"maximum":8333.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0}]}]},{"description":"Hyprphenylalninmia mntr quan","code_information":[{"code":"0382U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":38.73,"maximum":99.67,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":51.64,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":74.36},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":64.55},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":64.55},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":64.55},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":99.67,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":38.73,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":90.37},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":51.64},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":52.67,"additional_payer_notes":"APC"}]}]},{"description":"Onc sld tum dna&rna 437 gen","code_information":[{"code":"0391U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2700.0,"maximum":6948.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3600.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5391.36},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4500.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4500.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4500.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6948.0,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2700.0,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6300.0},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3600.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3672.0,"additional_payer_notes":"APC"}]}]},{"description":"Crd c hrt ds 9 gen 12 vrnts","code_information":[{"code":"0401U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":367.26,"maximum":945.08,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":489.68,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":705.14},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":612.1},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":612.1},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":612.1},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":945.08,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":367.26,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":856.94},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":489.68},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":499.47,"additional_payer_notes":"APC"}]}]},{"description":"Onc sld tum dna 80 & rna 36","code_information":[{"code":"0409U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2189.7,"maximum":5634.83,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2919.6,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4372.39},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3649.5},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3649.5},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3649.5},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5634.83,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2189.7,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5109.3},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2919.6},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2977.99,"additional_payer_notes":"APC"}]}]},{"description":"Onc brst aug alg aly whl sl8","code_information":[{"code":"0418U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":529.69,"maximum":1363.06,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":706.25,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1057.68},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":882.81},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":882.81},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":882.81},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1363.06,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":529.69,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1235.94},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":706.25},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":720.38,"additional_payer_notes":"APC"}]}]},{"description":"Onc chemo rx cytox csc 14 rx","code_information":[{"code":"0435U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2275.4,"maximum":5855.35,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3033.86,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4368.76},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3792.33},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3792.33},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3792.33},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5855.35,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2275.4,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5309.26},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3033.86},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3094.54,"additional_payer_notes":"APC"}]}]},{"description":"Onc bldr mthyl penk lte-qmsp","code_information":[{"code":"0452U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":144.0,"maximum":370.56,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":192.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":276.48},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":240.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":240.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":240.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":370.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":144.0,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":336.0},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":192.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":195.84,"additional_payer_notes":"APC"}]}]},{"description":"Rare ds whl gen seq ftl samp","code_information":[{"code":"0469U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":898.46,"maximum":2312.02,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1197.94,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1725.04},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1497.43},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1497.43},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1497.43},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2312.02,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":898.46,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2096.4},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1197.94},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1221.9,"additional_payer_notes":"APC"}]}]},{"description":"Rx metab psy 14&cyp2d6 gn-rx","code_information":[{"code":"0477U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":312.58,"maximum":804.39,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":416.78,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":600.17},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":520.98},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":520.98},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":520.98},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":804.39,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":312.58,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":729.37},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":416.78},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":425.12,"additional_payer_notes":"APC"}]}]},{"description":"Trnspl med quan dd-cfdna ngs","code_information":[{"code":"0493U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2064.94,"maximum":5313.77,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2753.25,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3964.68},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3441.56},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3441.56},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3441.56},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5313.77,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2064.94,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":4818.19},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2753.25},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2808.32,"additional_payer_notes":"APC"}]}]},{"description":"Ther rx mntr 80+ psyactiv rx","code_information":[{"code":"0517U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":185.19,"maximum":476.56,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":246.92,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":355.56},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":308.65},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":308.65},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":308.65},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":476.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":185.19,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":432.11},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":246.92},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":251.86,"additional_payer_notes":"APC"}]}]},{"description":"Obstetric panel","code_information":[{"code":"80081","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":56.14,"maximum":151.46,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":74.86,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":151.46},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":93.58},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":93.58},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":93.58},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":144.48,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":56.14,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":131.01},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":74.86},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":76.36,"additional_payer_notes":"APC"}]}]},{"description":"Drug assay cyclosporine","code_information":[{"code":"80158","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":13.54,"maximum":36.52,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18.05,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":36.52},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22.56},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22.56},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22.56},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":34.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.54,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31.59},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18.05},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18.41,"additional_payer_notes":"APC"}]}]},{"description":"Assay of ethosuximide","code_information":[{"code":"80168","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":12.26,"maximum":33.06,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16.34,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":33.06},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20.43},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20.43},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20.43},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":31.54,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.26,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28.6},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16.34},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16.67,"additional_payer_notes":"APC"}]}]},{"description":"Assay of lithium","code_information":[{"code":"80178","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4.96,"maximum":13.38,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6.61,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":13.38},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8.26},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8.26},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8.26},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":12.76,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4.96,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11.57},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6.61},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6.74,"additional_payer_notes":"APC"}]}]},{"description":"Drug assay posaconazole","code_information":[{"code":"80187","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":20.33,"maximum":52.32,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27.11,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":40.27},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":33.89},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":33.89},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":33.89},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":52.32,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20.33,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":47.44},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27.11},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27.65,"additional_payer_notes":"APC"}]}]},{"description":"Assay of tacrolimus","code_information":[{"code":"80197","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":10.3,"maximum":27.79,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.73,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":27.79},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17.16},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17.16},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17.16},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":26.5,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10.3,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24.03},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13.73},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14.0,"additional_payer_notes":"APC"}]}]},{"description":"Drug assay rufinamide","code_information":[{"code":"80210","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":20.33,"maximum":52.32,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27.11,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":40.27},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":33.89},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":33.89},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":33.89},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":52.32,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20.33,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":47.44},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27.11},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27.65,"additional_payer_notes":"APC"}]}]},{"description":"Drug test prsmv instrmnt","code_information":[{"code":"80306","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":12.86,"maximum":33.08,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17.14,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":29.64},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21.43},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21.43},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21.43},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":33.08,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.86,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30.0},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17.14},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17.48,"additional_payer_notes":"APC"}]}]},{"description":"Testosterone response","code_information":[{"code":"80414","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":38.73,"maximum":102.01,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":51.64,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":102.01},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":64.55},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":64.55},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":64.55},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":99.67,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":38.73,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":90.37},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":51.64},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":52.67,"additional_payer_notes":"APC"}]}]},{"description":"Gonadotropin hormone panel","code_information":[{"code":"80426","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":111.31,"maximum":300.31,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":148.41,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":300.31},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":185.51},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":185.51},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":185.51},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":286.43,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":111.31,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":259.72},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":148.41},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":151.38,"additional_payer_notes":"APC"}]}]},{"description":"TRH stimulation panel","code_information":[{"code":"80439","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":50.41,"maximum":136.01,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":67.21,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":136.01},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":84.01},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":84.01},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":84.01},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":129.72,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":50.41,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":117.62},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":67.21},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":68.55,"additional_payer_notes":"APC"}]}]},{"description":"Construct vagina with graft","code_information":[{"code":"57292","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3710.98,"maximum":9549.58,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4947.97,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":9549.58,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3710.98,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5046.93,"additional_payer_notes":"APC"}]}]},{"description":"Repair urethrovaginal lesion","code_information":[{"code":"57311","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0}]}]},{"description":"Exam/biopsy of vag w/scope","code_information":[{"code":"57421","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":683.26,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":911.02,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1758.27,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":683.26,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":929.24,"additional_payer_notes":"APC"}]}]},{"description":"Bx of cervix w/scope leep","code_information":[{"code":"57460","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2401.4,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3201.87,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6179.61,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2401.4,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3265.91,"additional_payer_notes":"APC"}]}]},{"description":"Conization of cervix","code_information":[{"code":"57522","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2401.4,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3201.87,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6179.61,"additional_payer_notes":"APC"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3396.0},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2401.4,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3265.91,"additional_payer_notes":"APC"}]}]},{"description":"D&C oF Cervical Stump","code_information":[{"code":"57558","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2401.4,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3201.87,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6179.61,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2401.4,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3265.91,"additional_payer_notes":"APC"}]}]},{"description":"Myomectomy vag method","code_information":[{"code":"58145","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2401.4,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3201.87,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6179.61,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2401.4,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3265.91,"additional_payer_notes":"APC"}]}]},{"description":"Vaginal hysterectomy","code_information":[{"code":"58260","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3710.98,"maximum":9549.58,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4947.97,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":9549.58,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3710.98,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5046.93,"additional_payer_notes":"APC"}]}]},{"description":"Vag hyst complex","code_information":[{"code":"58290","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5501.01,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7334.68,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":14155.93,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5501.01,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7481.37,"additional_payer_notes":"APC"}]}]},{"description":"Sperm washing","code_information":[{"code":"58323","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":149.98,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":199.97,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":385.94,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":149.98,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":203.97,"additional_payer_notes":"APC"}]}]},{"description":"Suspension of uterus","code_information":[{"code":"58410","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Laparo-myomectomy complex","code_information":[{"code":"58546","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":20292.15,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10514.07,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":20292.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7885.55,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10724.35,"additional_payer_notes":"APC"}]}]},{"description":"Hysteroscopy lysis","code_information":[{"code":"58559","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3710.98,"maximum":9549.58,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4947.97,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":9549.58,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3710.98,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5046.93,"additional_payer_notes":"APC"}]}]},{"description":"Tlh uterus over 250 g","code_information":[{"code":"58572","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":20292.15,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10514.07,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":20292.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7885.55,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10724.35,"additional_payer_notes":"APC"}]}]},{"description":"Laparoscopy lysis","code_information":[{"code":"58660","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4484.77,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5979.69,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5257.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11540.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4484.77,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6099.28,"additional_payer_notes":"APC"}]}]},{"description":"Removal of fallopian tube","code_information":[{"code":"58700","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0}]}]},{"description":"Drainage of ovarian cyst(s)","code_information":[{"code":"58805","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2401.4,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3201.87,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6179.61,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2401.4,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3265.91,"additional_payer_notes":"APC"}]}]},{"description":"Removal of ovary(s)","code_information":[{"code":"58943","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0}]}]},{"description":"Exploration of abdomen","code_information":[{"code":"58960","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0}]}]},{"description":"Chorion biopsy","code_information":[{"code":"59015","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":683.26,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":911.02,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1758.27,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":683.26,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":929.24,"additional_payer_notes":"APC"}]}]},{"description":"Fetal fluid drainage w/us","code_information":[{"code":"59074","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":226.06,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":301.41,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":581.72,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":226.06,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":307.44,"additional_payer_notes":"APC"}]}]},{"description":"Treat ectopic pregnancy","code_information":[{"code":"59150","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4484.77,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5979.69,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5257.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11540.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4484.77,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6099.28,"additional_payer_notes":"APC"}]}]},{"description":"Obstetrical care","code_information":[{"code":"59400","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Cesarean delivery","code_information":[{"code":"59510","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Attempted vbac delivery only","code_information":[{"code":"59620","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3388.0,"maximum":4106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0}]}]},{"description":"Abortion","code_information":[{"code":"59850","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3388.0,"maximum":4106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0}]}]},{"description":"Remove cerclage suture","code_information":[{"code":"59871","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2401.4,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3201.87,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6179.61,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2401.4,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3265.91,"additional_payer_notes":"APC"}]}]},{"description":"Partial thyroid excision","code_information":[{"code":"60212","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4484.77,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5979.69,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5257.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11540.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4484.77,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6099.28,"additional_payer_notes":"APC"}]}]},{"description":"Removal of thyroid","code_information":[{"code":"60271","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Removal of thymus gland","code_information":[{"code":"60520","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Laparo proc endocrine","code_information":[{"code":"60659","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4484.77,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5979.69,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5257.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11540.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4484.77,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6099.28,"additional_payer_notes":"APC"}]}]},{"description":"Brain canal shunt procedure","code_information":[{"code":"61070","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":523.65,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":698.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1347.51,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":523.65,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":712.16,"additional_payer_notes":"APC"}]}]},{"description":"Pierce skull & remove clot","code_information":[{"code":"61154","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Open skull for drainage","code_information":[{"code":"61312","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6779.0,"maximum":8333.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0}]}]},{"description":"Decompressive lobectomy","code_information":[{"code":"61323","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6779.0,"maximum":8333.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0}]}]},{"description":"Incise skull for surgery","code_information":[{"code":"61460","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6779.0,"maximum":8333.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0}]}]},{"description":"Tpmt gene com variants","code_information":[{"code":"81335","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":131.11,"maximum":337.38,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":174.81,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":259.67},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":218.51},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":218.51},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":218.51},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":337.38,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":131.11,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":305.92},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":174.81},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":178.31,"additional_payer_notes":"APC"}]}]},{"description":"Ppp2r2b gen detc abnor allel","code_information":[{"code":"81343","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":102.75,"maximum":264.41,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":137.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":203.51},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":171.25},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":171.25},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":171.25},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":264.41,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":102.75,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":239.75},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":137.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":139.74,"additional_payer_notes":"APC"}]}]},{"description":"Tp53 gene full gene sequence","code_information":[{"code":"81351","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":481.39,"maximum":1238.77,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":641.85,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":953.45},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":802.31},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":802.31},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":802.31},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1238.77,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":481.39,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1123.24},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":641.85},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":654.69,"additional_payer_notes":"APC"}]}]},{"description":"Hbb gene dup/del variants","code_information":[{"code":"81363","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":151.8,"maximum":390.63,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":202.4,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":300.67},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":253.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":253.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":253.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":390.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":151.8,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":354.2},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":202.4},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":206.45,"additional_payer_notes":"APC"}]}]},{"description":"Hla ii typing 1 locus lr","code_information":[{"code":"81376","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":91.66,"maximum":247.32,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":122.22,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":247.32},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":152.78},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":152.78},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":152.78},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":235.88,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":91.66,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":213.89},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":122.22},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":124.66,"additional_payer_notes":"APC"}]}]},{"description":"Mopath procedure level 1","code_information":[{"code":"81400","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":47.97,"maximum":123.44,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":63.96,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":95.03},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":79.95},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":79.95},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":79.95},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":123.44,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":47.97,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":111.93},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":63.96},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":65.24,"additional_payer_notes":"APC"}]}]},{"description":"Mopath procedure level 9","code_information":[{"code":"81408","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1500.0,"maximum":3860.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2000.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2970.94},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2500.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2500.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2500.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3860.0,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1500.0,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3500.0},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2000.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2040.0,"additional_payer_notes":"APC"}]}]},{"description":"Exome re-evaluation","code_information":[{"code":"81417","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":240.0,"maximum":617.6,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":320.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":475.36},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":400.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":400.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":400.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":617.6,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":240.0,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":560.0},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":320.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":326.4,"additional_payer_notes":"APC"}]}]},{"description":"Hearing loss sequence analys","code_information":[{"code":"81430","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1218.75,"maximum":3136.25,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1625.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2413.9},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2031.25},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2031.25},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2031.25},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3136.25,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1218.75,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2843.75},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1625.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1657.5,"additional_payer_notes":"APC"}]}]},{"description":"Heredtry nurondcrn tum dsrdr","code_information":[{"code":"81438","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":548.66,"maximum":894.41,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":894.41},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":548.66},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":548.66},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":548.66},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":768.13}]}]},{"description":"Tgsap so neo 5-50 rna alys","code_information":[{"code":"81449","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":448.43,"maximum":1153.97,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":597.91,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":885.36},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":747.39},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":747.39},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":747.39},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1153.97,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":448.43,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1046.34},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":597.91},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":609.87,"additional_payer_notes":"APC"}]}]},{"description":"Whole mitochondrial genome","code_information":[{"code":"81460","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":965.25,"maximum":2483.91,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1287.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1911.8},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1608.75},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1608.75},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1608.75},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2483.91,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":965.25,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2252.25},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1287.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1312.74,"additional_payer_notes":"APC"}]}]},{"description":"Cor artery disease mrna","code_information":[{"code":"81493","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":787.5,"maximum":2026.5,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1050.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1548.37},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1312.5},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1312.5},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1312.5},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2026.5,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":787.5,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1837.5},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1050.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1071.0,"additional_payer_notes":"APC"}]}]},{"description":"Ftl cgen abnor three anal","code_information":[{"code":"81510","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":41.66,"maximum":107.19,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":55.54,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":82.5},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":69.43},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":69.43},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":69.43},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":107.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":41.66,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":97.2},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":55.54},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":56.65,"additional_payer_notes":"APC"}]}]},{"description":"Oncology breast mrna","code_information":[{"code":"81519","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2904.75,"maximum":7474.89,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3873.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5079.44},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4841.25},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4841.25},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4841.25},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7474.89,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2904.75,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6777.75},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3873.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3950.46,"additional_payer_notes":"APC"}]}]},{"description":"Oncology gynecologic","code_information":[{"code":"81535","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":434.6,"maximum":1118.36,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":579.46,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":523.03},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":724.33},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":724.33},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":724.33},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1118.36,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":434.6,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1014.06},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":579.46},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":591.05,"additional_payer_notes":"APC"}]}]},{"description":"Onc prostate 3 genes","code_information":[{"code":"81551","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1522.5,"maximum":3917.9,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2030.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3015.5},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2537.5},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2537.5},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2537.5},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3917.9,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1522.5,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3552.5},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2070.6,"additional_payer_notes":"APC"}]}]},{"description":"Acetone assay","code_information":[{"code":"82010","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6.13,"maximum":16.54,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8.17,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":16.54},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10.21},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10.21},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10.21},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":15.77,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6.13,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14.3},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8.17},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8.33,"additional_payer_notes":"APC"}]}]},{"description":"Microalbumin quantitative","code_information":[{"code":"82043","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4.34,"maximum":11.69,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5.78,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":11.69},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7.23},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7.23},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7.23},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11.16,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4.34,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10.12},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5.78},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5.9,"additional_payer_notes":"APC"}]}]},{"description":"Removal of brain lesion","code_information":[{"code":"61518","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6779.0,"maximum":8333.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0}]}]},{"description":"Implant brain electrodes","code_information":[{"code":"61531","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3579.0,"maximum":8333.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0}]}]},{"description":"Removal of brain tissue","code_information":[{"code":"61540","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6779.0,"maximum":8333.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0}]}]},{"description":"Release of skull seams","code_information":[{"code":"61552","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6779.0,"maximum":8333.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0}]}]},{"description":"Incision of brain tissue","code_information":[{"code":"61567","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6779.0,"maximum":8333.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0}]}]},{"description":"Craniofacial approach skull","code_information":[{"code":"61583","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6779.0,"maximum":8333.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0}]}]},{"description":"Transcochlear approach/skull","code_information":[{"code":"61596","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6779.0,"maximum":8333.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0}]}]},{"description":"Resect/excise cranial lesion","code_information":[{"code":"61608","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6779.0,"maximum":8333.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0}]}]},{"description":"Transcath occlusion cns","code_information":[{"code":"61624","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6779.0,"maximum":34994.75,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18131.99,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":34994.75,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13599.0,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":27583.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18494.63,"additional_payer_notes":"APC"}]}]},{"description":"Evasc prlng admn rx agnt 1st","code_information":[{"code":"61650","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6019.0,"maximum":7398.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":7398.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6019.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":7398.0}]}]},{"description":"Brain aneurysm repr complx","code_information":[{"code":"61697","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6779.0,"maximum":8333.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0}]}]},{"description":"Fusion of skull arteries","code_information":[{"code":"61711","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6779.0,"maximum":8333.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0}]}]},{"description":"Scan proc cranial extra","code_information":[{"code":"61782","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Apply srs headframe add-on","code_information":[{"code":"61800","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Insrt/redo neurostim 1 array","code_information":[{"code":"61885","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8923.0,"maximum":58906.76,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":30521.64,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":10765.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":8923.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":10765.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":44873.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":44873.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":44873.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":58906.76,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22891.23,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":43285.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":31132.07,"additional_payer_notes":"APC"}]}]},{"description":"Reduction of skull defect","code_information":[{"code":"62117","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6779.0,"maximum":8333.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0}]}]},{"description":"Repair of skull with graft","code_information":[{"code":"62146","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6779.0,"maximum":8333.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0}]}]},{"description":"Establish brain cavity shunt","code_information":[{"code":"62180","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6779.0,"maximum":8333.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0}]}]},{"description":"Replace/irrigate catheter","code_information":[{"code":"62225","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2534.21,"maximum":6521.36,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3378.94,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6521.36,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2534.21,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3446.52,"additional_payer_notes":"APC"}]}]},{"description":"Drain spinal cord cyst","code_information":[{"code":"62268","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":656.13,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":874.84,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1688.44,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":656.13,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":892.34,"additional_payer_notes":"APC"}]}]},{"description":"Injection for myelogram","code_information":[{"code":"62284","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Myelography lumbar injection","code_information":[{"code":"62304","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":581.54,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":775.38,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1496.49,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":581.54,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":790.89,"additional_payer_notes":"APC"}]}]},{"description":"Remove spine infusion device","code_information":[{"code":"62365","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2534.21,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3378.94,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6521.36,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2534.21,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3446.52,"additional_payer_notes":"APC"}]}]},{"description":"Remove spine lamina 1/2 scrl","code_information":[{"code":"63011","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Laminotomy single cervical","code_information":[{"code":"63040","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Cervical laminoplsty 2/> seg","code_information":[{"code":"63050","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6779.0,"maximum":8333.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0}]}]},{"description":"Neck spine disk surgery","code_information":[{"code":"63076","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Remove vertebral body add-on","code_information":[{"code":"63088","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3388.0,"maximum":4106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0}]}]},{"description":"Drainage of spinal cyst","code_information":[{"code":"63173","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6779.0,"maximum":8333.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0}]}]},{"description":"Revise spine cord vsl thrlmb","code_information":[{"code":"63252","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6779.0,"maximum":27583.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":27583.0}]}]},{"description":"Excise intrspinl lesion scrl","code_information":[{"code":"63273","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6779.0,"maximum":8333.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0}]}]},{"description":"Bx/exc idrl spine lesn scrl","code_information":[{"code":"63283","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6779.0,"maximum":8333.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0}]}]},{"description":"Remove vert xdrl body thrlmb","code_information":[{"code":"63302","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6779.0,"maximum":8333.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0}]}]},{"description":"Stimulation of spinal cord","code_information":[{"code":"63610","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1448.59,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1931.46,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3727.72,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1448.59,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1970.09,"additional_payer_notes":"APC"}]}]},{"description":"Revise spine eltrd plate","code_information":[{"code":"63664","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8266.01,"maximum":21271.19,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11021.34,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":10765.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":8923.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":10765.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":21271.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8266.01,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11241.77,"additional_payer_notes":"APC"}]}]},{"description":"Repair spinal fluid leakage","code_information":[{"code":"63709","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Alpha-1-antitrypsin pheno","code_information":[{"code":"82104","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":10.84,"maximum":29.27,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14.46,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":29.27},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18.08},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18.08},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18.08},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":27.91,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10.84,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25.31},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14.46},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14.75,"additional_payer_notes":"APC"}]}]},{"description":"Amino acids single quant","code_information":[{"code":"82131","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":17.24,"maximum":44.35,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22.98,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":34.13},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28.73},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28.73},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28.73},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":44.35,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17.24,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":40.22},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22.98},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23.44,"additional_payer_notes":"APC"}]}]},{"description":"Assay of androstenedione","code_information":[{"code":"82157","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":21.96,"maximum":59.24,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":29.28,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":59.24},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":36.6},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":36.6},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":36.6},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":56.51,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21.96,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":51.24},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29.28},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":29.87,"additional_payer_notes":"APC"}]}]},{"description":"Atomic absorption","code_information":[{"code":"82190","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":11.92,"maximum":30.69,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15.9,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":24.73},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19.88},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19.88},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19.88},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":30.69,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11.92,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27.83},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15.9},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16.22,"additional_payer_notes":"APC"}]}]},{"description":"Fecal bilirubin test","code_information":[{"code":"82252","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3.42,"maximum":9.22,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4.56,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":9.22},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5.7},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5.7},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5.7},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":8.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3.42,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7.98},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":4.56},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4.65,"additional_payer_notes":"APC"}]}]},{"description":"Vitamin d 25 hydroxy","code_information":[{"code":"82306","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":22.2,"maximum":59.9,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":29.6,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":59.9},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":37.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":37.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":37.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":57.13,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22.2,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":51.8},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29.6},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":30.19,"additional_payer_notes":"APC"}]}]},{"description":"Calculus spectroscopy","code_information":[{"code":"82365","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":9.68,"maximum":26.09,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.9,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":26.09},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16.13},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16.13},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16.13},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":24.9,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9.68,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22.58},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12.9},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.16,"additional_payer_notes":"APC"}]}]},{"description":"Assay of carotene","code_information":[{"code":"82380","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6.92,"maximum":18.67,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9.22,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":18.67},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11.53},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11.53},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11.53},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":17.79,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6.92,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16.14},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9.22},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9.4,"additional_payer_notes":"APC"}]}]},{"description":"Assay of blood chloride","code_information":[{"code":"82435","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3.45,"maximum":9.31,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4.6,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":9.31},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5.75},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5.75},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5.75},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":8.88,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3.45,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8.05},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":4.6},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4.69,"additional_payer_notes":"APC"}]}]},{"description":"Assay of chromium","code_information":[{"code":"82495","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":14.72,"maximum":39.14,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20.28,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":14.72},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25.35},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25.35},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25.35},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":39.14,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15.21,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35.49},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20.28},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20.69,"additional_payer_notes":"APC"}]}]},{"description":"Col chromotography qual/quan","code_information":[{"code":"82542","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":18.07,"maximum":46.49,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":24.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":36.53},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":30.11},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":30.11},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":30.11},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":46.49,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18.07,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":42.16},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24.09},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":24.57,"additional_payer_notes":"APC"}]}]},{"description":"Assay of cryofibrinogen","code_information":[{"code":"82585","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":10.6,"maximum":27.29,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14.14,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":13.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17.68},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17.68},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17.68},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":27.29,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10.6,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24.75},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14.14},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14.42,"additional_payer_notes":"APC"}]}]},{"description":"Dehydroepiandrosterone","code_information":[{"code":"82627","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":16.67,"maximum":45.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22.23,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":45.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27.79},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27.79},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27.79},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":42.9,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16.67,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38.9},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22.23},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22.67,"additional_payer_notes":"APC"}]}]},{"description":"Enzyme cell activity","code_information":[{"code":"82657","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":16.63,"maximum":42.79,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22.17,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":36.53},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27.71},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27.71},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27.71},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":42.79,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16.63,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38.8},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22.17},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22.61,"additional_payer_notes":"APC"}]}]},{"description":"Assay of estrone","code_information":[{"code":"82679","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":18.71,"maximum":50.51,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":24.95,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":50.51},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":31.19},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":31.19},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":31.19},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":48.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18.71,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":43.66},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24.95},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25.45,"additional_payer_notes":"APC"}]}]},{"description":"Long chain fatty acids","code_information":[{"code":"82726","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":14.81,"maximum":38.12,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19.75,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":36.53},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24.69},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24.69},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24.69},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":38.12,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14.81,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34.56},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19.75},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20.14,"additional_payer_notes":"APC"}]}]},{"description":"Assay of galactose","code_information":[{"code":"82760","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8.4,"maximum":22.66,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11.2,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":22.66},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":21.62,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8.4,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19.6},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11.2},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11.42,"additional_payer_notes":"APC"}]}]},{"description":"Blood gases any combination","code_information":[{"code":"82803","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":19.55,"maximum":50.32,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26.07,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":39.14},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":32.59},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":32.59},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":32.59},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":50.32,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19.55,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":45.62},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26.07},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26.59,"additional_payer_notes":"APC"}]}]},{"description":"Glucose Other Fluid","code_information":[{"code":"82945","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2.95,"maximum":7.93,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3.93,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7.93},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4.91},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4.91},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4.91},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7.58,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2.95,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6.88},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3.93},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4.01,"additional_payer_notes":"APC"}]}]},{"description":"Test for G6PD enzyme","code_information":[{"code":"82960","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4.54,"maximum":12.24,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6.05,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":12.24},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7.56},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7.56},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7.56},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11.68,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4.54,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10.59},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6.05},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6.17,"additional_payer_notes":"APC"}]}]},{"description":"Assay of gonadotropin (fsh)","code_information":[{"code":"83001","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":13.94,"maximum":37.58,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18.58,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":37.58},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23.23},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23.23},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23.23},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":35.86,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.94,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32.52},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18.58},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18.95,"additional_payer_notes":"APC"}]}]},{"description":"H pylori drug admin","code_information":[{"code":"83014","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5.9,"maximum":15.91,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7.86,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":15.91},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":9.83},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":9.83},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":9.83},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":15.17,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5.9,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13.76},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7.86},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8.02,"additional_payer_notes":"APC"}]}]},{"description":"Glycosylated hemoglobin test","code_information":[{"code":"83036","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7.28,"maximum":19.64,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9.71,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":19.64},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12.14},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12.14},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12.14},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":18.74,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7.28,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16.99},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9.71},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9.9,"additional_payer_notes":"APC"}]}]},{"description":"Assay of urine hemoglobin","code_information":[{"code":"83069","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2.96,"maximum":8.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3.95,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":8.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4.94},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4.94},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4.94},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7.62,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2.96,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6.91},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3.95},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4.03,"additional_payer_notes":"APC"}]}]},{"description":"Assay of progesterone 17-d","code_information":[{"code":"83498","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":20.38,"maximum":54.97,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27.17,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":54.97},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":33.96},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":33.96},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":33.96},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":52.44,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20.38,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":47.55},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27.17},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27.71,"additional_payer_notes":"APC"}]}]},{"description":"Assay of insulin","code_information":[{"code":"83525","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8.57,"maximum":23.12,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11.43,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":23.12},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14.29},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14.29},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14.29},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":22.06,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8.57,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20.0},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11.43},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11.66,"additional_payer_notes":"APC"}]}]},{"description":"Assay 17- ketosteroids","code_information":[{"code":"83586","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":9.6,"maximum":25.91,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.8,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":25.91},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":24.7,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9.6,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22.4},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12.8},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.06,"additional_payer_notes":"APC"}]}]},{"description":"Test urine for lactose","code_information":[{"code":"83633","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8.44,"maximum":21.71,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11.25,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":11.12},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14.06},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14.06},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14.06},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":21.71,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8.44,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19.69},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11.25},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11.48,"additional_payer_notes":"APC"}]}]},{"description":"Assay of lipoprotein(a)","code_information":[{"code":"83695","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":10.74,"maximum":27.64,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14.32,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":26.2},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17.9},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17.9},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17.9},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":27.64,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10.74,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25.06},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14.32},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14.61,"additional_payer_notes":"APC"}]}]},{"description":"Lipoprtn dir meas sd ldl chl","code_information":[{"code":"83722","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":25.64,"maximum":65.99,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":34.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":52.08},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":42.74},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":42.74},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":42.74},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":65.99,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25.64,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":59.83},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34.19},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":34.87,"additional_payer_notes":"APC"}]}]},{"description":"Assay of methemalbumin","code_information":[{"code":"83857","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8.06,"maximum":21.74,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10.74,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":21.74},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13.43},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13.43},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13.43},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":20.73,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8.06,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18.8},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10.74},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10.95,"additional_payer_notes":"APC"}]}]},{"description":"Assay nephelometry not spec","code_information":[{"code":"83883","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":10.2,"maximum":27.5,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.6,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":27.5},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":26.25,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10.2,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23.8},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13.6},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.87,"additional_payer_notes":"APC"}]}]},{"description":"Assay of blood osmolality","code_information":[{"code":"83930","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4.96,"maximum":13.38,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6.61,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":13.38},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8.26},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8.26},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8.26},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":12.76,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4.96,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11.57},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6.61},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6.74,"additional_payer_notes":"APC"}]}]},{"description":"Exhaled breath condensate","code_information":[{"code":"83987","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2.68,"maximum":32.15,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3.58,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":32.15},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4.48},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4.48},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4.48},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6.91,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2.68,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6.27},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3.58},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3.65,"additional_payer_notes":"APC"}]}]},{"description":"Assay alkaline phosphatases","code_information":[{"code":"84080","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":11.08,"maximum":29.93,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14.78,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":29.93},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18.48},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18.48},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18.48},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":28.53,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11.08,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25.87},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14.78},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15.08,"additional_payer_notes":"APC"}]}]},{"description":"Removal of brain lesion","code_information":[{"code":"61520","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6779.0,"maximum":8333.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0}]}]},{"description":"Removal of brain lesion","code_information":[{"code":"61534","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6779.0,"maximum":8333.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0}]}]},{"description":"Removal of brain tissue","code_information":[{"code":"61543","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6779.0,"maximum":8333.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0}]}]},{"description":"Incise skull/sutures","code_information":[{"code":"61557","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6779.0,"maximum":8333.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0}]}]},{"description":"Incise skull for brain wound","code_information":[{"code":"61571","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6779.0,"maximum":8333.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0}]}]},{"description":"Orbitocranial approach/skull","code_information":[{"code":"61585","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6779.0,"maximum":8333.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0}]}]},{"description":"Transpetrosal approach/skull","code_information":[{"code":"61598","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6779.0,"maximum":8333.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0}]}]},{"description":"Remove aneurysm sinus","code_information":[{"code":"61613","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6779.0,"maximum":8333.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0}]}]},{"description":"Intracranial angioplasty","code_information":[{"code":"61630","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6779.0,"maximum":8333.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0}]}]},{"description":"Intracranial vessel surgery","code_information":[{"code":"61680","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6779.0,"maximum":8333.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0}]}]},{"description":"Brain aneurysm repr simple","code_information":[{"code":"61700","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6779.0,"maximum":8333.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0}]}]},{"description":"Incise skull/brain surgery","code_information":[{"code":"61735","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6779.0,"maximum":8333.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0}]}]},{"description":"Treat trigeminal nerve","code_information":[{"code":"61790","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1448.59,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1931.46,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3727.72,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1448.59,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1970.09,"additional_payer_notes":"APC"}]}]},{"description":"Implant neuroelectrodes","code_information":[{"code":"61860","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6779.0,"maximum":8333.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0}]}]},{"description":"Revise/remove neuroreceiver","code_information":[{"code":"61888","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":21271.19,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11021.34,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":21271.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8266.01,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11241.77,"additional_payer_notes":"APC"}]}]},{"description":"Incise skull repair","code_information":[{"code":"62121","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6779.0,"maximum":8333.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0}]}]},{"description":"Retr bone flap to fix skull","code_information":[{"code":"62148","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3388.0,"maximum":4106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0}]}]},{"description":"Establish brain cavity shunt","code_information":[{"code":"62192","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Csf Shunt Reprogram","code_information":[{"code":"62252","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":227.84,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":303.79,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":586.32,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":227.84,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":309.87,"additional_payer_notes":"APC"}]}]},{"description":"Spinal fluid tap diagnostic","code_information":[{"code":"62270","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":523.65,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":698.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1347.51,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":523.65,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":712.16,"additional_payer_notes":"APC"}]}]},{"description":"Inject for spine disk x-ray","code_information":[{"code":"62290","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Implant spinal canal cath","code_information":[{"code":"62350","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":16752.93,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8680.28,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":16752.93,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6510.21,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8853.88,"additional_payer_notes":"APC"}]}]},{"description":"Analyze sp inf pump w/reprog","code_information":[{"code":"62368","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":227.84,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":303.79,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":586.32,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":227.84,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":309.87,"additional_payer_notes":"APC"}]}]},{"description":"Remove spine lamina >2 crvcl","code_information":[{"code":"63015","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Laminotomy addl cervical","code_information":[{"code":"63043","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5512.0,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0}]}]},{"description":"Decompress spinal cord thrc","code_information":[{"code":"63055","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Spine disk surgery thorax","code_information":[{"code":"63078","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3388.0,"maximum":4106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0}]}]},{"description":"Remove vertebral body add-on","code_information":[{"code":"63091","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3388.0,"maximum":4106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0}]}]},{"description":"Incise spine nrv >2 segmnts","code_information":[{"code":"63190","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6779.0,"maximum":27583.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":27583.0}]}]},{"description":"Excise intrspinl lesion thrc","code_information":[{"code":"63266","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Bx/exc xdrl spine lesn thrc","code_information":[{"code":"63276","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6779.0,"maximum":8333.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0}]}]},{"description":"Bx/exc idrl imed lesn thrc","code_information":[{"code":"63286","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6779.0,"maximum":8333.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0}]}]},{"description":"Remove vert idrl body crvcl","code_information":[{"code":"63304","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6779.0,"maximum":8333.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0}]}]},{"description":"Srs spinal lesion addl","code_information":[{"code":"63621","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3388.0,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0}]}]},{"description":"Revise/remove neuroreceiver","code_information":[{"code":"63688","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2593.52,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3458.03,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6674.0,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2593.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3527.19,"additional_payer_notes":"APC"}]}]},{"description":"Install spinal shunt","code_information":[{"code":"63740","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Dstrj neurofibroma xtnsv","code_information":[{"code":"0420T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":548.27,"maximum":2334.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":731.02,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1410.87,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":548.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":745.64,"additional_payer_notes":"APC"}]}]},{"description":"Rmvl nstim apnea stimj ld","code_information":[{"code":"0430T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8770.0,"maximum":8770.0,"payers_information":[{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0}]}]},{"description":"Nsl/sins ndsc tot w/sphendt","code_information":[{"code":"31257","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5235.45,"maximum":13472.56,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6980.6,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":7398.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6019.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":7398.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13472.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5235.45,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7120.21,"additional_payer_notes":"APC"}]}]},{"description":"Eval amniotic fluid protein","code_information":[{"code":"84112","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":73.58,"maximum":189.35,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":98.11,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":130.33},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":122.64},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":122.64},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":122.64},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":189.35,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":73.58,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":171.69},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":98.11},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":100.07,"additional_payer_notes":"APC"}]}]},{"description":"Assay of pregnanetriol","code_information":[{"code":"84138","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":15.79,"maximum":40.63,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21.05,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":38.3},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26.31},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26.31},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26.31},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":40.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15.79,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36.84},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21.05},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21.47,"additional_payer_notes":"APC"}]}]},{"description":"Assay of psa total","code_information":[{"code":"84153","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":13.79,"maximum":37.22,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18.39,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":37.22},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22.99},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22.99},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22.99},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":35.49,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.79,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32.18},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18.39},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18.76,"additional_payer_notes":"APC"}]}]},{"description":"Protein e-phoresis/urine/csf","code_information":[{"code":"84166","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":13.37,"maximum":36.08,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17.83,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":36.08},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22.29},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22.29},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22.29},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":34.41,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.37,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31.2},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17.83},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18.19,"additional_payer_notes":"APC"}]}]},{"description":"Assay of pyruvate kinase","code_information":[{"code":"84220","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7.08,"maximum":19.09,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9.44,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":19.09},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11.8},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11.8},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11.8},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":18.22,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7.08,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16.52},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9.44},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9.63,"additional_payer_notes":"APC"}]}]},{"description":"Assay of selenium","code_information":[{"code":"84255","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":19.15,"maximum":51.67,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25.53,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":51.67},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":31.91},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":31.91},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":31.91},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":49.27,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19.15,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":44.68},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25.53},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26.04,"additional_payer_notes":"APC"}]}]},{"description":"Assay of somatomedin","code_information":[{"code":"84305","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":15.94,"maximum":43.02,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21.26,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":43.02},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26.58},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26.58},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26.58},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":41.03,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15.94,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37.21},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21.26},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21.69,"additional_payer_notes":"APC"}]}]},{"description":"Sugars multiple quant","code_information":[{"code":"84379","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8.65,"maximum":23.33,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11.53,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":23.33},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14.41},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14.41},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14.41},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":22.25,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8.65,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20.18},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11.53},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11.76,"additional_payer_notes":"APC"}]}]},{"description":"Assay of thiocyanate","code_information":[{"code":"84430","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8.72,"maximum":23.53,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11.63,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":23.53},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14.54},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14.54},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14.54},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":22.45,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8.72,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20.35},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11.63},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11.86,"additional_payer_notes":"APC"}]}]},{"description":"Assay thyroid stim hormone","code_information":[{"code":"84443","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":12.6,"maximum":34.01,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16.8,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":34.01},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":32.42,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.6,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29.4},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16.8},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17.14,"additional_payer_notes":"APC"}]}]},{"description":"Assay of thyroid (t3 or t4)","code_information":[{"code":"84479","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4.85,"maximum":13.08,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6.47,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":13.08},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8.09},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8.09},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8.09},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":12.49,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4.85,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11.32},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6.47},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6.6,"additional_payer_notes":"APC"}]}]},{"description":"Assay of tyrosine","code_information":[{"code":"84510","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7.97,"maximum":21.05,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10.63,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":21.05},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13.29},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13.29},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13.29},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":20.52,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7.97,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18.6},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10.63},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10.84,"additional_payer_notes":"APC"}]}]},{"description":"Assay of feces/urobilinogen","code_information":[{"code":"84577","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":12.6,"maximum":32.42,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16.8,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":25.25},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":32.42,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.6,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29.4},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16.8},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17.14,"additional_payer_notes":"APC"}]}]},{"description":"Assay Of Nos Vitamin","code_information":[{"code":"84591","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":12.8,"maximum":32.93,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17.06,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":23.48},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21.33},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21.33},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21.33},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":32.93,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.8,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29.86},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17.06},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17.4,"additional_payer_notes":"APC"}]}]},{"description":"Hcg free betachain test","code_information":[{"code":"84704","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":11.47,"maximum":30.47,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15.29,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":30.47},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19.11},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19.11},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19.11},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":29.51,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11.47,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26.76},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15.29},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15.6,"additional_payer_notes":"APC"}]}]},{"description":"Hematocrit","code_information":[{"code":"85014","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1.78,"maximum":4.79,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4.79},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2.96},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2.96},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2.96},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1.78,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":4.15},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2.37},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2.42,"additional_payer_notes":"APC"}]}]},{"description":"Reticyte/hgb concentrate","code_information":[{"code":"85046","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4.18,"maximum":11.27,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5.57,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":11.27},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":6.96},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":6.96},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":6.96},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":10.75,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4.18,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9.75},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5.57},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5.68,"additional_payer_notes":"APC"}]}]},{"description":"Blooc clot factor v test","code_information":[{"code":"85220","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":13.24,"maximum":35.7,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17.65,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":35.7},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22.06},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22.06},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22.06},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":34.06,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.24,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30.89},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17.65},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18.0,"additional_payer_notes":"APC"}]}]},{"description":"Clot factor x stuart-power","code_information":[{"code":"85260","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":13.42,"maximum":36.23,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17.9,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":36.23},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22.38},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22.38},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22.38},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":34.55,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.42,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31.33},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17.9},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18.26,"additional_payer_notes":"APC"}]}]},{"description":"Antithrombin iii antigen","code_information":[{"code":"85301","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8.11,"maximum":21.89,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10.81,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":21.89},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13.51},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13.51},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13.51},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":20.86,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8.11,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18.92},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10.81},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11.03,"additional_payer_notes":"APC"}]}]},{"description":"Coagulation time lee & white","code_information":[{"code":"85345","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3.52,"maximum":9.05,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4.69,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":8.33},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5.86},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5.86},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5.86},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":9.05,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3.52,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8.21},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":4.69},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4.78,"additional_payer_notes":"APC"}]}]},{"description":"Fibrin degradation quant","code_information":[{"code":"85379","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7.64,"maximum":19.65,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10.18,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":16.4},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12.73},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12.73},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12.73},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":19.65,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7.64,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17.82},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10.18},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10.38,"additional_payer_notes":"APC"}]}]},{"description":"Fibrinolytic plasminogen","code_information":[{"code":"85415","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":12.89,"maximum":34.8,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":34.8},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21.49},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21.49},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21.49},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":33.18,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.89,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30.08},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17.19},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17.53,"additional_payer_notes":"APC"}]}]},{"description":"Heparin assay","code_information":[{"code":"85520","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":9.82,"maximum":25.26,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":22.6},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16.36},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16.36},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16.36},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":25.26,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9.82,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22.91},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13.09},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.35,"additional_payer_notes":"APC"}]}]},{"description":"RBC osmotic fragility","code_information":[{"code":"85557","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":10.02,"maximum":27.04,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":27.04},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16.7},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16.7},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16.7},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":25.78,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10.02,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23.38},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13.36},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.63,"additional_payer_notes":"APC"}]}]},{"description":"Reptilase test","code_information":[{"code":"85635","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7.39,"maximum":19.93,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9.85,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":19.93},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12.31},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12.31},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12.31},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":19.01,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7.39,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17.24},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9.85},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10.05,"additional_payer_notes":"APC"}]}]},{"description":"Thromboplastin time partial","code_information":[{"code":"85732","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4.85,"maximum":13.08,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6.47,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":13.08},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8.09},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8.09},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8.09},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":12.49,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4.85,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11.32},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6.47},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6.6,"additional_payer_notes":"APC"}]}]},{"description":"WBC antibody identification","code_information":[{"code":"86021","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":11.29,"maximum":30.47,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15.05,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":30.47},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18.81},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18.81},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18.81},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":29.05,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11.29,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26.34},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15.05},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15.35,"additional_payer_notes":"APC"}]}]},{"description":"Acetylcholn rcptr blckg antb","code_information":[{"code":"86042","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":13.8,"maximum":35.51,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18.4,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":27.55},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":35.51,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.8,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32.2},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18.4},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18.77,"additional_payer_notes":"APC"}]}]},{"description":"C-reactive protein hs","code_information":[{"code":"86141","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":9.71,"maximum":26.2,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.95,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":26.2},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16.19},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16.19},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16.19},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":24.99,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9.71,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22.66},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12.95},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.21,"additional_payer_notes":"APC"}]}]},{"description":"Complement antigen","code_information":[{"code":"86160","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":9.0,"maximum":24.29,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":24.29},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":23.16,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9.0,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21.0},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.24,"additional_payer_notes":"APC"}]}]},{"description":"Ema each ig class","code_information":[{"code":"86231","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":9.07,"maximum":23.33,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":17.96},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15.11},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15.11},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15.11},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":23.33,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9.07,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21.16},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12.09},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.33,"additional_payer_notes":"APC"}]}]},{"description":"Immunoassay tumor ca 15-3","code_information":[{"code":"86300","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":15.61,"maximum":42.11,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20.81,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":42.11},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26.01},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26.01},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26.01},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":40.16,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15.61,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36.42},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20.81},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21.23,"additional_payer_notes":"APC"}]}]},{"description":"Immunoassay infectious agent","code_information":[{"code":"86317","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":11.24,"maximum":30.34,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14.99,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":30.34},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18.74},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18.74},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18.74},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":28.93,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11.24,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26.23},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14.99},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15.29,"additional_payer_notes":"APC"}]}]},{"description":"Immune complex assay","code_information":[{"code":"86332","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":18.28,"maximum":49.32,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":24.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":49.32},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":30.46},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":30.46},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":30.46},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":47.03,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18.28,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":42.65},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24.37},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":24.86,"additional_payer_notes":"APC"}]}]},{"description":"N block inj vagus","code_information":[{"code":"64408","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":227.71,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":303.61,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":585.96,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":227.71,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":309.68,"additional_payer_notes":"APC"}]}]},{"description":"N block inj pudendal","code_information":[{"code":"64430","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":656.13,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":874.84,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1688.44,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":656.13,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":892.34,"additional_payer_notes":"APC"}]}]},{"description":"N block inj plantar digit","code_information":[{"code":"64455","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":227.71,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":303.61,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":585.96,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":227.71,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":309.68,"additional_payer_notes":"APC"}]}]},{"description":"Tap block unil by injection","code_information":[{"code":"64486","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Inj paravert f jnt l/s 2 lev","code_information":[{"code":"64494","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":433.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":433.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Implant neuroelectrodes","code_information":[{"code":"64555","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4727.69,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6303.59,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":12165.93,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4727.69,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6429.66,"additional_payer_notes":"APC"}]}]},{"description":"Implant neuroelectrodes","code_information":[{"code":"64581","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4727.69,"maximum":27583.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6303.59,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":12165.93,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4727.69,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":27583.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6429.66,"additional_payer_notes":"APC"}]}]},{"description":"Destroy nerve face muscle","code_information":[{"code":"64612","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":227.71,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":303.61,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":585.96,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":227.71,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":309.68,"additional_payer_notes":"APC"}]}]},{"description":"Destroy c/th facet jnt addl","code_information":[{"code":"64634","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Chemodenerv trunk musc 1-5","code_information":[{"code":"64646","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":523.65,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":698.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1347.51,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":523.65,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":712.16,"additional_payer_notes":"APC"}]}]},{"description":"Revise arm/leg nerve","code_information":[{"code":"64708","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1448.59,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1931.46,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3727.72,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1448.59,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1970.09,"additional_payer_notes":"APC"}]}]},{"description":"Relieve pressure on nerve(s)","code_information":[{"code":"64722","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1448.59,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1931.46,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3727.72,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1448.59,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1970.09,"additional_payer_notes":"APC"}]}]},{"description":"Incision of facial nerve","code_information":[{"code":"64742","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1448.59,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1931.46,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3727.72,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1448.59,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1970.09,"additional_payer_notes":"APC"}]}]},{"description":"Incision of spinal nerve","code_information":[{"code":"64772","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1448.59,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1931.46,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3727.72,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1448.59,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1970.09,"additional_payer_notes":"APC"}]}]},{"description":"Implant nerve end","code_information":[{"code":"64787","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Remove sympathetic nerves","code_information":[{"code":"64818","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Repair of hand or foot nerve","code_information":[{"code":"64835","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2534.21,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3378.94,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6521.36,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2534.21,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3446.52,"additional_payer_notes":"APC"}]}]},{"description":"Repair of arm nerves","code_information":[{"code":"64861","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1448.59,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1931.46,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3727.72,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1448.59,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1970.09,"additional_payer_notes":"APC"}]}]},{"description":"Repair nerve/shorten bone","code_information":[{"code":"64876","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Nerve graft hand/foot >4 cm","code_information":[{"code":"64896","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":16752.93,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8680.28,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":16752.93,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6510.21,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8853.88,"additional_payer_notes":"APC"}]}]},{"description":"Neurorraphy w/vein autograft","code_information":[{"code":"64911","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":16752.93,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8680.28,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":16752.93,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6510.21,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8853.88,"additional_payer_notes":"APC"}]}]},{"description":"Remove eye/revise socket","code_information":[{"code":"65112","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2916.44,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3888.58,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7504.96,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2916.44,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3966.35,"additional_payer_notes":"APC"}]}]},{"description":"Removal of ocular implant","code_information":[{"code":"65175","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2916.44,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3888.58,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7504.96,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2916.44,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3966.35,"additional_payer_notes":"APC"}]}]},{"description":"Repair of eye wound","code_information":[{"code":"65270","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1763.69,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2351.59,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4538.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1763.69,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2398.62,"additional_payer_notes":"APC"}]}]},{"description":"Removal of eye lesion","code_information":[{"code":"65400","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":739.52,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":986.02,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1903.02,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":739.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1005.74,"additional_payer_notes":"APC"}]}]},{"description":"Revision of cornea","code_information":[{"code":"65600","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1763.69,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2351.59,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4538.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1763.69,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2398.62,"additional_payer_notes":"APC"}]}]},{"description":"Revision of cornea","code_information":[{"code":"65765","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0}]}]},{"description":"Ocular reconst transplant","code_information":[{"code":"65780","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2916.44,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3888.58,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7504.96,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2916.44,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3966.35,"additional_payer_notes":"APC"}]}]},{"description":"Incision of eye","code_information":[{"code":"65850","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1712.02,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2282.69,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4405.59,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1712.02,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2328.34,"additional_payer_notes":"APC"}]}]},{"description":"Remove implant of eye","code_information":[{"code":"65920","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1712.02,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2282.69,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4405.59,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1712.02,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2328.34,"additional_payer_notes":"APC"}]}]},{"description":"Glaucoma surgery","code_information":[{"code":"66170","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1712.02,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2282.69,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4405.59,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1712.02,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2328.34,"additional_payer_notes":"APC"}]}]},{"description":"Revise aqueous shunt eye","code_information":[{"code":"66185","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1712.02,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2282.69,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4405.59,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1712.02,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2328.34,"additional_payer_notes":"APC"}]}]},{"description":"Removal of iris","code_information":[{"code":"66630","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1712.02,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2282.69,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4405.59,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1712.02,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2328.34,"additional_payer_notes":"APC"}]}]},{"description":"Destruction ciliary body","code_information":[{"code":"66740","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1763.69,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2351.59,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4538.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1763.69,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2398.62,"additional_payer_notes":"APC"}]}]},{"description":"Removal of lens material","code_information":[{"code":"66840","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1712.02,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2282.69,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4405.59,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1712.02,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2328.34,"additional_payer_notes":"APC"}]}]},{"description":"Cataract surg w/iol 1 stage","code_information":[{"code":"66984","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1712.02,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2282.69,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4405.59,"additional_payer_notes":"APC"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":4112.0},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1712.02,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2328.34,"additional_payer_notes":"APC"}]}]},{"description":"Laryngoplasty laryngeal sten","code_information":[{"code":"31552","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Largsc w/ther injection","code_information":[{"code":"31573","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1320.39,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1760.51,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3397.79,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1320.39,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1795.72,"additional_payer_notes":"APC"}]}]},{"description":"Bypass graft patency/patch","code_information":[{"code":"35685","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Revise Graft w/Nonauto Graft","code_information":[{"code":"35883","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4127.91,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5503.89,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":10622.5,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4127.91,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5613.96,"additional_payer_notes":"APC"}]}]},{"description":"Vein access cutdown < 1 yr","code_information":[{"code":"36420","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":98.7,"maximum":2334.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":131.6,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":253.99,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":98.7,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":134.23,"additional_payer_notes":"APC"}]}]},{"description":"Leukocyte phagocytosis","code_information":[{"code":"86344","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7.79,"maximum":20.05,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10.39,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":16.18},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12.99},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12.99},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12.99},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":20.05,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7.79,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18.18},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10.39},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10.6,"additional_payer_notes":"APC"}]}]},{"description":"T cell absolute count","code_information":[{"code":"86361","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":20.08,"maximum":54.18,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26.78,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":54.18},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":33.48},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":33.48},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":33.48},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":51.69,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20.08,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":46.87},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26.78},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27.32,"additional_payer_notes":"APC"}]}]},{"description":"Neutralization test viral","code_information":[{"code":"86382","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":12.68,"maximum":34.24,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16.91,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":34.24},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21.14},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21.14},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21.14},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":32.64,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.68,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29.59},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16.91},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17.25,"additional_payer_notes":"APC"}]}]},{"description":"Rheumatoid factor test qual","code_information":[{"code":"86430","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4.6,"maximum":11.85,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6.14,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":11.48},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7.68},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7.68},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7.68},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11.85,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4.6,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10.75},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6.14},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6.26,"additional_payer_notes":"APC"}]}]},{"description":"Voltage-gtd ca chnl antb ea","code_information":[{"code":"86596","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":9.04,"maximum":27.34,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.05,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":27.34},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15.06},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15.06},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15.06},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":23.26,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9.04,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21.09},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18.4},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.29,"additional_payer_notes":"APC"}]}]},{"description":"Lyme disease antibody","code_information":[{"code":"86617","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":11.62,"maximum":31.33,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15.49,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":31.33},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19.36},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19.36},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19.36},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":29.9,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11.62,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27.11},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15.49},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15.8,"additional_payer_notes":"APC"}]}]},{"description":"Coccidioides antibody","code_information":[{"code":"86635","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8.6,"maximum":22.14,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11.47,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":11.77},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14.34},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14.34},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14.34},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":22.14,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8.6,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20.07},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11.47},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11.7,"additional_payer_notes":"APC"}]}]},{"description":"Encephaltis st louis antbody","code_information":[{"code":"86653","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":9.89,"maximum":25.46,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":11.77},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16.49},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16.49},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16.49},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":25.46,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9.89,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23.08},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13.19},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.45,"additional_payer_notes":"APC"}]}]},{"description":"Fungus nes antibody","code_information":[{"code":"86671","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":9.19,"maximum":23.64,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.25,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":10.3},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15.31},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15.31},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15.31},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":23.64,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9.19,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21.44},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12.25},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.5,"additional_payer_notes":"APC"}]}]},{"description":"Hepatitis delta agent antbdy","code_information":[{"code":"86692","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":12.87,"maximum":34.74,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17.16,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":34.74},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21.45},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21.45},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21.45},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":33.12,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.87,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30.03},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17.16},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17.5,"additional_payer_notes":"APC"}]}]},{"description":"Hep b core antibody total","code_information":[{"code":"86704","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":9.04,"maximum":24.38,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.05,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":24.38},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15.06},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15.06},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15.06},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":23.26,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9.04,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21.09},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12.05},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.29,"additional_payer_notes":"APC"}]}]},{"description":"Legionella antibody","code_information":[{"code":"86713","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":11.48,"maximum":30.96,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15.3,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":30.96},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19.13},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19.13},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19.13},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":29.53,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11.48,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26.78},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15.3},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15.61,"additional_payer_notes":"APC"}]}]},{"description":"Neisseria meningitidis","code_information":[{"code":"86741","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":9.89,"maximum":25.46,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":11.77},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16.49},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16.49},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16.49},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":25.46,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9.89,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23.08},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13.19},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.45,"additional_payer_notes":"APC"}]}]},{"description":"Rubella antibody","code_information":[{"code":"86762","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":10.79,"maximum":29.12,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14.39,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":29.12},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17.99},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17.99},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17.99},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":27.77,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10.79,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25.18},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14.39},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14.68,"additional_payer_notes":"APC"}]}]},{"description":"Treponema pallidum","code_information":[{"code":"86780","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":9.93,"maximum":25.55,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.24,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":16.01},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16.55},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16.55},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16.55},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":25.55,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9.93,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23.17},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13.24},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.5,"additional_payer_notes":"APC"}]}]},{"description":"Thyroglobulin antibody","code_information":[{"code":"86800","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":11.93,"maximum":32.2,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15.91,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":32.2},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19.89},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19.89},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19.89},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":30.71,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11.93,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27.84},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15.91},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16.23,"additional_payer_notes":"APC"}]}]},{"description":"Hla typing a b or c","code_information":[{"code":"86813","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":43.5,"maximum":117.35,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":58.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":117.35},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":72.5},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":72.5},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":72.5},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":111.94,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":43.5,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":101.5},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":58.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":59.16,"additional_payer_notes":"APC"}]}]},{"description":"Hla class i phenotype qual","code_information":[{"code":"86830","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":71.64,"maximum":184.35,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":95.52,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":163.37},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":119.4},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":119.4},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":119.4},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":184.35,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":71.64,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":167.16},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":95.52},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":97.43,"additional_payer_notes":"APC"}]}]},{"description":"Coombs test indirect qual","code_information":[{"code":"86885","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5.72,"maximum":325.23,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":168.51,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":11.58},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7.15},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7.15},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7.15},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":325.23,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":126.39,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10.01},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5.72},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":171.88,"additional_payer_notes":"APC"}]}]},{"description":"Hemolysins/agglutinins auto","code_information":[{"code":"86940","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6.58,"maximum":16.93,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8.77,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":16.6},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10.96},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10.96},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10.96},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":16.93,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6.58,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15.35},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8.77},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8.95,"additional_payer_notes":"APC"}]}]},{"description":"Culture aerobic quant other","code_information":[{"code":"87071","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7.42,"maximum":19.09,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9.89,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":19.09},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12.36},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12.36},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12.36},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":19.09,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7.42,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17.31},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9.89},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10.09,"additional_payer_notes":"APC"}]}]},{"description":"Urine bacteria culture","code_information":[{"code":"87088","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6.07,"maximum":16.39,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":16.39},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10.11},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10.11},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10.11},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":15.61,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6.07,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14.16},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8.09},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8.25,"additional_payer_notes":"APC"}]}]},{"description":"Mycobacteria culture","code_information":[{"code":"87116","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8.1,"maximum":21.85,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10.8,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":21.85},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13.5},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13.5},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13.5},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":20.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8.1,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18.9},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10.8},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11.02,"additional_payer_notes":"APC"}]}]},{"description":"Dna/rna sequencing","code_information":[{"code":"87153","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":86.52,"maximum":233.44,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":115.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":233.44},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":144.2},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":144.2},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":144.2},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":222.64,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":86.52,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":201.88},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":115.36},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":117.67,"additional_payer_notes":"APC"}]}]},{"description":"Tissue homogenization cultr","code_information":[{"code":"87176","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4.41,"maximum":11.89,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5.88,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":11.89},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7.35},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7.35},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7.35},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11.35,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4.41,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10.29},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5.88},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6.0,"additional_payer_notes":"APC"}]}]},{"description":"Microbe suscept mycobacteri","code_information":[{"code":"87190","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5.48,"maximum":14.11,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7.31,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5.83},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":9.14},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":9.14},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":9.14},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":14.11,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5.48,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12.79},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7.31},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7.46,"additional_payer_notes":"APC"}]}]},{"description":"Assay toxin or antitoxin","code_information":[{"code":"87230","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":14.8,"maximum":39.97,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19.74,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":39.97},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24.68},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24.68},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24.68},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":38.1,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14.8,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34.55},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19.74},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20.13,"additional_payer_notes":"APC"}]}]},{"description":"Enterovirus antibody dfa","code_information":[{"code":"87267","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":10.06,"maximum":25.9,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.42,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":24.26},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16.78},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16.78},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16.78},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":25.9,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10.06,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23.49},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13.42},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.69,"additional_payer_notes":"APC"}]}]},{"description":"Influenza a ag if","code_information":[{"code":"87276","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":12.05,"maximum":31.02,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16.07,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":24.26},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20.09},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20.09},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20.09},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":31.02,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.05,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28.12},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16.07},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16.39,"additional_payer_notes":"APC"}]}]},{"description":"Antibody detection nos if","code_information":[{"code":"87299","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":12.08,"maximum":31.07,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16.1,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":24.26},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20.13},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20.13},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20.13},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":31.07,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.08,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28.18},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16.1},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16.42,"additional_payer_notes":"APC"}]}]},{"description":"Giardia ag ia","code_information":[{"code":"87329","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8.98,"maximum":24.26,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11.98,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":24.26},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14.98},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14.98},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14.98},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":23.12,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8.98,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20.97},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11.98},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.22,"additional_payer_notes":"APC"}]}]},{"description":"Hepatitis b surface ag ia","code_information":[{"code":"87341","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7.75,"maximum":20.9,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10.33,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":20.9},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12.91},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12.91},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12.91},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":19.94,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7.75,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18.08},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10.33},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10.54,"additional_payer_notes":"APC"}]}]},{"description":"Resp syncytial ag ia","code_information":[{"code":"87420","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":10.43,"maximum":26.85,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.91,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":24.26},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17.39},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17.39},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17.39},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":26.85,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10.43,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24.34},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13.91},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14.19,"additional_payer_notes":"APC"}]}]},{"description":"Hepatitis b surface ag quan","code_information":[{"code":"87467","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":15.05,"maximum":48.87,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25.32,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":22.28},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":31.65},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":31.65},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":31.65},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":48.87,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18.99,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":44.31},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15.05},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25.83,"additional_payer_notes":"APC"}]}]},{"description":"Candida dna dir probe","code_information":[{"code":"87480","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":15.04,"maximum":40.58,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20.05,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":40.58},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25.06},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25.06},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25.06},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":38.7,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15.04,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35.09},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20.05},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20.45,"additional_payer_notes":"APC"}]}]},{"description":"Replace cvad cath","code_information":[{"code":"36580","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1167.76,"maximum":4106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1557.01,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3005.03,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1167.76,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1588.15,"additional_payer_notes":"APC"}]}]},{"description":"Draw blood off venous device","code_information":[{"code":"36591","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":98.7,"maximum":2334.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":131.6,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":253.99,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":98.7,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":134.23,"additional_payer_notes":"APC"}]}]},{"description":"Intro cath dialysis circuit","code_information":[{"code":"36902","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4222.18,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5629.58,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":10865.09,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4222.18,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5742.17,"additional_payer_notes":"APC"}]}]},{"description":"Ligation of abdomen artery","code_information":[{"code":"37617","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":10622.5,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5503.89,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":10622.5,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4127.91,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5613.96,"additional_payer_notes":"APC"}]}]},{"description":"Tumor cell deplete of harvst","code_information":[{"code":"38211","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":327.28,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":436.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":842.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":327.28,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":445.1,"additional_payer_notes":"APC"}]}]},{"description":"Ra tracer id of sentinl node","code_information":[{"code":"38792","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":296.56,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":395.42,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":763.16,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":296.56,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":403.33,"additional_payer_notes":"APC"}]}]},{"description":"Replace eye fluid","code_information":[{"code":"67025","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1712.02,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2282.69,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4405.59,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1712.02,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2328.34,"additional_payer_notes":"APC"}]}]},{"description":"Vit for macular pucker","code_information":[{"code":"67041","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3066.31,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4088.41,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7890.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3066.31,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4170.17,"additional_payer_notes":"APC"}]}]},{"description":"Repair retinal detach cplx","code_information":[{"code":"67113","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3947.51,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5263.35,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":10158.27,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3947.51,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5368.62,"additional_payer_notes":"APC"}]}]},{"description":"Treatment of retinal lesion","code_information":[{"code":"67218","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2916.44,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3888.58,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7504.96,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2916.44,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3966.35,"additional_payer_notes":"APC"}]}]},{"description":"Reinforce/graft eye wall","code_information":[{"code":"67255","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3066.31,"maximum":7890.63,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4088.41,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7890.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3066.31,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4170.17,"additional_payer_notes":"APC"}]}]},{"description":"Eye surgery follow-up add-on","code_information":[{"code":"67331","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Unlisted px extraocular musc","code_information":[{"code":"67399","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":235.46,"maximum":13249.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":313.95,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":13249.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":10779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":13249.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":605.92,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":235.46,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":320.23,"additional_payer_notes":"APC"}]}]},{"description":"Explore/treat eye socket","code_information":[{"code":"67430","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2916.44,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3888.58,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7504.96,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2916.44,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3966.35,"additional_payer_notes":"APC"}]}]},{"description":"Revise eye socket implant","code_information":[{"code":"67560","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2916.44,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3888.58,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7504.96,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2916.44,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3966.35,"additional_payer_notes":"APC"}]}]},{"description":"Remove eyelid lesions","code_information":[{"code":"67805","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":235.46,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":313.95,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":605.92,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":235.46,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":320.23,"additional_payer_notes":"APC"}]}]},{"description":"Treat eyelid lesion","code_information":[{"code":"67850","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":739.52,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":986.02,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1903.02,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":739.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1005.74,"additional_payer_notes":"APC"}]}]},{"description":"Repair eyelid defect","code_information":[{"code":"67904","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1763.69,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2351.59,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4538.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1763.69,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2398.62,"additional_payer_notes":"APC"}]}]},{"description":"Repair eyelid defect","code_information":[{"code":"67916","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1763.69,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2351.59,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4538.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1763.69,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2398.62,"additional_payer_notes":"APC"}]}]},{"description":"Remove eyelid foreign body","code_information":[{"code":"67938","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":235.46,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":313.95,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":605.92,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":235.46,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":320.23,"additional_payer_notes":"APC"}]}]},{"description":"Revision of eyelid","code_information":[{"code":"67999","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":235.46,"maximum":13249.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":313.95,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":13249.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":10779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":13249.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":605.92,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":235.46,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":320.23,"additional_payer_notes":"APC"}]}]},{"description":"Treat eyelid by injection","code_information":[{"code":"68200","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":331.39,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":441.86,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":852.79,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":331.39,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":450.7,"additional_payer_notes":"APC"}]}]},{"description":"Revise eyelid lining","code_information":[{"code":"68360","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2916.44,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3888.58,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7504.96,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2916.44,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3966.35,"additional_payer_notes":"APC"}]}]},{"description":"Partial removal tear gland","code_information":[{"code":"68505","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2916.44,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3888.58,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7504.96,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2916.44,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3966.35,"additional_payer_notes":"APC"}]}]},{"description":"Revise tear duct opening","code_information":[{"code":"68705","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":235.46,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":313.95,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":605.92,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":235.46,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":320.23,"additional_payer_notes":"APC"}]}]},{"description":"Probe nasolacrimal duct","code_information":[{"code":"68810","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":235.46,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":313.95,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":605.92,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":235.46,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":320.23,"additional_payer_notes":"APC"}]}]},{"description":"Drain external ear lesion","code_information":[{"code":"69005","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1225.21,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1633.61,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3152.87,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1225.21,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1666.28,"additional_payer_notes":"APC"}]}]},{"description":"Remove ear canal lesion(s)","code_information":[{"code":"69145","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2154.81,"maximum":5545.05,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2873.08,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5545.05,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2154.81,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2930.54,"additional_payer_notes":"APC"}]}]},{"description":"Clean out mastoid cavity","code_information":[{"code":"69222","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":400.09,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":533.45,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1029.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":400.09,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":544.12,"additional_payer_notes":"APC"}]}]},{"description":"Create eardrum opening","code_information":[{"code":"69433","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":400.09,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":533.45,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1029.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":400.09,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":544.12,"additional_payer_notes":"APC"}]}]},{"description":"Extensive mastoid surgery","code_information":[{"code":"69530","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Mastoid surgery revision","code_information":[{"code":"69603","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Rebuild eardrum structures","code_information":[{"code":"69636","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Release middle ear bone","code_information":[{"code":"69650","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2459.51,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3279.35,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6329.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2459.51,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3344.94,"additional_payer_notes":"APC"}]}]},{"description":"Close mastoid fistula","code_information":[{"code":"69700","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1151.01,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1534.69,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2961.94,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1151.01,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1565.38,"additional_payer_notes":"APC"}]}]},{"description":"Repair facial nerve","code_information":[{"code":"69745","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Implant cochlear device","code_information":[{"code":"69930","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8923.0,"maximum":62943.16,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":32613.04,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":10765.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":8923.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":10765.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":54996.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":54996.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":54996.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":62943.16,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":24459.78,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":51942.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":33265.3,"additional_payer_notes":"APC"}]}]},{"description":"Right heart cath","code_information":[{"code":"93451","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2404.97,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3206.62,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6188.79,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2404.97,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3270.76,"additional_payer_notes":"APC"}]}]},{"description":"L hrt art/grft angio","code_information":[{"code":"93459","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2404.97,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3206.62,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6188.79,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2404.97,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3270.76,"additional_payer_notes":"APC"}]}]},{"description":"Perc d-e cor stent ather s","code_information":[{"code":"C9602","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8923.0,"maximum":34994.75,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18131.99,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":10765.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":8923.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":10765.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":34994.75,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13599.0,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":27583.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18494.63,"additional_payer_notes":"APC"}]}]},{"description":"Rxt breast appl place/remov","code_information":[{"code":"C9726","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Bone graft peri per tooth","code_information":[{"code":"D3428","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":479.59,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":639.45,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1234.13,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":479.59,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":652.24,"additional_payer_notes":"APC"}]}]},{"description":"N block cont infuse b plex","code_information":[{"code":"64416","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":656.13,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":874.84,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1688.44,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":656.13,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":892.34,"additional_payer_notes":"APC"}]}]},{"description":"N block inj sciatic sng","code_information":[{"code":"64445","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":523.65,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":698.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1347.51,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":523.65,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":712.16,"additional_payer_notes":"APC"}]}]},{"description":"Pvb thoracic 2nd+ inj site","code_information":[{"code":"64462","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Tap block bi injection","code_information":[{"code":"64488","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"N block spenopalatine gangl","code_information":[{"code":"64505","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":227.71,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":303.61,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":585.96,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":227.71,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":309.68,"additional_payer_notes":"APC"}]}]},{"description":"Neuroeltrd stim post tibial","code_information":[{"code":"64566","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":227.71,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":303.61,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":585.96,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":227.71,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":309.68,"additional_payer_notes":"APC"}]}]},{"description":"Insrt/redo pn/gastr stimul","code_information":[{"code":"64590","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8923.0,"maximum":44873.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19188.83,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":10765.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":8923.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":10765.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":44873.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":44873.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":44873.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":37034.45,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14391.63,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":43285.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19572.61,"additional_payer_notes":"APC"}]}]},{"description":"Chemodenerv musc neck dyston","code_information":[{"code":"64616","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":227.71,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":303.61,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":585.96,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":227.71,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":309.68,"additional_payer_notes":"APC"}]}]},{"description":"Destroy l/s facet jnt addl","code_information":[{"code":"64636","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Chemodenerv eccrine glands","code_information":[{"code":"64650","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":227.71,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":303.61,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":585.96,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":227.71,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":309.68,"additional_payer_notes":"APC"}]}]},{"description":"Revision of arm nerve(s)","code_information":[{"code":"64713","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1448.59,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1931.46,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3727.72,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1448.59,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1970.09,"additional_payer_notes":"APC"}]}]},{"description":"Internal nerve revision","code_information":[{"code":"64727","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Incise diaphragm nerve","code_information":[{"code":"64746","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1448.59,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1931.46,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3727.72,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1448.59,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1970.09,"additional_payer_notes":"APC"}]}]},{"description":"Remove digit nerve lesion","code_information":[{"code":"64776","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1448.59,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1931.46,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3727.72,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1448.59,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1970.09,"additional_payer_notes":"APC"}]}]},{"description":"Removal of nerve lesion","code_information":[{"code":"64790","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1448.59,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1931.46,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3727.72,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1448.59,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1970.09,"additional_payer_notes":"APC"}]}]},{"description":"Remove sympathetic nerves","code_information":[{"code":"64821","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Repair nerve add-on","code_information":[{"code":"64837","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Repair of facial nerve","code_information":[{"code":"64864","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":16752.93,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8680.28,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":16752.93,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6510.21,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8853.88,"additional_payer_notes":"APC"}]}]},{"description":"Nerve graft head/neck >4 cm","code_information":[{"code":"64886","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":16752.93,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8680.28,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":16752.93,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6510.21,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8853.88,"additional_payer_notes":"APC"}]}]},{"description":"Nerve graft arm/leg >4 cm","code_information":[{"code":"64898","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":16752.93,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8680.28,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":16752.93,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6510.21,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8853.88,"additional_payer_notes":"APC"}]}]},{"description":"Revise eye","code_information":[{"code":"65091","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2916.44,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3888.58,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7504.96,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2916.44,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3966.35,"additional_payer_notes":"APC"}]}]},{"description":"Revise ocular implant","code_information":[{"code":"65125","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1763.69,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2351.59,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4538.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1763.69,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2398.62,"additional_payer_notes":"APC"}]}]},{"description":"Remove foreign body from eye","code_information":[{"code":"65210","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":331.39,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":441.86,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":852.79,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":331.39,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":450.7,"additional_payer_notes":"APC"}]}]},{"description":"Repair of eye wound","code_information":[{"code":"65273","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3388.0,"maximum":4106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0}]}]},{"description":"Removal of eye lesion","code_information":[{"code":"65420","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1763.69,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2351.59,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4538.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1763.69,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2398.62,"additional_payer_notes":"APC"}]}]},{"description":"Corneal transplant","code_information":[{"code":"65730","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3066.31,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4088.41,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7890.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3066.31,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4170.17,"additional_payer_notes":"APC"}]}]},{"description":"Revise cornea with implant","code_information":[{"code":"65770","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":27691.88,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14348.13,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":27691.88,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10761.09,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14635.09,"additional_payer_notes":"APC"}]}]},{"description":"Ocular reconst transplant","code_information":[{"code":"65782","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2916.44,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3888.58,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7504.96,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2916.44,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3966.35,"additional_payer_notes":"APC"}]}]},{"description":"Incise inner eye adhesions","code_information":[{"code":"65860","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":408.01,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":544.01,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1049.93,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":408.01,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":554.89,"additional_payer_notes":"APC"}]}]},{"description":"Injection treatment of eye","code_information":[{"code":"66020","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1712.02,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2282.69,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4405.59,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1712.02,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2328.34,"additional_payer_notes":"APC"}]}]},{"description":"Translum dil eye canal","code_information":[{"code":"66174","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3066.31,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4088.41,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7890.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3066.31,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4170.17,"additional_payer_notes":"APC"}]}]},{"description":"Follow-up surgery of eye","code_information":[{"code":"66250","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1763.69,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2351.59,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4538.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1763.69,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2398.62,"additional_payer_notes":"APC"}]}]},{"description":"Repair iris & ciliary body","code_information":[{"code":"66680","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1712.02,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2282.69,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4405.59,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1712.02,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2328.34,"additional_payer_notes":"APC"}]}]},{"description":"Revision of iris","code_information":[{"code":"66762","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":408.01,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":544.01,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1049.93,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":408.01,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":554.89,"additional_payer_notes":"APC"}]}]},{"description":"Removal of lens material","code_information":[{"code":"66852","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3066.31,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4088.41,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7890.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3066.31,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4170.17,"additional_payer_notes":"APC"}]}]},{"description":"Exchange lens prosthesis","code_information":[{"code":"66986","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1712.02,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2282.69,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4405.59,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1712.02,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2328.34,"additional_payer_notes":"APC"}]}]},{"description":"Laparoscope proc stom","code_information":[{"code":"43659","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4484.77,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5979.69,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5257.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11540.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4484.77,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6099.28,"additional_payer_notes":"APC"}]}]},{"description":"Place gastrostomy tube","code_information":[{"code":"43830","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1423.51,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1898.01,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3663.16,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1423.51,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1935.97,"additional_payer_notes":"APC"}]}]},{"description":"Drainage of pelvic abscess","code_information":[{"code":"45000","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":887.71,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1183.61,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2284.37,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":887.71,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1207.28,"additional_payer_notes":"APC"}]}]},{"description":"Gingivectomy/plasty 1 to 3","code_information":[{"code":"D4211","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2459.51,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3279.35,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6329.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2459.51,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3344.94,"additional_payer_notes":"APC"}]}]},{"description":"Osseous surgery 4 or more","code_information":[{"code":"D4260","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":11300.84,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Auto tissue graft 1st tooth","code_information":[{"code":"D4273","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1151.01,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1534.69,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2961.94,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1151.01,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1565.38,"additional_payer_notes":"APC"}]}]},{"description":"Endosteal implant","code_information":[{"code":"D6012","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5512.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0}]}]},{"description":"Extraction erupted tooth/exr","code_information":[{"code":"D7140","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":479.59,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":639.45,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1234.13,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":479.59,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":652.24,"additional_payer_notes":"APC"}]}]},{"description":"Oral antral fistula closure","code_information":[{"code":"D7260","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":479.59,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":639.45,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1234.13,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":479.59,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":652.24,"additional_payer_notes":"APC"}]}]},{"description":"Biopsy of oral tissue soft","code_information":[{"code":"D7286","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5512.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0}]}]},{"description":"Bone harvest,auto graft proc","code_information":[{"code":"D7295","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5512.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0}]}]},{"description":"Excision benign lesion>1.25c","code_information":[{"code":"D7411","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1151.01,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1534.69,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2961.94,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1151.01,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1565.38,"additional_payer_notes":"APC"}]}]},{"description":"Rem odontogen cyst > 1.25 cm","code_information":[{"code":"D7451","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2459.51,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3279.35,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6329.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2459.51,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3344.94,"additional_payer_notes":"APC"}]}]},{"description":"Maxilla or mandible resectio","code_information":[{"code":"D7490","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5512.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0}]}]},{"description":"Maxillary sinusotomy","code_information":[{"code":"D7560","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5512.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0}]}]},{"description":"Open red comp malar/zygma fx","code_information":[{"code":"D7750","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5512.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0}]}]},{"description":"Tmj excisn of joint membrane","code_information":[{"code":"D7854","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5512.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0}]}]},{"description":"Tmj arthroscopy lysis adhesn","code_information":[{"code":"D7873","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5512.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0}]}]},{"description":"Dental skin graft","code_information":[{"code":"D7920","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5512.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0}]}]},{"description":"Reconstruct maxilla segment","code_information":[{"code":"D7947","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5512.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0}]}]},{"description":"Frenuloplasty","code_information":[{"code":"D7963","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5512.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0}]}]},{"description":"Emergency tracheotomy","code_information":[{"code":"D7990","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5512.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0}]}]},{"description":"Colorectal scrn; hi risk ind","code_information":[{"code":"G0105","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":689.87,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":919.83,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1775.27,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":689.87,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":938.23,"additional_payer_notes":"APC"}]}]},{"description":"Percutaneous islet celltrans","code_information":[{"code":"G0341","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5257.0,"maximum":6462.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5257.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6462.0}]}]},{"description":"Dermal filler injection(s)","code_information":[{"code":"G0429","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1530.61,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2040.81,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3938.76,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1530.61,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2081.63,"additional_payer_notes":"APC"}]}]},{"description":"harvesting organs, cadaver donor","code_information":[{"code":"S2055","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5512.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0}]}]},{"description":"Heller esophagomyotomy","code_information":[{"code":"S2079","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5512.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0}]}]},{"description":"Arthroereisis, subtalar","code_information":[{"code":"S2117","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5512.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0}]}]},{"description":"Implant auditory brain imp","code_information":[{"code":"S2235","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5512.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0}]}]},{"description":"Fetal surg myelomeningo","code_information":[{"code":"S2404","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5512.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0}]}]},{"description":"Njx interlaminar lmbr/sac","code_information":[{"code":"62323","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":523.65,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":698.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1347.51,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":523.65,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":712.16,"additional_payer_notes":"APC"}]}]},{"description":"Egd flx trnsorl dplmnt balo","code_information":[{"code":"43290","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1423.51,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1898.01,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3663.16,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1423.51,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1935.97,"additional_payer_notes":"APC"}]}]},{"description":"Tmvi transthoracic exposure","code_information":[{"code":"0484T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5257.0,"maximum":6462.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5257.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6462.0}]}]},{"description":"Nsl/sins ndsc w/artery lig","code_information":[{"code":"31241","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1320.39,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1760.51,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3397.79,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1320.39,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1795.72,"additional_payer_notes":"APC"}]}]},{"description":"Rmvl rplcmt hrt sys f/trnspl","code_information":[{"code":"33929","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8923.0,"maximum":10765.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":10765.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":8923.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":10765.0}]}]},{"description":"Incision of gallbladder","code_information":[{"code":"47490","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2656.06,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3541.41,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6834.92,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2656.06,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3612.24,"additional_payer_notes":"APC"}]}]},{"description":"Perq plmt bile duct stent","code_information":[{"code":"47538","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4484.77,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5979.69,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5257.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11540.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4484.77,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6099.28,"additional_payer_notes":"APC"}]}]},{"description":"Biliary endo perq dx w/speci","code_information":[{"code":"47552","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":12358.4,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6403.32,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":12358.4,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4802.49,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6531.38,"additional_payer_notes":"APC"}]}]},{"description":"Peritoneal lavage","code_information":[{"code":"49084","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":672.83,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":897.11,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1731.42,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":672.83,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":915.05,"additional_payer_notes":"APC"}]}]},{"description":"Lap ing hernia repair recur","code_information":[{"code":"49651","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4484.77,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5979.69,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5257.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11540.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4484.77,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6099.28,"additional_payer_notes":"APC"}]}]},{"description":"Injection eye drug","code_information":[{"code":"67028","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":245.03,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":326.71,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":630.55,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":245.03,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":333.24,"additional_payer_notes":"APC"}]}]},{"description":"Vit for membrane dissect","code_information":[{"code":"67043","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3066.31,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4088.41,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7890.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3066.31,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4170.17,"additional_payer_notes":"APC"}]}]},{"description":"Remove eye implant material","code_information":[{"code":"67120","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1712.02,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2282.69,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4405.59,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1712.02,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2328.34,"additional_payer_notes":"APC"}]}]},{"description":"Ocular Photodynamic Ther","code_information":[{"code":"67221","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":408.01,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":544.01,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1049.93,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":408.01,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":554.89,"additional_payer_notes":"APC"}]}]},{"description":"Revise eye muscle","code_information":[{"code":"67311","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1763.69,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2351.59,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4538.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1763.69,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2398.62,"additional_payer_notes":"APC"}]}]},{"description":"Revise eye muscle w/suture","code_information":[{"code":"67334","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Explore/drain eye socket","code_information":[{"code":"67405","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1763.69,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2351.59,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4538.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1763.69,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2398.62,"additional_payer_notes":"APC"}]}]},{"description":"Explr/decompress eye socket","code_information":[{"code":"67445","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2916.44,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3888.58,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7504.96,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2916.44,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3966.35,"additional_payer_notes":"APC"}]}]},{"description":"Orbit surgery procedure","code_information":[{"code":"67599","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":235.46,"maximum":13249.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":313.95,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":13249.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":10779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":13249.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":605.92,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":235.46,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":320.23,"additional_payer_notes":"APC"}]}]},{"description":"Biopsy eyelid & lid margin","code_information":[{"code":"67810","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":235.46,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":313.95,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":605.92,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":235.46,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":320.23,"additional_payer_notes":"APC"}]}]},{"description":"Revision of eyelid","code_information":[{"code":"67880","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1763.69,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2351.59,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4538.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1763.69,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2398.62,"additional_payer_notes":"APC"}]}]},{"description":"Repair eyelid defect","code_information":[{"code":"67908","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1763.69,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2351.59,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4538.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1763.69,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2398.62,"additional_payer_notes":"APC"}]}]},{"description":"Repair eyelid defect","code_information":[{"code":"67921","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1763.69,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2351.59,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4538.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1763.69,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2398.62,"additional_payer_notes":"APC"}]}]},{"description":"Revision of eyelid","code_information":[{"code":"67961","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1763.69,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2351.59,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4538.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1763.69,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2398.62,"additional_payer_notes":"APC"}]}]},{"description":"Treatment of eyelid lesions","code_information":[{"code":"68040","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":235.46,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":313.95,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":605.92,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":235.46,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":320.23,"additional_payer_notes":"APC"}]}]},{"description":"Revise/graft eyelid lining","code_information":[{"code":"68325","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2916.44,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3888.58,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7504.96,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2916.44,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3966.35,"additional_payer_notes":"APC"}]}]},{"description":"Harvest eye tissue alograft","code_information":[{"code":"68371","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1763.69,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2351.59,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4538.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1763.69,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2398.62,"additional_payer_notes":"APC"}]}]},{"description":"Removal of tear sac","code_information":[{"code":"68520","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2916.44,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3888.58,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7504.96,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2916.44,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3966.35,"additional_payer_notes":"APC"}]}]},{"description":"Create tear duct drain","code_information":[{"code":"68745","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2916.44,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3888.58,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7504.96,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2916.44,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3966.35,"additional_payer_notes":"APC"}]}]},{"description":"Probe nasolacrimal duct","code_information":[{"code":"68815","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1763.69,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2351.59,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4538.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1763.69,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2398.62,"additional_payer_notes":"APC"}]}]},{"description":"Pierce earlobes","code_information":[{"code":"69090","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5512.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0}]}]},{"description":"Extensive ear/neck surgery","code_information":[{"code":"69155","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Rebuild outer ear canal","code_information":[{"code":"69310","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Exploration of middle ear","code_information":[{"code":"69440","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2459.51,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3279.35,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6329.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2459.51,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3344.94,"additional_payer_notes":"APC"}]}]},{"description":"Remove ear lesion","code_information":[{"code":"69540","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1151.01,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1534.69,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2961.94,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1151.01,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1565.38,"additional_payer_notes":"APC"}]}]},{"description":"Repair of eardrum","code_information":[{"code":"69610","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1151.01,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1534.69,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2961.94,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1151.01,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1565.38,"additional_payer_notes":"APC"}]}]},{"description":"Revise middle ear & mastoid","code_information":[{"code":"69641","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Revise middle ear bone","code_information":[{"code":"69661","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Remove/repair hearing aid","code_information":[{"code":"69711","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2459.51,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3279.35,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6329.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2459.51,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3344.94,"additional_payer_notes":"APC"}]}]},{"description":"Incise inner ear","code_information":[{"code":"69801","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1151.01,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1534.69,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2961.94,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1151.01,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1565.38,"additional_payer_notes":"APC"}]}]},{"description":"Incise inner ear nerve","code_information":[{"code":"69950","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"R&l hrt cath w/ventriclgrphy","code_information":[{"code":"93453","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2404.97,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3206.62,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6188.79,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2404.97,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3270.76,"additional_payer_notes":"APC"}]}]},{"description":"R&l hrt art/ventricle angio","code_information":[{"code":"93461","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2404.97,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3206.62,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6188.79,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2404.97,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3270.76,"additional_payer_notes":"APC"}]}]},{"description":"Perc d-e cor revasc t cabg s","code_information":[{"code":"C9604","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":27583.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11418.47,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":22037.64,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8563.85,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":27583.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11646.84,"additional_payer_notes":"APC"}]}]},{"description":"Place device/marker, non pro","code_information":[{"code":"C9728","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1026.79,"maximum":4106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1369.06,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2642.28,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1026.79,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1396.44,"additional_payer_notes":"APC"}]}]},{"description":"Guided tissue regeneration","code_information":[{"code":"D3432","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":479.59,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":639.45,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1234.13,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":479.59,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":652.24,"additional_payer_notes":"APC"}]}]},{"description":"Close bladder-uterus fistula","code_information":[{"code":"51920","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0}]}]},{"description":"Treatment of penis lesion","code_information":[{"code":"54200","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":185.35,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":247.13,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":476.96,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":185.35,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":252.07,"additional_payer_notes":"APC"}]}]},{"description":"Revision of penis","code_information":[{"code":"54300","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2614.94,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3486.59,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6729.12,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2614.94,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3556.32,"additional_payer_notes":"APC"}]}]},{"description":"Reconstruction of urethra","code_information":[{"code":"54326","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2614.94,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3486.59,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6729.12,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2614.94,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3556.32,"additional_payer_notes":"APC"}]}]},{"description":"Penis plastic surgery","code_information":[{"code":"54360","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2614.94,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3486.59,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6729.12,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2614.94,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3556.32,"additional_payer_notes":"APC"}]}]},{"description":"Repair multi-comp penis pros","code_information":[{"code":"54408","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3977.55,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5303.4,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":10235.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3977.55,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5409.47,"additional_payer_notes":"APC"}]}]},{"description":"Ana crown exp 4 or> per quad","code_information":[{"code":"D4230","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2459.51,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3279.35,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6329.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2459.51,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3344.94,"additional_payer_notes":"APC"}]}]},{"description":"Bone replce graft first site","code_information":[{"code":"D4263","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":479.59,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":639.45,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1234.13,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":479.59,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":652.24,"additional_payer_notes":"APC"}]}]},{"description":"Non-auto graft 1st tooth","code_information":[{"code":"D4275","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1151.01,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1534.69,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2961.94,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1151.01,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1565.38,"additional_payer_notes":"APC"}]}]},{"description":"Odontics eposteal implant","code_information":[{"code":"D6040","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5512.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0}]}]},{"description":"Impact tooth remov soft tiss","code_information":[{"code":"D7220","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":479.59,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":639.45,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1234.13,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":479.59,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":652.24,"additional_payer_notes":"APC"}]}]},{"description":"Tooth reimplantation","code_information":[{"code":"D7270","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":479.59,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":639.45,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1234.13,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":479.59,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":652.24,"additional_payer_notes":"APC"}]}]},{"description":"Brush biopsy","code_information":[{"code":"D7288","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5512.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0}]}]},{"description":"Alveoloplasty w/extract 1-3","code_information":[{"code":"D7311","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1151.01,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1534.69,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2961.94,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1151.01,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1565.38,"additional_payer_notes":"APC"}]}]},{"description":"Excision malig lesion<=1.25c","code_information":[{"code":"D7413","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1151.01,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1534.69,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2961.94,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1151.01,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1565.38,"additional_payer_notes":"APC"}]}]},{"description":"Rem nonodonto cyst > 1.25 cm","code_information":[{"code":"D7461","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":479.59,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":639.45,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1234.13,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":479.59,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":652.24,"additional_payer_notes":"APC"}]}]},{"description":"Incision/drain abscess intra","code_information":[{"code":"D7511","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":525.32,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":700.42,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1351.81,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":525.32,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":714.43,"additional_payer_notes":"APC"}]}]},{"description":"Open red simpl mandible fx","code_information":[{"code":"D7630","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5512.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0}]}]},{"description":"Reduct compnd facial bone fx","code_information":[{"code":"D7780","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5512.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0}]}]},{"description":"Tmj reconstruction","code_information":[{"code":"D7858","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5512.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0}]}]},{"description":"Tmj arthroscopy synovectomy","code_information":[{"code":"D7875","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5512.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0}]}]},{"description":"Reshaping bone orthognathic","code_information":[{"code":"D7940","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":479.59,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":639.45,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1234.13,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":479.59,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":652.24,"additional_payer_notes":"APC"}]}]},{"description":"Reconstruct midface w/graft","code_information":[{"code":"D7949","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5512.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0}]}]},{"description":"Excision pericoronal gingiva","code_information":[{"code":"D7971","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5512.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0}]}]},{"description":"Synthetic graft facial bones","code_information":[{"code":"D7995","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5512.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0}]}]},{"description":"Inject for sacroiliac joint","code_information":[{"code":"G0259","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Laparotomy islet cell transp","code_information":[{"code":"G0343","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8923.0,"maximum":10765.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":10765.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":8923.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":10765.0}]}]},{"description":"Screening protoscopy","code_information":[{"code":"S0601","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5512.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0}]}]},{"description":"Donor lobectomy, live donor","code_information":[{"code":"S2061","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5512.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0}]}]},{"description":"gastric band adjustment, percutaneous","code_information":[{"code":"S2083","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5512.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0}]}]},{"description":"Minimally invasive direct co","code_information":[{"code":"S2206","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5512.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0}]}]},{"description":"Diskectomy, anterior, with d","code_information":[{"code":"S2350","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5512.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0}]}]},{"description":"Fetal surg noc","code_information":[{"code":"S2409","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5512.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0}]}]},{"description":"Njx interlaminar crv/thrc","code_information":[{"code":"62325","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":656.13,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":874.84,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1688.44,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":656.13,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":892.34,"additional_payer_notes":"APC"}]}]},{"description":"Implantation iris prosthesis","code_information":[{"code":"66683","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3388.0,"maximum":31423.41,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16281.56,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":31423.41,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12211.17,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16607.19,"additional_payer_notes":"APC"}]}]},{"description":"Regn cell tx scldr h mlt inj","code_information":[{"code":"0490T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2654.0,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0}]}]},{"description":"Evasc rpr a-ao ndgft rpt","code_information":[{"code":"34702","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":9356.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0}]}]},{"description":"Repair bladder-vagina lesion","code_information":[{"code":"57320","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3710.98,"maximum":9549.58,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4947.97,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":9549.58,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3710.98,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5046.93,"additional_payer_notes":"APC"}]}]},{"description":"Repair paravag defect lap","code_information":[{"code":"57423","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":20292.15,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10514.07,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":20292.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7885.55,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10724.35,"additional_payer_notes":"APC"}]}]},{"description":"Conz of cervix w/scope leep","code_information":[{"code":"57461","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2401.4,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3201.87,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6179.61,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2401.4,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3265.91,"additional_payer_notes":"APC"}]}]},{"description":"Dilation of cervical canal","code_information":[{"code":"57800","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2401.4,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3201.87,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6179.61,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2401.4,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3265.91,"additional_payer_notes":"APC"}]}]},{"description":"Lsh uterus 250 g or less","code_information":[{"code":"58541","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5257.0,"maximum":20292.15,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10514.07,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5257.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":20292.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7885.55,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10724.35,"additional_payer_notes":"APC"}]}]},{"description":"Laparo-vag hyst incl t/o","code_information":[{"code":"58552","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":20292.15,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10514.07,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":20292.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7885.55,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10724.35,"additional_payer_notes":"APC"}]}]},{"description":"Hysteroscopy remove fb","code_information":[{"code":"58562","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2401.4,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3201.87,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6179.61,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2401.4,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3265.91,"additional_payer_notes":"APC"}]}]},{"description":"Laparoscopy tubal cautery","code_information":[{"code":"58670","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4484.77,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5979.69,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5257.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11540.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4484.77,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6099.28,"additional_payer_notes":"APC"}]}]},{"description":"Fetal shunt placement w/us","code_information":[{"code":"59076","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":226.06,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":301.41,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":581.72,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":226.06,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":307.44,"additional_payer_notes":"APC"}]}]},{"description":"Endocrine surgery procedure","code_information":[{"code":"60699","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4484.77,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5979.69,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":13249.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":10779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":13249.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11540.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4484.77,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6099.28,"additional_payer_notes":"APC"}]}]},{"description":"Insert brain-fluid device","code_information":[{"code":"61215","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":16752.93,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8680.28,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":16752.93,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6510.21,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8853.88,"additional_payer_notes":"APC"}]}]},{"description":"Treat skull fracture","code_information":[{"code":"62000","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2459.51,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3279.35,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6329.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2459.51,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3344.94,"additional_payer_notes":"APC"}]}]},{"description":"Njx interlaminar crv/thrc","code_information":[{"code":"62324","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":656.13,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":874.84,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1688.44,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":656.13,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":892.34,"additional_payer_notes":"APC"}]}]},{"description":"Remove spine lamina >2 thrc","code_information":[{"code":"63016","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Laminotomy addl lumbar","code_information":[{"code":"63044","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5512.0,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0}]}]},{"description":"Decompress spinal cord lmbr","code_information":[{"code":"63056","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Destroy lumb/sac facet jnt","code_information":[{"code":"64635","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1448.59,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1931.46,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3727.72,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1448.59,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1970.09,"additional_payer_notes":"APC"}]}]},{"description":"Chemodenerv trunk musc 6/>","code_information":[{"code":"64647","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":523.65,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":698.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1347.51,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":523.65,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":712.16,"additional_payer_notes":"APC"}]}]},{"description":"Revision of sciatic nerve","code_information":[{"code":"64712","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1448.59,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1931.46,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3727.72,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1448.59,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1970.09,"additional_payer_notes":"APC"}]}]},{"description":"Release foot/toe nerve","code_information":[{"code":"64726","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1448.59,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1931.46,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3727.72,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1448.59,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1970.09,"additional_payer_notes":"APC"}]}]},{"description":"Incise nerve back of head","code_information":[{"code":"64744","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1448.59,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1931.46,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3727.72,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1448.59,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1970.09,"additional_payer_notes":"APC"}]}]},{"description":"Digit nerve surgery add-on","code_information":[{"code":"64778","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Removal of nerve lesion","code_information":[{"code":"64792","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2534.21,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3378.94,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6521.36,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2534.21,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3446.52,"additional_payer_notes":"APC"}]}]},{"description":"Ophthalmic endoscope add-on","code_information":[{"code":"66990","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Drain outer ear canal lesion","code_information":[{"code":"69020","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":525.32,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":700.42,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1351.81,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":525.32,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":714.43,"additional_payer_notes":"APC"}]}]},{"description":"Clear outer ear canal","code_information":[{"code":"69200","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":98.7,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":131.6,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":253.99,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":98.7,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":134.23,"additional_payer_notes":"APC"}]}]},{"description":"Rebuild outer ear canal","code_information":[{"code":"69320","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Eardrum revision","code_information":[{"code":"69450","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2459.51,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3279.35,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6329.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2459.51,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3344.94,"additional_payer_notes":"APC"}]}]},{"description":"Implant Temple Bone W/Stimul","code_information":[{"code":"69714","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":27583.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12698.86,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":24508.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9524.15,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":27583.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12952.84,"additional_payer_notes":"APC"}]}]},{"description":"Gastroesophageal reflux test","code_information":[{"code":"91034","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":276.82,"maximum":2334.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":369.09,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":712.35,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":276.82,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":376.48,"additional_payer_notes":"APC"}]}]},{"description":"Gi wireless capsule measure","code_information":[{"code":"91112","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":672.83,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":897.11,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1731.42,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":672.83,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":915.05,"additional_payer_notes":"APC"}]}]},{"description":"Eye exam & treatment","code_information":[{"code":"92019","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1763.69,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2351.59,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4538.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1763.69,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2398.62,"additional_payer_notes":"APC"}]}]},{"description":"Prq card stent/ath/angio","code_information":[{"code":"92933","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":13599.0,"maximum":34994.75,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18131.99,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":34994.75,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13599.0,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18494.63,"additional_payer_notes":"APC"}]}]},{"description":"Temporary external pacing","code_information":[{"code":"92953","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":490.31,"maximum":3030.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":653.75,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1261.73,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":490.31,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":666.82,"additional_payer_notes":"APC"}]}]},{"description":"Revision of aortic valve","code_information":[{"code":"92986","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4222.18,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5629.58,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":10865.09,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4222.18,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5742.17,"additional_payer_notes":"APC"}]}]},{"description":"Coronary artery angio s&i","code_information":[{"code":"93454","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2404.97,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3206.62,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6188.79,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2404.97,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3270.76,"additional_payer_notes":"APC"}]}]},{"description":"L hrt cath trnsptl puncture","code_information":[{"code":"93462","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Inject r ventr/atrial angio","code_information":[{"code":"93566","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":2334.0,"payers_information":[{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Njx cath slct p angrph mapca","code_information":[{"code":"93575","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":2334.0,"payers_information":[{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Map tachycardia add-on","code_information":[{"code":"93609","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":2334.0,"payers_information":[{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Electrophysiology evaluation","code_information":[{"code":"93620","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5786.04,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7714.72,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":14889.41,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5786.04,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7869.01,"additional_payer_notes":"APC"}]}]},{"description":"Electrophysiology evaluation","code_information":[{"code":"93642","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":903.21,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1204.28,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2324.26,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":903.21,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1228.36,"additional_payer_notes":"APC"}]}]},{"description":"Tilt table evaluation","code_information":[{"code":"93660","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":276.82,"maximum":2334.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":369.09,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":712.35,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":276.82,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":376.48,"additional_payer_notes":"APC"}]}]},{"description":"Photodynmc tx 30 min add-on","code_information":[{"code":"96570","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":2334.0,"payers_information":[{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Low cost skin substitute app","code_information":[{"code":"C5273","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3579.0,"maximum":4761.0,"payers_information":[{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0}]}]},{"description":"Insert palate implants","code_information":[{"code":"C9727","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1151.01,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1534.69,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2961.94,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1151.01,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1565.38,"additional_payer_notes":"APC"}]}]},{"description":"Interatrial shunt IDE","code_information":[{"code":"C9758","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":12707.2,"maximum":44873.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16942.93,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":44873.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":44873.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":44873.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":32699.86,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12707.2,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":43285.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17281.79,"additional_payer_notes":"APC"}]}]},{"description":"Cysto w/temp pros implant","code_information":[{"code":"C9769","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7529.0,"maximum":7791.0,"payers_information":[{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0}]}]},{"description":"ESD endoscopy or colonoscopy","code_information":[{"code":"C9779","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2860.11,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3813.48,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7360.02,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2860.11,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3889.75,"additional_payer_notes":"APC"}]}]},{"description":"Trim nail(s)","code_information":[{"code":"G0127","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":43.76,"maximum":2334.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":58.35,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":112.62,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":43.76,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":59.52,"additional_payer_notes":"APC"}]}]},{"description":"Iiv adjuvant vaccine im","code_information":[{"code":"90653","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":91.84,"maximum":227.3,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":91.84},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":158.63},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":158.63},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":158.63},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":154.46},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":227.3}]}]},{"description":"Pcv15 vaccine im","code_information":[{"code":"90671","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":287.27,"maximum":690.31,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":287.27},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":496.18},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":496.18},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":496.18},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":469.09},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":690.31}]}]},{"description":"Hepb vacc 2 dose adult im","code_information":[{"code":"90739","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":195.32,"maximum":458.21,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":195.32},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":337.35},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":337.35},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":337.35},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":311.36},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":458.21}]}]},{"description":"Sarscov2 vac 3mcg trs-suc im","code_information":[{"code":"91318","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":72.11,"maximum":178.46,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":72.11},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":124.55},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":124.55},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":124.55},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":121.27},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":178.46}]}]},{"description":"Inj multihance","code_information":[{"code":"A9577","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2.0,"maximum":4.95,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3.31},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3.31},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3.31},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3.37},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":4.95}]}]},{"description":"Inj., eravacycline, 1 mg","code_information":[{"code":"J0122","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1.04,"maximum":3.3,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1.38,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1.33},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2.45},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2.45},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2.45},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2.67,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1.31},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1.04,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2.24},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3.3},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1.41,"additional_payer_notes":"APC"}]}]},{"description":"Injection, acetaminoph 10 mg","code_information":[{"code":"J0138","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":0.07,"maximum":0.76,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":0.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":0.24},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.41},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.41},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.41},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":0.18,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":0.07,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.76},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":0.09,"additional_payer_notes":"APC"}]}]},{"description":"Inj, lecanemab-irmb","code_information":[{"code":"J0174","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1.01,"maximum":3.61,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1.34,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1.46},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2.52},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2.52},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2.52},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2.59,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1.44},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1.01,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2.46},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3.61},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1.37,"additional_payer_notes":"APC"}]}]},{"description":"Inj allopurinol sodium 1 mg","code_information":[{"code":"J0206","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3.06,"maximum":11.98,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4.07,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4.9},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8.63},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8.63},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8.63},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7.86,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":4.75},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3.06,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8.14},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11.98},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4.16,"additional_payer_notes":"APC"}]}]},{"description":"Inj, vutrisiran, 1 mg","code_information":[{"code":"J0225","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3759.45,"maximum":13388.58,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5012.6,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5451.94},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":9469.32},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":9469.32},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":9469.32},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":9674.32,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5324.57},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3759.45,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9097.84},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13388.58},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5112.85,"additional_payer_notes":"APC"}]}]},{"description":"Inj, amiodarone (nexterone)","code_information":[{"code":"J0283","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2.73,"maximum":6.86,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2.85},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4.96},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4.96},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4.96},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2.73},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":4.66},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6.86}]}]},{"description":"Inj, rezafungin, 1 mg","code_information":[{"code":"J0349","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8.25,"maximum":28.36,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":11.46},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20.17},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20.17},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20.17},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":21.23,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11.29},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8.25,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19.28},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28.36},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11.22,"additional_payer_notes":"APC"}]}]},{"description":"Baclofen intrathecal trial","code_information":[{"code":"J0476","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":44.1,"maximum":127.69,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":59.2},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":127.69},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":127.69},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":127.69},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":44.1},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":75.35},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":110.88}]}]},{"description":"PenG benzathine/procaine inj","code_information":[{"code":"J0558","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":14.64,"maximum":47.29,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19.52,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":19.11},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":33.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":33.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":33.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":37.68,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18.8},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14.64,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32.13},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":47.29},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19.91,"additional_payer_notes":"APC"}]}]},{"description":"Abobotulinumtoxina","code_information":[{"code":"J0586","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6.71,"maximum":23.22,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8.95,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":9.94},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17.42},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17.42},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17.42},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":17.27,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9.23},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6.71,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15.78},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23.22},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9.12,"additional_payer_notes":"APC"}]}]},{"description":"Injection, ruconest","code_information":[{"code":"J0596","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":28.37,"maximum":94.4,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":37.83,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":38.23},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":69.8},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":69.8},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":69.8},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":73.02,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37.53},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":28.37,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":64.14},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":94.4},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":38.59,"additional_payer_notes":"APC"}]}]},{"description":"Canakinumab injection","code_information":[{"code":"J0638","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":117.41,"maximum":369.93,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":156.54,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":150.22},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":267.89},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":267.89},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":267.89},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":302.12,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":147.12},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":117.41,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":251.38},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":369.93},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":159.67,"additional_payer_notes":"APC"}]}]},{"description":"Inj, bupivacaine liposome","code_information":[{"code":"J0666","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1.09,"maximum":3.94,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1.45,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1.56},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2.84},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2.84},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2.84},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2.81,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1.56},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1.09,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2.68},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3.94},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1.48,"additional_payer_notes":"APC"}]}]},{"description":"Inj ceftolozane tazobactam","code_information":[{"code":"J0695","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7.53,"maximum":22.19,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10.04,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":8.84},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17.34},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17.34},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17.34},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":19.37,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8.82},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7.53,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15.08},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22.19},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10.24,"additional_payer_notes":"APC"}]}]},{"description":"Inj ceftazidime per 500 mg","code_information":[{"code":"J0713","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1.76,"maximum":4.49,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1.76},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3.12},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3.12},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3.12},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1.79},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3.05},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":4.49}]}]},{"description":"Cidofovir injection","code_information":[{"code":"J0740","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":326.01,"maximum":1033.97,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":535.74,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":574.01},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1005.81},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1005.81},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1005.81},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1033.97,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":326.01},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":401.8,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":557.04},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":819.75},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":546.45,"additional_payer_notes":"APC"}]}]},{"description":"Collagenase, clost hist inj","code_information":[{"code":"J0775","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":58.72,"maximum":193.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":78.3,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":80.72},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":139.01},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":139.01},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":139.01},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":151.12,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":76.75},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":58.72,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":131.15},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":193.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":79.86,"additional_payer_notes":"APC"}]}]},{"description":"Cytomegalovirus imm IV /vial","code_information":[{"code":"J0850","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1394.12,"maximum":4938.91,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1858.82,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1993.21},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3437.94},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3437.94},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3437.94},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3587.52,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1964.18},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1394.12,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3356.1},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":4938.91},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1896.0,"additional_payer_notes":"APC"}]}]},{"description":"Darbepoetin alfa, non-esrd","code_information":[{"code":"J0881","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2.19,"maximum":8.09,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2.92,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3.21},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5.69},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5.69},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5.69},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5.64,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3.22},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2.19,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5.49},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8.09},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2.98,"additional_payer_notes":"APC"}]}]},{"description":"Decitabine injection","code_information":[{"code":"J0894","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1.95,"maximum":6.34,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1.95},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3.02},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3.02},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3.02},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2.52},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":4.31},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6.34}]}]},{"description":"Rbc dna hea 35 ag 11 bld grp","code_information":[{"code":"0001U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":540.0,"maximum":1389.6,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":720.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1069.54},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":900.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":900.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":900.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1389.6,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":540.0,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1260.0},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":720.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":734.4,"additional_payer_notes":"APC"}]}]},{"description":"Onc gastro 51 gene nomogram","code_information":[{"code":"0007M","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":281.25,"maximum":723.75,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":375.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":557.05},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":468.75},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":468.75},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":468.75},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":723.75,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":281.25,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":656.25},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":382.5,"additional_payer_notes":"APC"}]}]},{"description":"Onc mrna 5 gen recr urthl ca","code_information":[{"code":"0013M","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":570.0,"maximum":1466.8,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":760.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1128.96},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":950.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":950.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":950.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1466.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":570.0,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1330.0},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":760.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":775.2,"additional_payer_notes":"APC"}]}]},{"description":"Cv ds plasma alys prtn bmrk","code_information":[{"code":"0019M","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":534.3,"maximum":1374.93,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":712.4,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1025.86},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":890.5},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":890.5},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":890.5},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1374.93,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":534.3,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1246.7},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":712.4},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":726.65,"additional_payer_notes":"APC"}]}]},{"description":"Onc thyr dna&mrna 112 genes","code_information":[{"code":"0026U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2700.0,"maximum":6948.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3600.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5347.69},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4500.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4500.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4500.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6948.0,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2700.0,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6300.0},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3600.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3672.0,"additional_payer_notes":"APC"}]}]},{"description":"Neuro csf prion prtn qual","code_information":[{"code":"0035U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":405.74,"maximum":1044.11,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":540.99,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":676.24},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":676.24},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":676.24},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1044.11,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":405.74,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":946.73},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":540.99},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":551.81,"additional_payer_notes":"APC"}]}]},{"description":"Tbrf b grp antb 4 prtn igm","code_information":[{"code":"0043U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":11.14,"maximum":28.68,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14.86,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18.58},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18.58},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18.58},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":28.68,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11.14,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26.01},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14.86},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15.16,"additional_payer_notes":"APC"}]}]},{"description":"Rx mntr lc-ms/ms ur 31 pnl","code_information":[{"code":"0051U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":185.19,"maximum":476.56,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":246.92,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":305.47},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":308.65},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":308.65},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":308.65},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":476.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":185.19,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":432.11},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":193.71},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":251.86,"additional_payer_notes":"APC"}]}]},{"description":"Onc clrct 3 ur metab alg plp","code_information":[{"code":"0002U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":18.75,"maximum":48.25,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":37.14},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":31.25},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":31.25},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":31.25},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":48.25,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18.75,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":43.75},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25.5,"additional_payer_notes":"APC"}]}]},{"description":"Hpylori detcj abx rstnc dna","code_information":[{"code":"0008U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":448.43,"maximum":1153.97,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":597.91,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":888.18},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":747.39},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":747.39},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":747.39},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1153.97,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":448.43,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1046.34},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":597.91},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":609.87,"additional_payer_notes":"APC"}]}]},{"description":"Onc bladder mrna 209 gen alg","code_information":[{"code":"0016M","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2617.22,"maximum":6734.99,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3489.63,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5183.75},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4362.04},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4362.04},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4362.04},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6734.99,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2617.22,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6106.85},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3489.63},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3559.42,"additional_payer_notes":"APC"}]}]},{"description":"Rx metab advrs trgt seq alys","code_information":[{"code":"0029U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":742.27,"maximum":1298.97,"payers_information":[{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":927.84},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":927.84},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":927.84},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1298.97},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":742.27}]}]},{"description":"Trgt gen seq dna 324 genes","code_information":[{"code":"0037U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2625.0,"maximum":6755.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3500.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5199.14},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4375.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4375.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4375.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6755.0,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2625.0,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6125.0},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3500.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3570.0,"additional_payer_notes":"APC"}]}]},{"description":"Onc brst dux carc is 12 gene","code_information":[{"code":"0045U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2904.75,"maximum":7474.89,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3873.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5753.22},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4841.25},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4841.25},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4841.25},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7474.89,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2904.75,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6777.75},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3873.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3950.46,"additional_payer_notes":"APC"}]}]},{"description":"Rx mntr 14+ drugs & sbsts","code_information":[{"code":"0054U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":148.96,"maximum":383.57,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":198.74,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":245.87},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":248.43},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":248.43},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":248.43},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":383.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":149.06,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":347.8},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":148.96},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":202.71,"additional_payer_notes":"APC"}]}]},{"description":"Inj testosterone cypionate","code_information":[{"code":"J1071","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":0.03,"maximum":0.08,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":0.03},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.06},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.06},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.06},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.04},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.06},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.08}]}]},{"description":"Inj, diltiazem hcl, 0.5 mg","code_information":[{"code":"J1163","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":0.07,"maximum":0.07,"payers_information":[{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.07},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.07},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.07}]}]},{"description":"Dimethyl sulfoxide 50% 50 ML","code_information":[{"code":"J1212","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":561.66,"maximum":1947.64,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":748.88,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":786.19},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1411.5},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1411.5},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1411.5},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1445.34,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":774.57},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":561.66,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1323.47},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1947.64},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":763.86,"additional_payer_notes":"APC"}]}]},{"description":"Ecallantide injection","code_information":[{"code":"J1290","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":446.96,"maximum":1533.05,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":595.94,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":621.1},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1101.98},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1101.98},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1101.98},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1150.17,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":609.68},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":446.96,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1041.74},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1533.05},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":607.86,"additional_payer_notes":"APC"}]}]},{"description":"Inj, famotidine, 0.25 mg","code_information":[{"code":"J1308","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":0.01,"maximum":0.02,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":0.01},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.02},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.02},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.02}]}]},{"description":"Inj estrogen conjugate 25 MG","code_information":[{"code":"J1410","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":301.13,"maximum":1042.47,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":401.5,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":421.18},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":742.41},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":742.41},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":742.41},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":774.9,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":414.59},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":301.13,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":708.38},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1042.47},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":409.53,"additional_payer_notes":"APC"}]}]},{"description":"Injection, trilaciclib, 1mg","code_information":[{"code":"J1448","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4.1,"maximum":14.62,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5.46,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5.93},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10.25},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10.25},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10.25},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":10.54,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5.81},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4.1,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9.93},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14.62},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5.57,"additional_payer_notes":"APC"}]}]},{"description":"Inj IVIG privigen 500 mg","code_information":[{"code":"J1459","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":38.41,"maximum":134.16,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":51.22,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":54.1},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":95.82},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":95.82},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":95.82},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":98.85,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":53.36},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":38.41,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":91.17},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":134.16},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":52.24,"additional_payer_notes":"APC"}]}]},{"description":"Inj. xembify, 100 mg","code_information":[{"code":"J1558","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":11.43,"maximum":38.82,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15.24,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":15.71},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28.33},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28.33},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28.33},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":29.42,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15.43},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11.43,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26.38},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38.82},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15.55,"additional_payer_notes":"APC"}]}]},{"description":"HepaGam B IM injection","code_information":[{"code":"J1571","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":49.21,"maximum":179.52,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":65.61,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":71.67},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":136.16},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":136.16},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":136.16},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":126.63,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":71.39},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":49.21,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":121.99},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":179.52},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":66.92,"additional_payer_notes":"APC"}]}]},{"description":"Glucagon hydrochloride/1 mg","code_information":[{"code":"J1610","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":88.0,"maximum":501.44,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":117.33,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":209.84},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":372.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":372.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":372.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":226.45,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":199.42},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":88.0,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":340.73},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":501.44},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":119.68,"additional_payer_notes":"APC"}]}]},{"description":"Inj heparin sodium per 10 u","code_information":[{"code":"J1642","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":0.02,"maximum":0.05,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":0.02},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.04},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.04},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.04},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.02},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.04},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.05}]}]},{"description":"Ibandronate sodium injection","code_information":[{"code":"J1740","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":24.44,"maximum":69.04,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":24.44},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":58.52},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":58.52},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":58.52},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27.45},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":46.92},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":69.04}]}]},{"description":"Iron sucrose injection","code_information":[{"code":"J1756","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":0.24,"maximum":0.63,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":0.26},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.43},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.43},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.43},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.24},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.43},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.63}]}]},{"description":"Insulin for insulin pump use","code_information":[{"code":"J1817","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2.58,"maximum":6.48,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2.74},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":6.15},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":6.15},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":6.15},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2.58},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":4.4},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6.48}]}]},{"description":"Inj, lanreotide, (cipla) 1mg","code_information":[{"code":"J1932","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":15.25,"maximum":83.52,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20.33,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":27.96},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":46.46},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":46.46},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":46.46},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":39.24,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33.22},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15.25,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":56.76},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":83.52},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20.74,"additional_payer_notes":"APC"}]}]},{"description":"Levetiracetam injection","code_information":[{"code":"J1953","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":0.06,"maximum":0.13,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":0.06},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.09},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.09},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.09},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.06},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.09},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.13}]}]},{"description":"Inj, linezolid (hospira)","code_information":[{"code":"J2021","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6.97,"maximum":22.52,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6.97},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12.04},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12.04},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12.04},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8.95},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15.3},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22.52}]}]},{"description":"Methylergonovin maleate inj","code_information":[{"code":"J2210","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":23.42,"maximum":59.4,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":23.42},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":41.91},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":41.91},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":41.91},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23.63},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":40.37},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":59.4}]}]},{"description":"Morphine sulfate injection","code_information":[{"code":"J2270","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4.95,"maximum":12.47,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5.09},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8.64},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8.64},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8.64},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":4.95},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8.47},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12.47}]}]},{"description":"Inj nalbuphine hydrochloride","code_information":[{"code":"J2300","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3.39,"maximum":9.34,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3.39},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":6.68},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":6.68},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":6.68},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3.71},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6.35},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9.34}]}]},{"description":"Injection, ocrelizumab, 1 mg","code_information":[{"code":"J2350","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":45.73,"maximum":160.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":60.97,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":63.59},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":113.44},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":113.44},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":113.44},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":117.67,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":63.63},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":45.73,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":108.72},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":160.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":62.19,"additional_payer_notes":"APC"}]}]},{"description":"Orphenadrine injection","code_information":[{"code":"J2360","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":13.56,"maximum":38.08,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":13.56},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17.95},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17.95},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17.95},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15.15},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25.88},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38.08}]}]},{"description":"Injection, oritavancin 10 mg","code_information":[{"code":"J2406","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":35.56,"maximum":117.94,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":47.41,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":47.05},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":78.67},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":78.67},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":78.67},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":91.5,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":46.91},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":35.56,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":80.14},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":117.94},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":48.36,"additional_payer_notes":"APC"}]}]},{"description":"Paricalcitol","code_information":[{"code":"J2501","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":0.89,"maximum":2.46,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":0.89},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1.27},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1.27},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1.27},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.98},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1.67},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2.46}]}]},{"description":"Promethazine hcl injection","code_information":[{"code":"J2550","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3.64,"maximum":9.72,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3.64},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5.45},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5.45},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5.45},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3.86},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6.6},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9.72}]}]},{"description":"Inj fluphenazine hcl 1.25 mg","code_information":[{"code":"J2679","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7.87,"maximum":20.94,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7.87},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14.11},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14.11},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14.11},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8.33},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14.23},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20.94}]}]},{"description":"Metoclopramide hcl injection","code_information":[{"code":"J2765","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1.12,"maximum":2.81,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1.24},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1.89},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1.89},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1.89},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1.12},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1.91},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2.81}]}]},{"description":"Injection, reslizumab, 1mg","code_information":[{"code":"J2786","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8.8,"maximum":28.1,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11.73,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":11.54},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20.09},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20.09},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20.09},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":22.64,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11.18},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8.8,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19.09},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28.1},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11.96,"additional_payer_notes":"APC"}]}]},{"description":"Inj, uzedy, 1 mg","code_information":[{"code":"J2799","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":19.64,"maximum":67.3,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26.18,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":27.08},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":47.64},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":47.64},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":47.64},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":50.53,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26.77},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19.64,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":45.73},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":67.3},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26.7,"additional_payer_notes":"APC"}]}]},{"description":"Na ferric gluconate complex","code_information":[{"code":"J2916","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2.13,"maximum":5.41,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2.13},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4.14},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4.14},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4.14},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2.16},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3.68},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5.41}]}]},{"description":"Inj tedizolid phosphate","code_information":[{"code":"J3090","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1.56,"maximum":4.93,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2.08,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1.98},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3.63},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3.63},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3.63},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4.02,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1.96},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1.56,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3.35},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":4.93},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2.12,"additional_payer_notes":"APC"}]}]},{"description":"Thyrotropin injection","code_information":[{"code":"J3240","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1619.0,"maximum":5629.88,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2158.66,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2286.58},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4015.15},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4015.15},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4015.15},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4166.22,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2238.97},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1619.0,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3825.63},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5629.88},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2201.83,"additional_payer_notes":"APC"}]}]},{"description":"Tocilizumab injection","code_information":[{"code":"J3262","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4.06,"maximum":16.25,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5.41,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6.47},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10.99},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10.99},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10.99},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":10.44,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6.46},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4.06,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11.04},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16.25},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5.52,"additional_payer_notes":"APC"}]}]},{"description":"Inj., triptorelin xr 3.75 mg","code_information":[{"code":"J3316","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2864.95,"maximum":9561.67,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3819.93,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3856.64},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7168.42},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7168.42},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7168.42},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7372.47,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2864.95,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9561.67},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3896.33,"additional_payer_notes":"APC"}]}]},{"description":"Antb tp total&rpr ia qual","code_information":[{"code":"0064U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":23.5,"maximum":60.47,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":31.33,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":46.54},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":39.16},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":39.16},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":39.16},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":60.47,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23.5,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":54.83},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31.33},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":31.96,"additional_payer_notes":"APC"}]}]},{"description":"Cyp2d6 gen cyp2d6-2d7 hybrid","code_information":[{"code":"0072U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":338.18,"maximum":870.26,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":450.91,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":669.83},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":563.64},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":563.64},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":563.64},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":870.26,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":338.18,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":789.09},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":450.91},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":459.93,"additional_payer_notes":"APC"}]}]},{"description":"Rx test def 90+ rx/sbsts ur","code_information":[{"code":"0082U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":185.19,"maximum":476.56,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":246.92,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":366.8},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":308.65},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":308.65},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":308.65},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":476.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":185.19,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":432.11},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":246.92},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":251.86,"additional_payer_notes":"APC"}]}]},{"description":"Onc lng 3 prtn bmrk plsm alg","code_information":[{"code":"0092U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1866.0,"maximum":4801.84,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2488.0,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3110.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3110.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3110.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4801.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1866.0,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":4354.0},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2488.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2537.76,"additional_payer_notes":"APC"}]}]},{"description":"Neph ckd mult eclia tum nec","code_information":[{"code":"0105U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":712.5,"maximum":1833.5,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":950.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1411.2},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1187.5},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1187.5},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1187.5},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1833.5,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":712.5,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1662.5},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":950.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":969.0,"additional_payer_notes":"APC"}]}]},{"description":"Onc prst8 pca3&tmprss2-erg","code_information":[{"code":"0113U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":570.0,"maximum":1466.8,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":760.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1128.96},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":950.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":950.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":950.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1466.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":570.0,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1330.0},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":760.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":775.2,"additional_payer_notes":"APC"}]}]},{"description":"Sc dis vcam-1 whole blood","code_information":[{"code":"0121U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":381.9,"maximum":982.76,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":509.2,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":636.5},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":636.5},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":636.5},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":982.76,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":381.9,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":891.1},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":509.2},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":519.38,"additional_payer_notes":"APC"}]}]},{"description":"Hered pan ca mrna pnl 18 gen","code_information":[{"code":"0134U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":561.29,"maximum":1444.39,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":748.39,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":935.49},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":935.49},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":935.49},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1444.39,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":561.29,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1309.68},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":748.39},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":763.36,"additional_payer_notes":"APC"}]}]},{"description":"Nfct bct fng prst dna >1000","code_information":[{"code":"0152U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1594.65,"maximum":4103.57,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2126.2,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3158.4},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2657.75},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2657.75},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2657.75},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4103.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1594.65,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3720.85},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2126.2},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2168.72,"additional_payer_notes":"APC"}]}]},{"description":"Msh6 mrna seq alys","code_information":[{"code":"0160U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":212.16,"maximum":545.96,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":282.88,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":420.22},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":353.6},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":353.6},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":353.6},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":545.96,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":212.16,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":495.04},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":282.88},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":288.54,"additional_payer_notes":"APC"}]}]},{"description":"Neuro asd rna next gen seq","code_information":[{"code":"0170U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1462.5,"maximum":3763.5,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1950.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2607.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2437.5},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2437.5},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2437.5},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3763.5,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1462.5,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3412.5},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1755.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1989.0,"additional_payer_notes":"APC"}]}]},{"description":"Peanut allg asmt epi clin rx","code_information":[{"code":"0178U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":344.9,"maximum":887.53,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":459.86,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":683.09},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":574.83},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":574.83},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":574.83},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":887.53,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":344.9,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":804.76},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":459.86},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":469.06,"additional_payer_notes":"APC"}]}]},{"description":"Fut2 gnotyp fut2 exon 2","code_information":[{"code":"0186U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":138.9,"maximum":357.44,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":185.2,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":275.11},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":231.5},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":231.5},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":231.5},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":357.44,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":138.9,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":324.1},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":185.2},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":188.9,"additional_payer_notes":"APC"}]}]},{"description":"Kel gnotyp kel exon 8","code_information":[{"code":"0194U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":138.9,"maximum":357.44,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":185.2,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":275.11},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":231.5},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":231.5},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":231.5},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":357.44,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":138.9,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":324.1},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":185.2},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":188.9,"additional_payer_notes":"APC"}]}]},{"description":"Nfct ds 22 trgt sars-cov-2","code_information":[{"code":"0202U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":312.58,"maximum":804.39,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":416.78,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":619.1},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":520.98},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":520.98},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":520.98},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":804.39,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":312.58,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":729.37},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":416.78},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":425.12,"additional_payer_notes":"APC"}]}]},{"description":"Rare ds gen dna alys proband","code_information":[{"code":"0212U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4106.4,"maximum":10567.14,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5475.2,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":8133.24},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":6844.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":6844.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":6844.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":10567.14,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4106.4,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9581.6},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5475.2},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5584.7,"additional_payer_notes":"APC"}]}]},{"description":"Onc brst ca ai assmt 12 feat","code_information":[{"code":"0220U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":529.69,"maximum":1363.06,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":706.25,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1049.12},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":882.81},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":882.81},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":882.81},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1363.06,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":529.69,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1235.94},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":706.25},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":720.38,"additional_payer_notes":"APC"}]}]},{"description":"Onc prst8 ma molec prfl alg","code_information":[{"code":"0228U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":129.77,"maximum":333.95,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":173.03,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":256.21},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":216.29},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":216.29},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":216.29},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":333.95,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":129.77,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":302.8},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":173.03},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":176.49,"additional_payer_notes":"APC"}]}]},{"description":"Smn1&smn2 full gene analysis","code_information":[{"code":"0236U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":452.02,"maximum":1163.21,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":602.7,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":895.3},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":753.38},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":753.38},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":753.38},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1163.21,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":452.02,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1054.73},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":602.7},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":614.75,"additional_payer_notes":"APC"}]}]},{"description":"Onc solid orgn dna 257 genes","code_information":[{"code":"0244U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2625.0,"maximum":6755.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3500.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5199.14},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4375.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4375.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4375.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6755.0,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2625.0,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6125.0},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3500.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3570.0,"additional_payer_notes":"APC"}]}]},{"description":"Ftl aneuploidy str alys dna","code_information":[{"code":"0252U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":569.29,"maximum":1464.97,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":759.05,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1123.97},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":948.81},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":948.81},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":948.81},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1464.97,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":569.29,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1328.34},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":759.05},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":774.23,"additional_payer_notes":"APC"}]}]},{"description":"Rare ds id opt genome mapg","code_information":[{"code":"0260U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":947.65,"maximum":2438.61,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1263.53,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1870.98},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1579.41},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1579.41},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1579.41},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2438.61,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":947.65,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2211.18},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1263.53},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1288.8,"additional_payer_notes":"APC"}]}]},{"description":"Hem ahus gen seq alys 15 gen","code_information":[{"code":"0268U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":456.13,"maximum":1173.77,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":608.17,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":900.54},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":760.21},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":760.21},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":760.21},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1173.77,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":456.13,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1064.3},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":608.17},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":620.33,"additional_payer_notes":"APC"}]}]},{"description":"Hem inh thrombocytopenia 23","code_information":[{"code":"0276U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1836.42,"maximum":4725.72,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2448.56,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3625.7},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3060.7},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3060.7},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3060.7},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4725.72,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1836.42,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":4284.98},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2448.56},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2497.53,"additional_payer_notes":"APC"}]}]},{"description":"Vw factor type 2n eval plsm","code_information":[{"code":"0284U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":12.95,"maximum":33.33,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17.27,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":25.66},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21.59},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21.59},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21.59},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":33.33,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.95,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30.22},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17.27},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17.62,"additional_payer_notes":"APC"}]}]},{"description":"Psyc strs do mrna 72 genes","code_information":[{"code":"0292U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1316.25,"maximum":3387.15,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1755.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2628.29},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2193.75},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2193.75},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2193.75},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3387.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1316.25,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3071.25},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1755.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1790.1,"additional_payer_notes":"APC"}]}]},{"description":"Onc pan tum whl gen seq&opt","code_information":[{"code":"0300U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3137.35,"maximum":8073.44,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4183.13,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6264.66},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5228.91},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5228.91},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5228.91},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":8073.44,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3137.35,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7320.48},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":4183.13},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4266.79,"additional_payer_notes":"APC"}]}]},{"description":"Crd cad alys 3 prtn plsm alg","code_information":[{"code":"0308U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":293.06,"maximum":754.15,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":390.75,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":578.62},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":488.44},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":488.44},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":488.44},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":754.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":293.06,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":683.81},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":390.75},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":398.56,"additional_payer_notes":"APC"}]}]},{"description":"B brgdrferi lyme ds ospa evl","code_information":[{"code":"0316U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":14.0,"maximum":36.01,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18.66,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":27.64},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23.33},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23.33},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23.33},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":36.01,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14.0,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32.66},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18.66},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19.03,"additional_payer_notes":"APC"}]}]},{"description":"Trgt gen seq alys pnl 83+","code_information":[{"code":"0326U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3750.0,"maximum":9650.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5000.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7488.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":6250.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":6250.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":6250.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":9650.0,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3750.0,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8750.0},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5000.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5100.0,"additional_payer_notes":"APC"}]}]},{"description":"Onc sld orgn tgsa dna 84/+","code_information":[{"code":"0334U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2625.0,"maximum":6755.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3500.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4323.2},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4375.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4375.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4375.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6755.0,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2625.0,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6125.0},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2919.6},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3570.0,"additional_payer_notes":"APC"}]}]},{"description":"Onc pncrtc ca mult ia eclia","code_information":[{"code":"0342U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":897.0,"maximum":1569.75,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1328.23},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1121.25},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1121.25},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1121.25},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1569.75},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":897.0}]}]},{"description":"Nfct ds bct/viral trail ip10","code_information":[{"code":"0351U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":195.38,"maximum":502.76,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":260.5,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":385.74},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":325.63},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":325.63},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":325.63},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":502.76,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":195.38,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":455.88},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":260.5},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":265.71,"additional_payer_notes":"APC"}]}]},{"description":"Onc urthl mrna 5 gen alg","code_information":[{"code":"0363U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":570.0,"maximum":1466.8,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":760.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1138.18},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":950.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":950.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":950.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1466.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":570.0,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1330.0},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":760.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":775.2,"additional_payer_notes":"APC"}]}]},{"description":"Iadna gu pthgn semiq dna16&1","code_information":[{"code":"0371U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":312.58,"maximum":804.39,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":416.78,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":624.18},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":520.98},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":520.98},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":520.98},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":804.39,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":312.58,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":729.37},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":416.78},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":425.12,"additional_payer_notes":"APC"}]}]},{"description":"Ai sle igg&igm alys 80 bmrk","code_information":[{"code":"0062U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":285.54,"maximum":734.79,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":380.72,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":475.9},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":475.9},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":475.9},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":734.79,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":285.54,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":666.26},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":380.72},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":388.33,"additional_payer_notes":"APC"}]}]},{"description":"Cyp2d6 gen com&slct rar vrnt","code_information":[{"code":"0070U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":507.28,"maximum":1305.39,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":676.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1004.72},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":845.46},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":845.46},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":845.46},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1305.39,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":507.28,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1183.65},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":676.37},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":689.9,"additional_payer_notes":"APC"}]}]},{"description":"Pain mgt opi use gnotyp pnl","code_information":[{"code":"0078U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":563.64,"maximum":789.09,"payers_information":[{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":563.64},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":563.64},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":563.64},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":789.09}]}]},{"description":"Onc mlnma prame & linc00518","code_information":[{"code":"0089U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":570.0,"maximum":1466.8,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":760.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1128.96},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":950.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":950.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":950.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1466.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":570.0,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1330.0},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":760.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":775.2,"additional_payer_notes":"APC"}]}]},{"description":"Hered brst ca rltd do 17 gen","code_information":[{"code":"0102U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":977.96,"maximum":2516.62,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1303.95,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1936.98},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1629.94},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1629.94},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1629.94},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2516.62,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":977.96,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2281.91},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1117.98},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1330.03,"additional_payer_notes":"APC"}]}]},{"description":"Onc colon ca kras&nras alys","code_information":[{"code":"0111U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":511.72,"maximum":1316.82,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":682.29,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1013.51},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":852.86},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":852.86},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":852.86},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1316.82,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":511.72,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1194.01},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":682.29},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":695.94,"additional_payer_notes":"APC"}]}]},{"description":"Crd ceramides liq chrom plsm","code_information":[{"code":"0119U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":62.82,"maximum":161.66,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":83.76,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":104.7},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":104.7},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":104.7},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":161.66,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":62.82,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":146.58},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":83.76},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":85.44,"additional_payer_notes":"APC"}]}]},{"description":"Hered ova ca rltd do pnl 17","code_information":[{"code":"0132U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":741.64,"maximum":1297.87,"payers_information":[{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":927.05},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":927.05},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":927.05},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1297.87},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":741.64}]}]},{"description":"Nfct ds bact&fng gram pos","code_information":[{"code":"0141U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":117.56,"maximum":302.53,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":156.75,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":232.84},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":195.94},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":195.94},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":195.94},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":302.53,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":117.56,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":274.31},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":156.75},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":159.88,"additional_payer_notes":"APC"}]}]},{"description":"Mlh1 mrna seq alys","code_information":[{"code":"0158U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":212.16,"maximum":545.96,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":282.88,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":420.22},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":353.6},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":353.6},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":353.6},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":545.96,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":212.16,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":495.04},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":282.88},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":288.54,"additional_payer_notes":"APC"}]}]},{"description":"Liver ds 10 biochem asy srm","code_information":[{"code":"0166U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":377.55,"maximum":971.56,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":503.4,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":747.79},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":629.25},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":629.25},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":629.25},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":971.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":377.55,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":880.95},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":503.4},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":513.47,"additional_payer_notes":"APC"}]}]},{"description":"Cdtb&vinculin igg antb ia","code_information":[{"code":"0176U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":48.14,"maximum":123.89,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":64.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":95.36},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":80.24},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":80.24},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":80.24},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":123.89,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":48.14,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":112.33},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":64.19},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":65.47,"additional_payer_notes":"APC"}]}]},{"description":"Do gnotyp art4 exon 2","code_information":[{"code":"0184U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":138.9,"maximum":357.44,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":185.2,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":275.11},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":231.5},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":231.5},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":231.5},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":357.44,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":138.9,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":324.1},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":185.2},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":188.9,"additional_payer_notes":"APC"}]}]},{"description":"Jk gnotyp slc14a1 exon 9","code_information":[{"code":"0192U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":206.12,"maximum":530.42,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":274.83,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":408.24},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":343.54},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":343.54},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":343.54},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":530.42,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":206.12,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":480.95},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":274.83},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":280.33,"additional_payer_notes":"APC"}]}]},{"description":"Xk gnotyp xk exons 1-3","code_information":[{"code":"0200U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":206.12,"maximum":530.42,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":274.83,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":408.24},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":343.54},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":343.54},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":343.54},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":530.42,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":206.12,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":480.95},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":274.83},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":280.33,"additional_payer_notes":"APC"}]}]},{"description":"Syphilis tst antb ia quan","code_information":[{"code":"0210U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":13.97,"maximum":35.96,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18.63,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":27.68},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23.29},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23.29},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23.29},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":35.96,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.97,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32.6},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18.63},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19.0,"additional_payer_notes":"APC"}]}]},{"description":"Neuro musc dys dmd seq alys","code_information":[{"code":"0218U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1709.25,"maximum":4398.47,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2279.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3385.38},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2848.75},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2848.75},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2848.75},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4398.47,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1709.25,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3988.25},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2279.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2324.58,"additional_payer_notes":"APC"}]}]},{"description":"Svnt sarscov2 elisa plsm srm","code_information":[{"code":"0226U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":31.71,"maximum":81.6,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":42.28,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":62.81},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":52.85},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":52.85},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":52.85},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":81.6,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":31.71,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":73.99},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":42.13},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":43.13,"additional_payer_notes":"APC"}]}]},{"description":"Mecp2 full gene analysis","code_information":[{"code":"0234U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":395.9,"maximum":1018.79,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":527.87,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":784.13},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":659.84},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":659.84},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":659.84},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1018.79,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":395.9,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":923.77},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":527.87},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":538.43,"additional_payer_notes":"APC"}]}]},{"description":"Trgt gen seq alys pnl 55-74","code_information":[{"code":"0242U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3750.0,"maximum":9650.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5000.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7427.35},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":6250.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":6250.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":6250.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":9650.0,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3750.0,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8750.0},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5000.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5100.0,"additional_payer_notes":"APC"}]}]},{"description":"Onc sld org neo dna 505 gene","code_information":[{"code":"0250U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2189.7,"maximum":5634.83,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2919.6,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4336.97},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3649.5},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3649.5},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3649.5},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5634.83,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2189.7,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5109.3},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2919.6},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2977.99,"additional_payer_notes":"APC"}]}]},{"description":"Ai psor mrna 50-100 gen alg","code_information":[{"code":"0258U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2756.25,"maximum":7092.75,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3675.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5459.1},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4593.75},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4593.75},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4593.75},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7092.75,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2756.25,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6431.25},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3675.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3748.5,"additional_payer_notes":"APC"}]}]},{"description":"Unxpl cnst hrtbl do gn xprsn","code_information":[{"code":"0266U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2400.0,"maximum":6176.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3200.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4738.4},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4000.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4000.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4000.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6176.0,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2400.0,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5600.0},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3200.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3264.0,"additional_payer_notes":"APC"}]}]},{"description":"Hem gen pltlt do 43 genes","code_information":[{"code":"0274U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":456.13,"maximum":1173.77,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":608.17,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":900.54},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":760.21},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":760.21},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":760.21},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1173.77,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":456.13,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1064.3},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":608.17},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":620.33,"additional_payer_notes":"APC"}]}]},{"description":"Rbc dna gntyp 12 bld grp gen","code_information":[{"code":"0282U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":540.0,"maximum":1389.6,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":720.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1069.54},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":900.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":900.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":900.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1389.6,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":540.0,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1260.0},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":720.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":734.4,"additional_payer_notes":"APC"}]}]},{"description":"Pain mgmt mrna gen xprsn 36","code_information":[{"code":"0290U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":570.0,"maximum":1466.8,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":760.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1125.37},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":950.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":950.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":950.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1466.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":570.0,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1330.0},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":760.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":775.2,"additional_payer_notes":"APC"}]}]},{"description":"Onc pan tum whl trns seq rna","code_information":[{"code":"0298U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2189.7,"maximum":5634.83,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2919.6,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4323.2},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3649.5},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3649.5},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3649.5},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5634.83,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2189.7,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5109.3},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2919.6},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2977.99,"additional_payer_notes":"APC"}]}]},{"description":"Onc mrd nxt-gnrj alys 1st","code_information":[{"code":"0306U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2908.84,"maximum":7485.41,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3878.45,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5808.37},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4848.06},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4848.06},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4848.06},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7485.41,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2908.84,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6787.29},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3878.45},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3956.02,"additional_payer_notes":"APC"}]}]},{"description":"Onc cutan mlnma mrna 35 gene","code_information":[{"code":"0314U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1462.5,"maximum":3763.5,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1950.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2920.32},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2437.5},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2437.5},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2437.5},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3763.5,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1462.5,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3412.5},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1950.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1989.0,"additional_payer_notes":"APC"}]}]},{"description":"Neuro asd meas 14 acyl carn","code_information":[{"code":"0322U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":562.5,"maximum":1447.5,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":750.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1110.58},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":937.5},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":937.5},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":937.5},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1447.5,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":562.5,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1312.5},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":750.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":765.0,"additional_payer_notes":"APC"}]}]},{"description":"Onc pan tum gen prflg 8 dna","code_information":[{"code":"0332U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":856.54,"maximum":2204.18,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1142.06,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1710.35},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1427.58},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1427.58},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1427.58},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2204.18,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":856.54,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1998.61},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1142.06},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1164.9,"additional_payer_notes":"APC"}]}]},{"description":"Onc pan ca alys mrd plasma","code_information":[{"code":"0340U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2692.5,"maximum":6928.7,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3590.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5804.54},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3649.5},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3649.5},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3649.5},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6928.7,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2692.5,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5109.3},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3920.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3661.8,"additional_payer_notes":"APC"}]}]},{"description":"Rx metab/pcx dna 27gen rx ia","code_information":[{"code":"0349U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":556.7,"maximum":1432.58,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":742.27,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1099.13},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":927.84},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":927.84},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":927.84},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1432.58,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":556.7,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1298.97},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":742.27},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":757.12,"additional_payer_notes":"APC"}]}]},{"description":"Neurflmnt lt chn dig ia quan","code_information":[{"code":"0361U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":116.23,"maximum":203.4,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":167.38},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":145.29},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":145.29},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":145.29},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":203.4},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":116.23}]}]},{"description":"Iadna gi pthgn 31 org&21 arg","code_information":[{"code":"0369U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":416.78,"maximum":729.37,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":624.18},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":520.98},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":520.98},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":520.98},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":729.37},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":416.78}]}]},{"description":"Verteporfin injection","code_information":[{"code":"J3396","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8.53,"maximum":31.32,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":12.67},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21.95},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21.95},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21.95},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":21.95,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12.46},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8.53,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21.28},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31.32},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11.6,"additional_payer_notes":"APC"}]}]},{"description":"Injection, voriconazole","code_information":[{"code":"J3465","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1.05,"maximum":2.64,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1.17},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1.48},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1.48},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1.48},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1.05},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1.79},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2.64}]}]},{"description":"Zoledronic acid 1mg","code_information":[{"code":"J3489","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6.06,"maximum":15.25,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":10.47},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":9.89},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":9.89},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":9.89},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6.06},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10.36},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15.25}]}]},{"description":"Inj., emicizumab-kxwh 0.5 mg","code_information":[{"code":"J7170","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":43.52,"maximum":141.62,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":58.03,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":57.18},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":109.12},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":109.12},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":109.12},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":112.0,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":56.32},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":43.52,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":96.24},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":141.62},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":59.19,"additional_payer_notes":"APC"}]}]},{"description":"Factor xiii recomb a-subunit","code_information":[{"code":"J7181","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":14.34,"maximum":46.74,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19.11,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":19.07},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":34.76},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":34.76},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":34.76},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":36.89,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18.59},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14.34,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31.76},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":46.74},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19.5,"additional_payer_notes":"APC"}]}]},{"description":"Factor viii","code_information":[{"code":"J7190","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":0.93,"maximum":3.05,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1.25,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1.23},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2.15},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2.15},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2.15},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2.4,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1.21},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":0.93,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2.07},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3.05},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1.27,"additional_payer_notes":"APC"}]}]},{"description":"Factor ix alprolix recomb","code_information":[{"code":"J7201","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2.78,"maximum":9.75,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3.71,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3.91},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":6.89},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":6.89},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":6.89},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7.16,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3.87},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2.78,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6.62},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9.75},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3.79,"additional_payer_notes":"APC"}]}]},{"description":"Inj, afstyla, 1 i.u.","code_information":[{"code":"J7210","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1.21,"maximum":4.14,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1.62,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1.66},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3.12,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1.64},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1.21,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2.81},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":4.14},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1.65,"additional_payer_notes":"APC"}]}]},{"description":"Fluocinol acet intravit imp","code_information":[{"code":"J7313","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":387.3,"maximum":1344.04,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":516.41,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":539.85},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":945.81},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":945.81},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":945.81},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":996.66,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":534.53},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":387.3,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":913.31},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1344.04},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":526.73,"additional_payer_notes":"APC"}]}]},{"description":"Synvisc or Synvisc-One","code_information":[{"code":"J7325","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4.51,"maximum":24.93,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6.02,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":10.18},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17.27},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17.27},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17.27},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11.61,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9.92},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4.51,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16.95},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24.93},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6.14,"additional_payer_notes":"APC"}]}]},{"description":"Carbidopa levodopa ent 100ml","code_information":[{"code":"J7340","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":183.37,"maximum":642.38,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":244.5,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":259.35},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":461.98},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":461.98},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":461.98},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":471.88,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":255.47},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":183.37,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":436.51},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":642.38},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":249.39,"additional_payer_notes":"APC"}]}]},{"description":"Tacrol envarsus ex rel oral","code_information":[{"code":"J7503","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1.95,"maximum":4.9,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1.99},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3.48},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3.48},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3.48},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1.95},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3.33},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":4.9}]}]},{"description":"Cyclosporine oral 25 mg","code_information":[{"code":"J7515","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":0.81,"maximum":2.26,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":0.81},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1.46},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1.46},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1.46},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.89},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1.54},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2.26}]}]},{"description":"Oral everolimus","code_information":[{"code":"J7527","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2.22,"maximum":6.32,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2.22},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3.77},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3.77},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3.77},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2.51},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":4.29},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6.32}]}]},{"description":"Levalbuterol non-comp unit","code_information":[{"code":"J7614","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":0.09,"maximum":0.25,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":0.1},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.17},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.17},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.17},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.09},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.17},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.25}]}]},{"description":"Tobramycin non-comp unit","code_information":[{"code":"J7682","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":16.28,"maximum":43.56,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":16.28},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27.47},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27.47},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27.47},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17.32},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29.6},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":43.56}]}]},{"description":"Oral methotrexate (jylamvo)","code_information":[{"code":"J8611","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":12.35,"maximum":51.65,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16.47,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":35.2},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":35.2},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":35.2},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":31.78,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.35,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":51.65},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16.8,"additional_payer_notes":"APC"}]}]},{"description":"Inj, aspara, rylaze, 0.1 mg","code_information":[{"code":"J9021","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":44.02,"maximum":147.39,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":58.7,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":59.82},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":105.07},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":105.07},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":105.07},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":113.29,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":58.62},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":44.02,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":100.16},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":147.39},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":59.87,"additional_payer_notes":"APC"}]}]},{"description":"Inj, adstiladrin, per tx dos","code_information":[{"code":"J9029","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":48248.71,"maximum":172612.06,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":64331.61,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":69559.17},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":120519.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":120519.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":120519.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":124160.02,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":68646.98},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":48248.71,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":117293.77},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":172612.06},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":65618.25,"additional_payer_notes":"APC"}]}]},{"description":"Bleomycin sulfate injection","code_information":[{"code":"J9040","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":22.64,"maximum":56.93,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":23.72},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":39.71},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":39.71},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":39.71},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22.64},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38.68},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":56.93}]}]},{"description":"Cetuximab injection","code_information":[{"code":"J9055","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":61.25,"maximum":209.91,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":81.67,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":85.27},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":149.09},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":149.09},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":149.09},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":157.62,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":83.47},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":61.25,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":142.64},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":209.91},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":83.3,"additional_payer_notes":"APC"}]}]},{"description":"Inj cyclophosphamd (ingenus)","code_information":[{"code":"J9073","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":0.37,"maximum":5.96,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":0.5,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1.94},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2.2},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2.2},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2.2},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":0.96,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2.37},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":0.37,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":4.05},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5.96},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":0.51,"additional_payer_notes":"APC"}]}]},{"description":"Dacarbazine 100 mg inj","code_information":[{"code":"J9130","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4.52,"maximum":11.35,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4.95},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7.25},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7.25},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7.25},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":4.52},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7.71},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11.35}]}]},{"description":"Inj., durvalumab, 10 mg","code_information":[{"code":"J9173","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":65.96,"maximum":228.36,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":87.95,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":92.26},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":161.98},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":161.98},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":161.98},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":169.74,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":90.83},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":65.96,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":155.18},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":228.36},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":89.71,"additional_payer_notes":"APC"}]}]},{"description":"Inj gemcitabine hcl (accord)","code_information":[{"code":"J9196","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":9.52,"maximum":25.43,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":9.52},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10.05},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10.05},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10.05},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10.11},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17.28},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25.43}]}]},{"description":"Ixabepilone injection","code_information":[{"code":"J9207","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":104.82,"maximum":371.43,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":139.75,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":149.83},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":263.48},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":263.48},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":263.48},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":269.73,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":147.71},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":104.82,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":252.4},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":371.43},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":142.55,"additional_payer_notes":"APC"}]}]},{"description":"Inj. isatuximab-irfc 10 mg","code_information":[{"code":"J9227","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":66.12,"maximum":216.03,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":88.16,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":86.75},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":157.43},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":157.43},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":157.43},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":170.15,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":85.91},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":66.12,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":146.8},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":216.03},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":89.92,"additional_payer_notes":"APC"}]}]},{"description":"Oxaliplatin","code_information":[{"code":"J9263","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":0.06,"maximum":0.21,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":0.06},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.17},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.17},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.17},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.08},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.15},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.21}]}]},{"description":"Inj tisotu vedotin-tftv, 1mg","code_information":[{"code":"J9273","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":147.09,"maximum":495.15,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":196.12,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":207.52},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":358.43},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":358.43},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":358.43},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":378.51,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":196.92},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":147.09,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":336.46},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":495.15},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":200.04,"additional_payer_notes":"APC"}]}]},{"description":"Inj pemetrexed, hospira 10mg","code_information":[{"code":"J9294","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2.21,"maximum":9.36,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2.94,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4.25},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":9.36},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":9.36},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":9.36},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5.68,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2.78},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2.21,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":4.75},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3.0,"additional_payer_notes":"APC"}]}]},{"description":"Inj. pemetrexed, 10 mg","code_information":[{"code":"J9304","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6.0,"maximum":143.48,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7.99,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":50.99},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":100.21},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":100.21},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":100.21},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":15.43,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":57.05},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6.0,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":97.5},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":143.48},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8.15,"additional_payer_notes":"APC"}]}]},{"description":"Inj pemetrexed (teva) 10mg","code_information":[{"code":"J9314","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7.2,"maximum":21.2,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10.99,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":9.21},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7.2},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7.2},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7.2},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":21.2,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7.73},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8.24,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13.21},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19.44},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11.21,"additional_payer_notes":"APC"}]}]},{"description":"Inj talimogene laherparepvec","code_information":[{"code":"J9325","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":58.0,"maximum":191.58,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":77.34,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":77.42},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":139.74},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":139.74},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":139.74},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":149.26,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":76.19},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":58.0,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":130.18},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":191.58},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":78.89,"additional_payer_notes":"APC"}]}]},{"description":"Inj thiotepa nos 1 mg","code_information":[{"code":"J9342","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3.7,"maximum":23.25,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4.93,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23.25},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23.25},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23.25},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":9.52,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3.7,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5.03,"additional_payer_notes":"APC"}]}]},{"description":"Inj. margetuximab-cmkb, 5 mg","code_information":[{"code":"J9353","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":42.33,"maximum":134.49,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":56.44,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":53.38},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":95.86},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":95.86},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":95.86},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":108.93,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":53.49},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":42.33,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":91.39},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":134.49},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":57.57,"additional_payer_notes":"APC"}]}]},{"description":"Vincristine sulfate 1 MG inj","code_information":[{"code":"J9370","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":9.02,"maximum":22.67,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":9.02},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14.94},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14.94},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14.94},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9.02},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15.41},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22.67}]}]},{"description":"Albumin (human), 5%, 250 ml","code_information":[{"code":"P9045","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":39.81,"maximum":144.51,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":53.08,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":58.39},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":100.85},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":100.85},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":100.85},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":102.44,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":39.81,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":98.2},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":144.51},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":54.14,"additional_payer_notes":"APC"}]}]},{"description":"Tocilizumab for covid-19","code_information":[{"code":"Q0249","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8.33,"maximum":20.61,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":8.33},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14.38},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14.38},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14.38},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14.0},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20.61}]}]},{"description":"Ciltacabtagene car-pos t","code_information":[{"code":"Q2056","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":440983.32,"maximum":1500964.18,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":587977.76,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":608486.23},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1051419.78},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1051419.78},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1051419.78},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1134797.07,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":440983.32,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1019938.93},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1500964.18},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":599737.31,"additional_payer_notes":"APC"}]}]},{"description":"Integra drt or omnigraft","code_information":[{"code":"Q4105","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":25.58,"maximum":237.56,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":123.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":25.58},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":49.57},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":49.57},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":49.57},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":237.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":92.32,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":56.02},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":82.43},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":125.55,"additional_payer_notes":"APC"}]}]},{"description":"Alloskin","code_information":[{"code":"Q4123","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":78.71,"maximum":237.56,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":123.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":78.71},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":135.95},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":135.95},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":135.95},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":237.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":92.32,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":217.21},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":125.55,"additional_payer_notes":"APC"}]}]},{"description":"Biodfence dryflex, 1cm","code_information":[{"code":"Q4138","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":92.32,"maximum":254.74,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":123.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":103.69},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":190.76},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":190.76},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":190.76},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":237.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":92.32,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":173.1},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":254.74},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":125.55,"additional_payer_notes":"APC"}]}]},{"description":"Dermapure 1 square cm","code_information":[{"code":"Q4152","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":60.08,"maximum":237.56,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":123.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":60.08},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":86.28},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":86.28},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":86.28},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":237.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":92.32,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":96.29},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":141.7},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":125.55,"additional_payer_notes":"APC"}]}]},{"description":"Bio-connekt per square cm","code_information":[{"code":"Q4161","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":92.32,"maximum":7928.12,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":123.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2039.03},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3142.25},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3142.25},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3142.25},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":237.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":92.32,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7928.12},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":125.55,"additional_payer_notes":"APC"}]}]},{"description":"Miroderm","code_information":[{"code":"Q4175","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":75.42,"maximum":237.56,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":123.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":75.42},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":128.66},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":128.66},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":128.66},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":237.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":92.32,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":127.72},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":187.97},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":125.55,"additional_payer_notes":"APC"}]}]},{"description":"Restorigin 1 sq cm","code_information":[{"code":"Q4191","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":92.32,"maximum":2766.9,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":123.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1034.17},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1387.82},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1387.82},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1387.82},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":237.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":92.32,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1880.17},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2766.9},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":125.55,"additional_payer_notes":"APC"}]}]},{"description":"Derma-gide, 1 sq cm","code_information":[{"code":"Q4203","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":92.32,"maximum":1655.6,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":123.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":330.2},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1655.6},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1655.6},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1655.6},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":237.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":92.32,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":555.33},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":817.25},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":125.55,"additional_payer_notes":"APC"}]}]},{"description":"Cogenex amnio memb per sq cm","code_information":[{"code":"Q4229","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":92.32,"maximum":1418.51,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":123.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":551.71},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":627.59},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":627.59},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":627.59},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":237.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":92.32,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":963.91},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1418.51},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":125.55,"additional_payer_notes":"APC"}]}]},{"description":"Amniply, per sq cm","code_information":[{"code":"Q4249","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":92.32,"maximum":7356.62,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":123.09,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3400.14},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3400.14},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3400.14},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":237.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":92.32,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7356.62},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":125.55,"additional_payer_notes":"APC"}]}]},{"description":"Dual layer impax, per sq cm","code_information":[{"code":"Q4262","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":92.32,"maximum":823.61,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":123.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":186.85},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":119.42},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":119.42},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":119.42},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":237.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":92.32,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":559.66},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":823.61},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":125.55,"additional_payer_notes":"APC"}]}]},{"description":"Esano ac, per sq cm","code_information":[{"code":"Q4274","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":92.32,"maximum":5802.93,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":123.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2022.12},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3481.4},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3481.4},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3481.4},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":237.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":92.32,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5802.93},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":125.55,"additional_payer_notes":"APC"}]}]},{"description":"Biovance tri or 3l, sq cm","code_information":[{"code":"Q4283","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":92.32,"maximum":1797.89,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":123.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":605.7},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":868.91},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":868.91},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":868.91},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":237.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":92.32,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1221.7},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1797.89},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":125.55,"additional_payer_notes":"APC"}]}]},{"description":"Amnicore pro, per sq cm","code_information":[{"code":"Q4298","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":92.32,"maximum":5914.39,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":123.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2506.9},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4224.02},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4224.02},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4224.02},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":237.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":92.32,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":4018.96},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5914.39},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":125.55,"additional_payer_notes":"APC"}]}]},{"description":"Procenta, per 100 mg","code_information":[{"code":"Q4310","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2434.45,"maximum":5866.94,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2434.45},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2502.98},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2502.98},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2502.98},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3986.71},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5866.94}]}]},{"description":"Axolotl graft, per sq cm","code_information":[{"code":"Q4331","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":92.32,"maximum":5530.07,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":123.09,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3111.34},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3111.34},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3111.34},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":237.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":92.32,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5530.07},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":125.55,"additional_payer_notes":"APC"}]}]},{"description":"Epixpress, per sq cm","code_information":[{"code":"Q4361","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":92.32,"maximum":3021.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":123.09,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3021.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3021.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3021.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":237.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":92.32,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":125.55,"additional_payer_notes":"APC"}]}]},{"description":"Injection, fulphila","code_information":[{"code":"Q5108","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":50.27,"maximum":341.14,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":67.02,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":124.19},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":197.04},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":197.04},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":197.04},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":129.36,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":50.27,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":231.81},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":341.14},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":68.36,"additional_payer_notes":"APC"}]}]},{"description":"Inj., kanjinti, 10 mg","code_information":[{"code":"Q5117","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":30.7,"maximum":116.81,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":60.52,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":30.7},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":82.22},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":82.22},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":82.22},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":116.81,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":45.39,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":64.18},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":94.45},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":61.73,"additional_payer_notes":"APC"}]}]},{"description":"Inj, releuko 1 mcg","code_information":[{"code":"Q5125","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":0.23,"maximum":1.22,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":0.31,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":0.47},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.78},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.78},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.78},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":0.6,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":0.23,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.83},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1.22},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":0.32,"additional_payer_notes":"APC"}]}]},{"description":"Inj, hercessi, 10 mg","code_information":[{"code":"Q5146","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":24.34,"maximum":288.17,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":32.46,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":144.74},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":144.74},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":144.74},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":62.65,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":24.34,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":288.17},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":33.11,"additional_payer_notes":"APC"}]}]},{"description":"LOCM 100-199mg/ml iodine,1ml","code_information":[{"code":"Q9965","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1.02,"maximum":3.42,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1.02},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3.42},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3.42},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3.42},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2.22},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3.27}]}]},{"description":"Tgsap sl or neo dna523&rna55","code_information":[{"code":"0379U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2466.38,"maximum":6346.82,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3288.51,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4735.45},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4110.64},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4110.64},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4110.64},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6346.82,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2466.38,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5754.89},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3288.51},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3354.28,"additional_payer_notes":"APC"}]}]},{"description":"Ped fbrl kd ifi27&mcemp1 rna","code_information":[{"code":"0389U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":52.65,"maximum":135.49,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":70.2,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":101.09},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":87.75},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":87.75},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":87.75},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":135.49,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":52.65,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":122.85},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":70.2},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":71.6,"additional_payer_notes":"APC"}]}]},{"description":"Neuro cere folate defncy srm","code_information":[{"code":"0399U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":225.0,"maximum":579.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":300.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":432.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":375.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":375.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":375.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":579.0,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":225.0,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":525.0},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":300.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":306.0,"additional_payer_notes":"APC"}]}]},{"description":"Neph dbtc ckd mult eclia alg","code_information":[{"code":"0407U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":712.5,"maximum":1833.5,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":950.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1422.72},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1187.5},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1187.5},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1187.5},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1833.5,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":712.5,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1662.5},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":950.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":969.0,"additional_payer_notes":"APC"}]}]},{"description":"Cv ds acs bld alg 5 yr score","code_information":[{"code":"0415U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":293.06,"maximum":754.15,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":390.75,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":585.19},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":488.44},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":488.44},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":488.44},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":754.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":293.06,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":683.81},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":390.75},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":398.56,"additional_payer_notes":"APC"}]}]},{"description":"Onc prst8 xom alys 53 sncrna","code_information":[{"code":"0424U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":570.0,"maximum":1466.8,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":760.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1094.4},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":950.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":950.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":950.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1466.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":570.0,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1330.0},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":760.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":775.2,"additional_payer_notes":"APC"}]}]},{"description":"Onc prst8 5 dna reg mrk pcr","code_information":[{"code":"0433U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":570.0,"maximum":1466.8,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":760.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1094.4},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":950.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":950.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":950.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1466.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":570.0,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1330.0},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":760.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":775.2,"additional_payer_notes":"APC"}]}]},{"description":"Onc mm lc-ms/ms monoc p-prtn","code_information":[{"code":"0450U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":43.43,"maximum":76.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":62.54},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":54.29},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":54.29},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":54.29},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":76.0},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":43.43}]}]},{"description":"Abeta42 & ttau eclia csf","code_information":[{"code":"0459U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":195.38,"maximum":502.76,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":260.5,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":375.12},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":325.63},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":325.63},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":325.63},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":502.76,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":195.38,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":455.88},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":260.5},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":265.71,"additional_payer_notes":"APC"}]}]},{"description":"Onc bldr dna ngs 60gen&aneup","code_information":[{"code":"0467U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1139.3,"maximum":2931.79,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1519.06,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2187.44},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1898.83},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1898.83},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1898.83},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2931.79,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1139.3,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2658.36},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1519.06},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1549.44,"additional_payer_notes":"APC"}]}]},{"description":"Hered prst8 ca gsap 23 genes","code_information":[{"code":"0475U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":977.96,"maximum":2516.62,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1303.95,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1877.69},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1629.94},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1629.94},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1629.94},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2516.62,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":977.96,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2281.91},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1303.95},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1330.03,"additional_payer_notes":"APC"}]}]},{"description":"Onc sol tum ctc slct er prtn","code_information":[{"code":"0491U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1826.25,"maximum":4699.55,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2435.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3506.4},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3043.75},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3043.75},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3043.75},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4699.55,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1826.25,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":4261.25},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2435.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2483.7,"additional_payer_notes":"APC"}]}]},{"description":"Onc clrct&lng dna ngs 8gene","code_information":[{"code":"0499U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":448.43,"maximum":1153.97,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":597.91,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":860.99},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":747.39},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":747.39},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":747.39},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1153.97,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":448.43,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1046.34},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":597.91},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":609.87,"additional_payer_notes":"APC"}]}]},{"description":"Onc ovr dna whole gen w/5hmc","code_information":[{"code":"0507U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":870.0,"maximum":2238.8,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1160.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1670.4},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1450.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1450.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1450.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2238.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":870.0,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2030.0},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1160.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1183.2,"additional_payer_notes":"APC"}]}]},{"description":"Gi ibd ia quan deter ifx lvl","code_information":[{"code":"0515U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":28.93,"maximum":74.44,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":38.57,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":55.54},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":48.21},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":48.21},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":48.21},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":74.44,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":28.93,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":67.5},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38.57},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":39.34,"additional_payer_notes":"APC"}]}]},{"description":"Breath test analysis c-14","code_information":[{"code":"78268","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":70.81,"maximum":182.21,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":94.41,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":136.3},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":118.01},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":118.01},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":118.01},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":182.21,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":70.81,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":165.22},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":96.3,"additional_payer_notes":"APC"}]}]},{"description":"Acute hepatitis panel","code_information":[{"code":"80074","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":35.72,"maximum":96.4,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":47.63,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":96.4},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":59.54},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":59.54},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":59.54},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":91.93,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":35.72,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":83.35},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":47.63},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":48.58,"additional_payer_notes":"APC"}]}]},{"description":"Assay carbamazepine total","code_information":[{"code":"80156","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":10.93,"maximum":29.46,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14.57,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":29.46},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18.21},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18.21},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18.21},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":28.12,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10.93,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25.5},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14.57},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14.86,"additional_payer_notes":"APC"}]}]},{"description":"Dipropylacetic acid free","code_information":[{"code":"80165","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":10.16,"maximum":27.43,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.54,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":27.43},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16.93},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16.93},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16.93},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":26.13,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10.16,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23.7},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13.54},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.81,"additional_payer_notes":"APC"}]}]},{"description":"Assay of lidocaine","code_information":[{"code":"80176","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":11.02,"maximum":29.71,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14.69,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":29.71},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18.36},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18.36},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18.36},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":28.35,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11.02,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25.71},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14.69},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14.98,"additional_payer_notes":"APC"}]}]},{"description":"Assay of phenytoin total","code_information":[{"code":"80185","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":9.94,"maximum":26.82,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.25,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":26.82},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16.56},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16.56},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16.56},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":25.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9.94,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23.19},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13.25},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.52,"additional_payer_notes":"APC"}]}]},{"description":"Assay of quinidine","code_information":[{"code":"80194","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":10.95,"maximum":29.56,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14.6,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":29.56},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18.25},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18.25},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18.25},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":28.18,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10.95,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25.55},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14.6},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14.89,"additional_payer_notes":"APC"}]}]},{"description":"Drug screen quant zonisamide","code_information":[{"code":"80203","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":9.94,"maximum":26.82,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.25,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":26.82},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16.56},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16.56},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16.56},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":25.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9.94,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23.19},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13.25},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.52,"additional_payer_notes":"APC"}]}]},{"description":"Quantitative assay drug","code_information":[{"code":"80299","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":13.98,"maximum":35.98,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18.64,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":27.73},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23.3},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23.3},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23.3},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":35.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.98,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32.62},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18.64},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19.01,"additional_payer_notes":"APC"}]}]},{"description":"Calcitonin stimul panel","code_information":[{"code":"80410","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":60.28,"maximum":162.56,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":80.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":162.56},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":100.46},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":100.46},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":100.46},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":155.11,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":60.28,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":140.65},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":80.37},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":81.98,"additional_payer_notes":"APC"}]}]},{"description":"Glucagon tolerance panel","code_information":[{"code":"80422","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":34.55,"maximum":93.23,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":46.07,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":93.23},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":57.59},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":57.59},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":57.59},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":88.92,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":34.55,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":80.62},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":46.07},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":46.99,"additional_payer_notes":"APC"}]}]},{"description":"Metyrapone panel","code_information":[{"code":"80436","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":68.37,"maximum":184.46,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":91.16,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":184.46},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":113.95},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":113.95},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":113.95},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":175.94,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":68.37,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":159.53},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":91.16},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":92.98,"additional_payer_notes":"APC"}]}]},{"description":"Urine screen for bacteria","code_information":[{"code":"81007","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5.2,"maximum":57.86,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":29.98,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5.2},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":37.48},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":37.48},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":37.48},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":57.86,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22.48,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":52.47},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29.98},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":30.58,"additional_payer_notes":"APC"}]}]},{"description":"Hpa-4 genotyping","code_information":[{"code":"81108","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":91.66,"maximum":235.88,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":122.22,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":224.14},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":152.78},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":152.78},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":152.78},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":235.88,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":91.66,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":213.89},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":122.22},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":124.66,"additional_payer_notes":"APC"}]}]},{"description":"Brca1&2 seq & full dup/del","code_information":[{"code":"81162","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1368.66,"maximum":3692.66,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1824.88,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3692.66},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2281.1},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2281.1},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2281.1},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3522.02,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1368.66,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3193.54},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1824.88},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1861.38,"additional_payer_notes":"APC"}]}]},{"description":"Aff2 gene detc abnor alleles","code_information":[{"code":"81171","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":102.75,"maximum":264.41,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":137.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":203.51},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":171.25},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":171.25},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":171.25},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":264.41,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":102.75,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":239.75},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":137.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":139.74,"additional_payer_notes":"APC"}]}]},{"description":"Atxn2 gene detc abnor allele","code_information":[{"code":"81179","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":102.75,"maximum":264.41,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":137.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":203.51},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":171.25},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":171.25},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":171.25},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":264.41,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":102.75,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":239.75},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":137.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":139.74,"additional_payer_notes":"APC"}]}]},{"description":"Cnbp gene detc abnor allele","code_information":[{"code":"81187","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":102.75,"maximum":264.41,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":137.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":203.51},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":171.25},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":171.25},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":171.25},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":264.41,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":102.75,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":239.75},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":137.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":139.74,"additional_payer_notes":"APC"}]}]},{"description":"Cv ds quan advsrm/plsm lprtn","code_information":[{"code":"0377U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":35.68,"maximum":91.83,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":47.58,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":71.26},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":59.48},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":59.48},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":59.48},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":91.83,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":35.68,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":83.27},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":47.58},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":48.53,"additional_payer_notes":"APC"}]}]},{"description":"Onc mlnma ambra1&amlo","code_information":[{"code":"0387U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":711.38,"maximum":1830.6,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":948.5,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1420.48},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1185.63},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1185.63},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1185.63},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1830.6,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":711.38,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1659.88},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":948.5},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":967.47,"additional_payer_notes":"APC"}]}]},{"description":"Onc lng multiomics plsm alg","code_information":[{"code":"0395U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":598.09,"maximum":1539.08,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":797.45,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1148.33},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":996.81},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":996.81},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":996.81},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1539.08,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":598.09,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1395.54},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":797.45},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":813.4,"additional_payer_notes":"APC"}]}]},{"description":"Onc pncrtc 59 mthltn blk mrk","code_information":[{"code":"0405U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1327.86,"maximum":3417.03,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1770.48,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2651.47},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2213.1},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2213.1},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2213.1},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3417.03,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1327.86,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3098.34},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1770.48},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1805.89,"additional_payer_notes":"APC"}]}]},{"description":"Onc hl neo opt gen mapg dna","code_information":[{"code":"0413U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":947.65,"maximum":2438.61,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1263.53,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1892.27},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1579.41},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1579.41},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1579.41},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2438.61,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":947.65,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2211.18},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1263.53},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1288.8,"additional_payer_notes":"APC"}]}]},{"description":"Gly rcptr alpha1 igg srm/csf","code_information":[{"code":"0431U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":27.43,"maximum":70.58,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":36.57,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":52.66},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":45.71},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":45.71},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":45.71},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":70.58,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27.43,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":64.0},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36.57},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":37.3,"additional_payer_notes":"APC"}]}]},{"description":"Ai ds sle alys 11 cytokine","code_information":[{"code":"0447U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":630.49,"maximum":1622.45,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":840.65,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1210.54},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1050.81},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1050.81},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1050.81},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1622.45,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":630.49,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1471.14},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":840.65},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":857.46,"additional_payer_notes":"APC"}]}]},{"description":"Pfas 9 cmpnd lcms/ms pls/sr","code_information":[{"code":"0457U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":149.06,"maximum":383.57,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":198.74,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":286.19},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":248.43},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":248.43},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":248.43},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":383.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":149.06,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":347.8},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":198.74},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":202.71,"additional_payer_notes":"APC"}]}]},{"description":"Onc urthl carc dna qmsp 2gen","code_information":[{"code":"0465U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1453.51,"maximum":3740.36,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1938.01,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2790.73},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2422.51},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2422.51},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2422.51},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3740.36,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1453.51,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3391.52},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1938.01},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1976.77,"additional_payer_notes":"APC"}]}]},{"description":"Onc sld tum bld/slv 648 gene","code_information":[{"code":"0473U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3375.0,"maximum":8685.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4500.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6480.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5625.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5625.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5625.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":8685.0,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3375.0,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7875.0},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":4500.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4590.0,"additional_payer_notes":"APC"}]}]},{"description":"Idh1 idh2&tert promoter ngs","code_information":[{"code":"0481U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":505.68,"maximum":1301.28,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":674.24,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":970.91},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":842.8},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":842.8},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":842.8},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1301.28,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":505.68,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1179.92},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":674.24},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":687.72,"additional_payer_notes":"APC"}]}]},{"description":"Onc prst8 mrna rt-pcr 6 gene","code_information":[{"code":"0497U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2904.75,"maximum":7474.89,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3873.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5577.12},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4841.25},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4841.25},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4841.25},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7474.89,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2904.75,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6777.75},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3873.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3950.46,"additional_payer_notes":"APC"}]}]},{"description":"Nfct ds vag infctj id 32orgs","code_information":[{"code":"0505U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":509.83,"maximum":1311.96,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":679.77,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":978.86},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":849.71},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":849.71},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":849.71},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1311.96,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":509.83,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1189.6},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":679.77},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":693.37,"additional_payer_notes":"APC"}]}]},{"description":"Onc prst8 alg alys msi&hrd","code_information":[{"code":"0513U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":529.69,"maximum":1363.06,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":706.25,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1017.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":882.81},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":882.81},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":882.81},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1363.06,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":529.69,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1235.94},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":706.25},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":720.38,"additional_payer_notes":"APC"}]}]},{"description":"Routine venipuncture","code_information":[{"code":"36415","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3.0,"maximum":18.03,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9.34,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4.45},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11.36},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11.36},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11.36},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":18.03,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7.0,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15.91},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9.53,"additional_payer_notes":"APC"}]}]},{"description":"Lipid panel","code_information":[{"code":"80061","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":10.04,"maximum":27.1,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.39,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":27.1},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16.74},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16.74},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16.74},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":25.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10.04,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23.43},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13.39},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.66,"additional_payer_notes":"APC"}]}]},{"description":"Drug assay amiodarone","code_information":[{"code":"80151","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":13.98,"maximum":35.98,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18.64,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":27.71},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23.3},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23.3},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23.3},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":35.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.98,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32.62},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18.64},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19.01,"additional_payer_notes":"APC"}]}]},{"description":"Assay of digoxin free","code_information":[{"code":"80163","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":9.96,"maximum":26.87,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.28,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":26.87},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16.6},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16.6},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16.6},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":25.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9.96,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23.24},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13.28},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.55,"additional_payer_notes":"APC"}]}]},{"description":"Assay Of Haloperidol","code_information":[{"code":"80173","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":11.84,"maximum":30.46,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15.78,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":29.46},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19.73},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19.73},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19.73},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":30.46,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11.84,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27.62},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15.78},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16.1,"additional_payer_notes":"APC"}]}]},{"description":"Drug scrn quant oxcarbazepin","code_information":[{"code":"80183","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":9.94,"maximum":26.82,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.25,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":26.82},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16.56},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16.56},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16.56},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":25.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9.94,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23.19},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13.25},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.52,"additional_payer_notes":"APC"}]}]},{"description":"Assay of procainamide","code_information":[{"code":"80192","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":12.56,"maximum":33.9,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16.75,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":33.9},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20.94},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20.94},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20.94},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":32.33,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.56,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29.31},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16.75},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17.08,"additional_payer_notes":"APC"}]}]},{"description":"Assay of topiramate","code_information":[{"code":"80201","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8.94,"maximum":24.12,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11.92,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":24.12},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14.9},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14.9},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14.9},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":23.01,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8.94,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20.86},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11.92},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.16,"additional_payer_notes":"APC"}]}]},{"description":"Drug assay vedolizumab","code_information":[{"code":"80280","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":28.93,"maximum":74.44,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":38.57,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":57.3},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":48.21},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":48.21},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":48.21},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":74.44,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":28.93,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":67.5},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38.57},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":39.34,"additional_payer_notes":"APC"}]}]},{"description":"Urinalysis auto w/o scope","code_information":[{"code":"81003","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1.69,"maximum":4.55,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2.25,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4.55},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2.81},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2.81},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2.81},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4.34,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1.69,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3.94},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2.25},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2.3,"additional_payer_notes":"APC"}]}]},{"description":"Hpa-2 genotyping","code_information":[{"code":"81106","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":91.66,"maximum":235.88,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":122.22,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":224.14},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":152.78},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":152.78},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":152.78},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":235.88,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":91.66,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":213.89},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":122.22},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":124.66,"additional_payer_notes":"APC"}]}]},{"description":"Idh2 common variants","code_information":[{"code":"81121","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":221.84,"maximum":570.87,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":295.79,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":439.39},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":369.74},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":369.74},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":369.74},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":570.87,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":221.84,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":517.63},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":295.79},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":301.71,"additional_payer_notes":"APC"}]}]},{"description":"Ccnd1/igh translocation alys","code_information":[{"code":"81168","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":155.48,"maximum":400.11,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":207.31,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":307.94},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":259.14},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":259.14},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":259.14},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":400.11,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":155.48,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":362.79},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":207.31},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":211.46,"additional_payer_notes":"APC"}]}]},{"description":"Atn1 gene detc abnor alleles","code_information":[{"code":"81177","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":102.75,"maximum":264.41,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":137.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":203.51},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":171.25},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":171.25},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":171.25},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":264.41,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":102.75,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":239.75},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":137.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":139.74,"additional_payer_notes":"APC"}]}]},{"description":"Cacna1a gene full gene seq","code_information":[{"code":"81185","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":634.7,"maximum":1633.3,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":846.27,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1257.11},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1057.84},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1057.84},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1057.84},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1633.3,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":634.7,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1480.97},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":846.27},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":863.2,"additional_payer_notes":"APC"}]}]},{"description":"Ntrk3 translocation analysis","code_information":[{"code":"81193","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":155.48,"maximum":400.11,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":207.31,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":307.94},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":259.14},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":259.14},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":259.14},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":400.11,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":155.48,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":362.79},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":207.31},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":211.46,"additional_payer_notes":"APC"}]}]},{"description":"Bckdhb gene","code_information":[{"code":"81205","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":71.24,"maximum":183.33,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":94.99,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":141.1},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":118.74},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":118.74},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":118.74},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":183.33,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":71.24,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":166.23},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":94.99},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":96.89,"additional_payer_notes":"APC"}]}]},{"description":"Brca2 gene full sequence","code_information":[{"code":"81216","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":138.84,"maximum":357.28,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":185.12,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":274.98},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":231.4},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":231.4},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":231.4},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":357.28,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":138.84,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":323.96},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":185.12},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":188.82,"additional_payer_notes":"APC"}]}]},{"description":"Cftr gene intron poly t","code_information":[{"code":"81224","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":126.56,"maximum":325.69,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":168.75,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":250.68},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":210.94},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":210.94},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":210.94},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":325.69,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":126.56,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":295.31},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":168.75},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":172.12,"additional_payer_notes":"APC"}]}]},{"description":"Dpyd gene common variants","code_information":[{"code":"81232","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":131.11,"maximum":337.38,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":174.81,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":259.67},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":218.51},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":218.51},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":218.51},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":337.38,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":131.11,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":305.92},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":174.81},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":178.31,"additional_payer_notes":"APC"}]}]},{"description":"F2 gene","code_information":[{"code":"81240","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":49.27,"maximum":126.78,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":65.69,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":99.56},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":82.11},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":82.11},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":82.11},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":126.78,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":49.27,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":114.96},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":65.69},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":67.0,"additional_payer_notes":"APC"}]}]},{"description":"G6pd known familial variant","code_information":[{"code":"81248","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":281.44,"maximum":724.23,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":375.25,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":557.42},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":469.06},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":469.06},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":469.06},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":724.23,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":281.44,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":656.69},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":375.25},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":382.76,"additional_payer_notes":"APC"}]}]},{"description":"Hfe gene","code_information":[{"code":"81256","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":49.02,"maximum":132.26,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":65.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":132.26},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":81.7},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":81.7},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":81.7},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":126.14,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":49.02,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":114.38},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":65.36},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":66.67,"additional_payer_notes":"APC"}]}]},{"description":"Igk rearrangeabn clonal pop","code_information":[{"code":"81264","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":129.55,"maximum":333.37,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":172.73,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":302.16},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":215.91},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":215.91},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":215.91},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":333.37,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":129.55,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":302.28},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":172.73},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":176.18,"additional_payer_notes":"APC"}]}]},{"description":"Kit gene targeted seq analys","code_information":[{"code":"81272","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":247.13,"maximum":635.95,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":329.51,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":489.48},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":411.89},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":411.89},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":411.89},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":635.95,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":247.13,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":576.64},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":329.51},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":336.1,"additional_payer_notes":"APC"}]}]},{"description":"Ifnl3 gene","code_information":[{"code":"81283","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":55.03,"maximum":141.6,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":73.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":112.07},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":91.71},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":91.71},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":91.71},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":141.6,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":55.03,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":128.4},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":73.37},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":74.84,"additional_payer_notes":"APC"}]}]},{"description":"Mthfr gene","code_information":[{"code":"81291","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":49.0,"maximum":126.11,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":65.34,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":88.33},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":81.68},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":81.68},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":81.68},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":126.11,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":49.0,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":114.35},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":65.34},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":66.65,"additional_payer_notes":"APC"}]}]},{"description":"Msh6 gene known variants","code_information":[{"code":"81299","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":231.0,"maximum":594.44,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":308.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":239.17},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":385.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":385.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":385.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":594.44,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":231.0,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":539.0},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":308.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":314.16,"additional_payer_notes":"APC"}]}]},{"description":"Palb2 gene full gene seq","code_information":[{"code":"81307","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":282.88,"maximum":1305.64,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":676.5,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":420.22},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":845.63},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":845.63},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":845.63},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1305.64,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":507.38,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1183.88},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":282.88},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":690.03,"additional_payer_notes":"APC"}]}]},{"description":"Pml/raralpha com breakpoints","code_information":[{"code":"81315","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":155.48,"maximum":419.51,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":207.31,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":419.51},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":259.14},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":259.14},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":259.14},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":400.11,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":155.48,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":362.79},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":207.31},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":211.46,"additional_payer_notes":"APC"}]}]},{"description":"Pten gene dup/delet variant","code_information":[{"code":"81323","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":129.94,"maximum":579.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":300.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":129.94},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":375.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":375.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":375.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":579.0,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":225.0,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":525.0},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":300.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":306.0,"additional_payer_notes":"APC"}]}]},{"description":"Snrpn/ube3a gene","code_information":[{"code":"81331","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":38.3,"maximum":98.57,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":51.07,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":75.85},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":63.84},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":63.84},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":63.84},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":98.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":38.3,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":89.37},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":51.07},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":52.09,"additional_payer_notes":"APC"}]}]},{"description":"Mpl gene seq alys exon 10","code_information":[{"code":"81339","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":138.9,"maximum":357.44,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":185.2,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":275.11},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":231.5},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":231.5},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":231.5},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":357.44,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":138.9,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":324.1},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":185.2},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":188.9,"additional_payer_notes":"APC"}]}]},{"description":"Sf3b1 gene common variants","code_information":[{"code":"81347","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":144.94,"maximum":372.97,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":193.25,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":287.06},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":241.56},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":241.56},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":241.56},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":372.97,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":144.94,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":338.19},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":193.25},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":197.12,"additional_payer_notes":"APC"}]}]},{"description":"U2af1 gene common variants","code_information":[{"code":"81357","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":144.94,"maximum":372.97,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":193.25,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":287.06},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":241.56},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":241.56},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":241.56},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":372.97,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":144.94,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":338.19},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":193.25},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":197.12,"additional_payer_notes":"APC"}]}]},{"description":"Hla i typing complete lr","code_information":[{"code":"81372","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":302.69,"maximum":778.93,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":403.59,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":447.01},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":504.49},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":504.49},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":504.49},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":778.93,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":302.69,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":706.28},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":403.59},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":411.66,"additional_payer_notes":"APC"}]}]},{"description":"Hla i typing 1 locus hr","code_information":[{"code":"81380","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":132.94,"maximum":358.68,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":177.25,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":358.68},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":221.56},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":221.56},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":221.56},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":342.09,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":132.94,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":310.19},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":177.25},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":180.8,"additional_payer_notes":"APC"}]}]},{"description":"Mopath procedure level 5","code_information":[{"code":"81404","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":206.12,"maximum":530.42,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":274.83,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":408.24},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":343.54},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":343.54},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":343.54},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":530.42,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":206.12,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":480.95},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":274.83},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":280.33,"additional_payer_notes":"APC"}]}]},{"description":"Car ion chnnlpath inc 10 gns","code_information":[{"code":"81413","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":438.68,"maximum":1191.84,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":584.9,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1191.84},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":731.13},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":731.13},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":731.13},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1128.86,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":438.68,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1023.58},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":584.9},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":596.6,"additional_payer_notes":"APC"}]}]},{"description":"Fetal chrmoml microdeltj","code_information":[{"code":"81422","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":569.29,"maximum":1464.97,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":759.05,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1191.84},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":948.81},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":948.81},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":948.81},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1464.97,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":569.29,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1328.34},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":759.05},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":774.23,"additional_payer_notes":"APC"}]}]},{"description":"Hereditary retinal disorders","code_information":[{"code":"81434","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":448.43,"maximum":1153.97,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":597.91,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":894.41},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":747.39},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":747.39},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":747.39},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1153.97,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":448.43,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1046.34},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":597.91},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":609.87,"additional_payer_notes":"APC"}]}]},{"description":"Noonan spectrum disorders","code_information":[{"code":"81442","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":894.41,"maximum":4137.15,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2143.6,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":894.41},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2679.5},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2679.5},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2679.5},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4137.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1607.7,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3751.3},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2143.6},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2186.47,"additional_payer_notes":"APC"}]}]},{"description":"Tgsap so/hl 51/< rna alys","code_information":[{"code":"81456","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2189.7,"maximum":5634.83,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2919.6,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4323.2},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3649.5},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3649.5},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3649.5},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5634.83,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2189.7,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5109.3},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2919.6},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2977.99,"additional_payer_notes":"APC"}]}]},{"description":"Whole mitochondrial genome","code_information":[{"code":"81465","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":702.0,"maximum":1806.48,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":936.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1390.39},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1170.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1170.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1170.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1806.48,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":702.0,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1638.0},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":936.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":954.72,"additional_payer_notes":"APC"}]}]},{"description":"Endo assay seven anal","code_information":[{"code":"81506","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":51.69,"maximum":133.02,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":68.92,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":120.36},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":86.15},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":86.15},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":86.15},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":133.02,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":51.69,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":120.61},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":68.92},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":70.3,"additional_payer_notes":"APC"}]}]},{"description":"Nfct ds bv&vaginitis dna alg","code_information":[{"code":"81514","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":197.24,"maximum":507.57,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":262.99,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":390.67},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":328.74},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":328.74},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":328.74},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":507.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":197.24,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":460.23},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":262.99},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":268.25,"additional_payer_notes":"APC"}]}]},{"description":"Onc brst mrna 70 cnt 31 gene","code_information":[{"code":"81523","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2904.75,"maximum":7474.89,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3873.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5753.22},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4841.25},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4841.25},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4841.25},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7474.89,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2904.75,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6777.75},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3873.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3950.46,"additional_payer_notes":"APC"}]}]},{"description":"Oncology tum unknown origin","code_information":[{"code":"81540","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2812.5,"maximum":7237.5,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3750.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4338.01},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4687.5},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4687.5},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4687.5},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7237.5,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2812.5,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6562.5},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3750.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3825.0,"additional_payer_notes":"APC"}]}]},{"description":"Trnsplj pd lvr&bwl cd154+cll","code_information":[{"code":"81560","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":480.55,"maximum":1236.61,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":640.73,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":948.76},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":800.91},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":800.91},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":800.91},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1236.61,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":480.55,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1121.28},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":640.73},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":653.54,"additional_payer_notes":"APC"}]}]},{"description":"Assay of acth","code_information":[{"code":"82024","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":28.96,"maximum":78.13,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":38.62,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":78.13},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":48.28},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":48.28},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":48.28},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":74.54,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":28.96,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":67.59},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38.62},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":39.39,"additional_payer_notes":"APC"}]}]},{"description":"Cytog genom-wid alys hem mal","code_information":[{"code":"81195","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1263.53,"maximum":3596.01,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1863.22,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1819.49},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1579.41},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1579.41},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1579.41},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3596.01,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1397.42,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2211.18},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1263.53},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1900.48,"additional_payer_notes":"APC"}]}]},{"description":"Bcr/abl1 gene minor bp","code_information":[{"code":"81207","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":108.63,"maximum":293.08,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":144.84,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":293.08},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":181.05},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":181.05},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":181.05},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":279.54,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":108.63,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":253.47},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":144.84},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":147.74,"additional_payer_notes":"APC"}]}]},{"description":"Cebpa gene full sequence","code_information":[{"code":"81218","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":181.42,"maximum":489.48,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":241.9,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":489.48},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":302.38},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":302.38},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":302.38},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":466.87,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":181.42,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":423.33},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":241.9},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":246.74,"additional_payer_notes":"APC"}]}]},{"description":"Cyp2d6 gene com variants","code_information":[{"code":"81226","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":338.18,"maximum":870.26,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":450.91,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":669.83},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":563.64},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":563.64},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":563.64},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":870.26,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":338.18,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":789.09},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":450.91},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":459.93,"additional_payer_notes":"APC"}]}]},{"description":"Dmpk gene detc abnor allele","code_information":[{"code":"81234","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":102.75,"maximum":264.41,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":137.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":203.51},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":171.25},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":171.25},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":171.25},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":264.41,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":102.75,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":239.75},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":137.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":139.74,"additional_payer_notes":"APC"}]}]},{"description":"Fancc gene","code_information":[{"code":"81242","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":27.46,"maximum":70.68,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":36.62,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":54.4},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":45.78},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":45.78},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":45.78},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":70.68,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27.46,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":64.09},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36.62},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":37.35,"additional_payer_notes":"APC"}]}]},{"description":"G6pc gene","code_information":[{"code":"81250","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":43.87,"maximum":112.89,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":58.49,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":86.88},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":73.11},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":73.11},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":73.11},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":112.89,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":43.87,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":102.36},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":58.49},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":59.66,"additional_payer_notes":"APC"}]}]},{"description":"Hba1/hba2 gene fam vrnt","code_information":[{"code":"81258","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":281.44,"maximum":724.23,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":375.25,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":557.42},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":469.06},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":469.06},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":469.06},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":724.23,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":281.44,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":656.69},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":375.25},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":382.76,"additional_payer_notes":"APC"}]}]},{"description":"Str markers spec anal addl","code_information":[{"code":"81266","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":228.61,"maximum":588.28,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":304.81,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":452.78},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":381.01},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":381.01},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":381.01},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":588.28,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":228.61,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":533.42},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":304.81},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":310.91,"additional_payer_notes":"APC"}]}]},{"description":"Htt gene charac alleles","code_information":[{"code":"81274","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":206.12,"maximum":530.42,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":274.83,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":408.24},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":343.54},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":343.54},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":343.54},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":530.42,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":206.12,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":480.95},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":274.83},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":280.33,"additional_payer_notes":"APC"}]}]},{"description":"Fxn gene charac alleles","code_information":[{"code":"81285","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":206.12,"maximum":530.42,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":274.83,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":408.24},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":343.54},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":343.54},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":343.54},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":530.42,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":206.12,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":480.95},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":274.83},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":280.33,"additional_payer_notes":"APC"}]}]},{"description":"Mlh1 gene known variants","code_information":[{"code":"81293","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":248.25,"maximum":638.83,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":331.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":384.25},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":413.75},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":413.75},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":413.75},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":638.83,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":248.25,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":579.25},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":331.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":337.62,"additional_payer_notes":"APC"}]}]},{"description":"Microsatellite instability","code_information":[{"code":"81301","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":261.42,"maximum":672.72,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":348.56,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":585.94},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":435.7},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":435.7},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":435.7},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":672.72,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":261.42,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":609.98},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":348.56},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":355.53,"additional_payer_notes":"APC"}]}]},{"description":"Pik3ca gene trgt seq alys","code_information":[{"code":"81309","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":206.12,"maximum":530.42,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":274.83,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":408.24},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":343.54},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":343.54},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":343.54},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":530.42,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":206.12,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":480.95},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":274.83},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":280.33,"additional_payer_notes":"APC"}]}]},{"description":"Pms2 gene full seq analysis","code_information":[{"code":"81317","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":507.38,"maximum":1305.64,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":676.5,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1158.84},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":845.63},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":845.63},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":845.63},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1305.64,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":507.38,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1183.88},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":676.5},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":690.03,"additional_payer_notes":"APC"}]}]},{"description":"Pmp22 gene full sequence","code_information":[{"code":"81325","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":577.18,"maximum":1485.29,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":769.58,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1143.18},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":961.98},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":961.98},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":961.98},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1485.29,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":577.18,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1346.77},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":769.58},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":784.97,"additional_payer_notes":"APC"}]}]},{"description":"Tgfbi gene common variants","code_information":[{"code":"81333","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":102.75,"maximum":264.41,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":137.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":203.51},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":171.25},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":171.25},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":171.25},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":264.41,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":102.75,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":239.75},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":137.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":139.74,"additional_payer_notes":"APC"}]}]},{"description":"Trb@ gene rearrange dirprobe","code_information":[{"code":"81341","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":37.19,"maximum":100.34,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":49.59,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":100.34},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":61.99},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":61.99},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":61.99},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":95.71,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":37.19,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":86.78},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":49.59},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":50.58,"additional_payer_notes":"APC"}]}]},{"description":"Cytog alys chrml abnr lw-ps","code_information":[{"code":"81349","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":898.46,"maximum":2312.02,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1197.94,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1717.67},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1497.43},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1497.43},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1497.43},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2312.02,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":898.46,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2096.4},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1160.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1221.9,"additional_payer_notes":"APC"}]}]},{"description":"Hbb gene com variants","code_information":[{"code":"81361","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":131.11,"maximum":337.38,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":174.81,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":259.67},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":218.51},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":218.51},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":218.51},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":337.38,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":131.11,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":305.92},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":174.81},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":178.31,"additional_payer_notes":"APC"}]}]},{"description":"Hla i typing 1 antigen lr","code_information":[{"code":"81374","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":55.75,"maximum":147.22,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":74.33,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":147.22},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":92.91},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":92.91},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":92.91},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":143.46,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":55.75,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":130.08},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":74.33},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":75.82,"additional_payer_notes":"APC"}]}]},{"description":"Hla ii typing 1 loc hr","code_information":[{"code":"81382","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":92.76,"maximum":250.27,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":123.68,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":250.27},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":154.6},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":154.6},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":154.6},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":238.7,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":92.76,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":216.44},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":123.68},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":126.15,"additional_payer_notes":"APC"}]}]},{"description":"Mopath procedure level 7","code_information":[{"code":"81406","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":212.16,"maximum":545.96,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":282.88,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":420.22},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":353.6},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":353.6},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":353.6},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":545.96,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":212.16,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":495.04},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":282.88},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":288.54,"additional_payer_notes":"APC"}]}]},{"description":"Exome sequence analysis","code_information":[{"code":"81415","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3585.0,"maximum":9225.4,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4780.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7100.54},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5975.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5975.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5975.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":9225.4,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3585.0,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8365.0},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":4780.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4875.6,"additional_payer_notes":"APC"}]}]},{"description":"Genome sequence analysis","code_information":[{"code":"81426","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2032.46,"maximum":5230.2,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2709.95,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4025.54},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3387.44},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3387.44},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3387.44},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5230.2,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2032.46,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":4742.41},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2709.95},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2764.15,"additional_payer_notes":"APC"}]}]},{"description":"Hereditary colon ca dsordrs","code_information":[{"code":"81436","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":731.13,"maximum":1183.55,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1183.55},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":731.13},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":731.13},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":731.13},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1023.58}]}]},{"description":"Targeted genomic seq analys","code_information":[{"code":"81445","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":448.43,"maximum":1153.97,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":597.91,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":888.18},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":747.39},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":747.39},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":747.39},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1153.97,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":448.43,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1046.34},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":597.91},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":609.87,"additional_payer_notes":"APC"}]}]},{"description":"So gsap dna cpy nmbr&mcrstl","code_information":[{"code":"81458","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":784.76,"maximum":2019.46,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1046.35,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1506.74},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1307.94},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1307.94},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1307.94},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2019.46,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":784.76,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1831.11},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1046.35},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1067.28,"additional_payer_notes":"APC"}]}]},{"description":"X-linked intellectual dblt","code_information":[{"code":"81471","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":685.5,"maximum":1764.02,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":914.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1357.73},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1142.5},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1142.5},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1142.5},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1764.02,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":685.5,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1599.5},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":914.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":932.28,"additional_payer_notes":"APC"}]}]},{"description":"Ftl cgen abnor two proteins","code_information":[{"code":"81508","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":40.72,"maximum":104.8,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":54.3,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":80.66},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":67.88},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":67.88},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":67.88},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":104.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":40.72,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":95.03},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":54.3},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":55.39,"additional_payer_notes":"APC"}]}]},{"description":"Liver ds alys 3 bmrk srm alg","code_information":[{"code":"81517","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":132.14,"maximum":340.05,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":176.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":263.87},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":220.24},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":220.24},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":220.24},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":340.05,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":132.14,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":308.33},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":176.19},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":179.71,"additional_payer_notes":"APC"}]}]},{"description":"Oncology colorectal scr","code_information":[{"code":"81528","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":381.65,"maximum":982.12,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":508.87,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":755.9},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":636.09},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":636.09},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":636.09},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":982.12,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":381.65,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":890.52},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":508.87},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":519.05,"additional_payer_notes":"APC"}]}]},{"description":"Onc prostate mrna 22 cnt gen","code_information":[{"code":"81542","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2904.75,"maximum":7474.89,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3873.0,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4841.25},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4841.25},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4841.25},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7474.89,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2904.75,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6777.75},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3873.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3950.46,"additional_payer_notes":"APC"}]}]},{"description":"Nfct ds chrnc hcv 6 assays","code_information":[{"code":"81596","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":54.14,"maximum":139.33,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":72.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":107.24},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":90.24},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":90.24},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":90.24},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":139.33,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":54.14,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":126.33},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":72.19},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":73.63,"additional_payer_notes":"APC"}]}]},{"description":"Assay of serum albumin","code_information":[{"code":"82040","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3.71,"maximum":10.01,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4.95,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":10.01},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":6.19},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":6.19},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":6.19},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":9.55,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3.71,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8.66},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":4.95},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5.05,"additional_payer_notes":"APC"}]}]},{"description":"Assay spec xcp ur&breath ia","code_information":[{"code":"82077","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":12.95,"maximum":33.33,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17.27,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":25.66},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21.59},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21.59},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21.59},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":33.33,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.95,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30.22},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17.27},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17.62,"additional_payer_notes":"APC"}]}]},{"description":"Assay of aluminum","code_information":[{"code":"82108","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":19.11,"maximum":51.56,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25.48,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":51.56},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":31.85},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":31.85},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":31.85},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":49.18,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19.11,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":44.59},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25.48},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25.99,"additional_payer_notes":"APC"}]}]},{"description":"Assay of ammonia","code_information":[{"code":"82140","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":10.93,"maximum":29.5,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14.57,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":29.5},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18.21},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18.21},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18.21},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":28.12,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10.93,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25.5},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14.57},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14.86,"additional_payer_notes":"APC"}]}]},{"description":"Assay anti-mullerian horm","code_information":[{"code":"82166","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":28.96,"maximum":74.54,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":38.62,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":57.83},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":48.28},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":48.28},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":48.28},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":74.54,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":28.96,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":67.59},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38.62},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":39.39,"additional_payer_notes":"APC"}]}]},{"description":"Bile acids total","code_information":[{"code":"82239","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":12.84,"maximum":33.04,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17.12,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":28.61},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21.4},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21.4},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21.4},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":33.04,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.84,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29.96},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17.12},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17.46,"additional_payer_notes":"APC"}]}]},{"description":"Occult bld feces 1-3 tests","code_information":[{"code":"82272","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3.17,"maximum":8.16,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4.23,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6.58},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5.29},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5.29},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5.29},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":8.16,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3.17,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7.4},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":4.23},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4.31,"additional_payer_notes":"APC"}]}]},{"description":"Calcium infusion test","code_information":[{"code":"82331","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":10.0,"maximum":25.75,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.34,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":10.48},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16.68},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16.68},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16.68},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":25.75,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10.0,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23.35},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13.34},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.61,"additional_payer_notes":"APC"}]}]},{"description":"Assay carboxyhb quant","code_information":[{"code":"82375","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":9.24,"maximum":24.92,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.32,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":24.92},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15.4},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15.4},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15.4},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":23.78,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9.24,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21.56},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12.32},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.57,"additional_payer_notes":"APC"}]}]},{"description":"Assay of cathepsin-d","code_information":[{"code":"82387","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":13.54,"maximum":34.86,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18.06,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":34.63},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22.58},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22.58},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22.58},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":34.86,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.54,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31.61},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18.06},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18.42,"additional_payer_notes":"APC"}]}]},{"description":"Assay bld/serum cholesterol","code_information":[{"code":"82465","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3.26,"maximum":8.8,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4.35,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":8.8},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5.44},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5.44},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5.44},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":8.4,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3.26,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7.61},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":4.35},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4.44,"additional_payer_notes":"APC"}]}]},{"description":"Assay of corticosterone","code_information":[{"code":"82528","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":16.89,"maximum":45.56,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22.52,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":45.56},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28.15},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28.15},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28.15},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":43.46,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16.89,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":39.41},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22.52},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22.97,"additional_payer_notes":"APC"}]}]},{"description":"Creatine isoforms","code_information":[{"code":"82554","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8.9,"maximum":22.91,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11.87,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":12.48},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14.84},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14.84},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14.84},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":22.91,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8.9,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20.77},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11.87},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.11,"additional_payer_notes":"APC"}]}]},{"description":"B-12 binding capacity","code_information":[{"code":"82608","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":10.74,"maximum":28.99,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14.32,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":28.99},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17.9},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17.9},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17.9},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":27.64,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10.74,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25.06},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14.32},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14.61,"additional_payer_notes":"APC"}]}]},{"description":"Dihydrotestosterone","code_information":[{"code":"82642","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":21.96,"maximum":56.51,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":29.28,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":48.31},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":36.6},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":36.6},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":36.6},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":56.51,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21.96,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":51.24},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29.28},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":29.87,"additional_payer_notes":"APC"}]}]},{"description":"Assay of estradiol","code_information":[{"code":"82670","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":20.96,"maximum":56.53,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27.94,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":56.53},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":34.93},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":34.93},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":34.93},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":53.92,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20.96,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":48.9},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27.94},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":28.5,"additional_payer_notes":"APC"}]}]},{"description":"Fats/lipids feces qual","code_information":[{"code":"82705","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3.82,"maximum":10.3,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5.1,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":10.3},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":6.38},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":6.38},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":6.38},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":9.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3.82,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8.93},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5.1},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5.2,"additional_payer_notes":"APC"}]}]},{"description":"Assay of folic acid serum","code_information":[{"code":"82746","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":11.02,"maximum":29.75,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14.7,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":29.75},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18.38},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18.38},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18.38},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":28.37,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11.02,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25.73},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14.7},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14.99,"additional_payer_notes":"APC"}]}]},{"description":"Assay iga/igd/igg/igm each","code_information":[{"code":"82784","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6.98,"maximum":18.83,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9.3,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":18.83},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11.63},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11.63},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11.63},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":17.95,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6.98,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16.28},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9.3},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9.49,"additional_payer_notes":"APC"}]}]},{"description":"Gastric analy w/ph ea spec","code_information":[{"code":"82930","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5.03,"maximum":12.95,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6.71,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":11.02},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8.39},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8.39},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8.39},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":12.95,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5.03,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11.74},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6.71},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6.84,"additional_payer_notes":"APC"}]}]},{"description":"Glucose test","code_information":[{"code":"82950","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3.56,"maximum":9.62,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4.75,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":9.62},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5.94},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5.94},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5.94},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":9.17,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3.56,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8.31},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":4.75},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4.84,"additional_payer_notes":"APC"}]}]},{"description":"Assay of GGT","code_information":[{"code":"82977","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5.4,"maximum":14.58,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7.2,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":14.58},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":9.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":9.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":9.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13.9,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5.4,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12.6},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7.2},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7.34,"additional_payer_notes":"APC"}]}]},{"description":"H pylori (c-13) blood","code_information":[{"code":"83009","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":50.52,"maximum":136.3,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":67.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":136.3},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":84.2},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":84.2},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":84.2},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":130.0,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":50.52,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":117.88},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":67.36},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":68.71,"additional_payer_notes":"APC"}]}]},{"description":"Hemoglobin chromotography","code_information":[{"code":"83021","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":13.54,"maximum":36.53,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18.06,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":36.53},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22.58},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22.58},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22.58},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":34.86,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.54,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31.61},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18.06},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18.42,"additional_payer_notes":"APC"}]}]},{"description":"Assay of plasma hemoglobin","code_information":[{"code":"83051","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5.48,"maximum":14.11,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7.31,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7.04},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":9.14},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":9.14},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":9.14},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":14.11,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5.48,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12.79},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7.31},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7.46,"additional_payer_notes":"APC"}]}]},{"description":"Assay Of Homocystine","code_information":[{"code":"83090","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":13.44,"maximum":34.59,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17.92,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":34.13},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22.4},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22.4},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22.4},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":34.59,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.44,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31.36},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17.92},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18.28,"additional_payer_notes":"APC"}]}]},{"description":"Immunoassay dipstick","code_information":[{"code":"83518","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7.23,"maximum":18.61,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9.64,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":17.14},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12.05},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12.05},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12.05},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":18.61,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7.23,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16.87},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9.64},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9.83,"additional_payer_notes":"APC"}]}]},{"description":"Assay of iron","code_information":[{"code":"83540","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4.85,"maximum":13.1,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6.47,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":13.1},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8.09},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8.09},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8.09},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":12.49,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4.85,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11.32},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6.47},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6.6,"additional_payer_notes":"APC"}]}]},{"description":"Assay of ldh enzymes","code_information":[{"code":"83625","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":9.59,"maximum":25.9,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.79,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":25.9},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15.99},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15.99},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15.99},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":24.68,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9.59,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22.38},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12.79},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.05,"additional_payer_notes":"APC"}]}]},{"description":"Fluoro polarize fetal lung","code_information":[{"code":"83663","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":14.18,"maximum":38.27,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18.91,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":38.27},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23.64},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23.64},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23.64},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":36.5,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14.18,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33.09},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18.91},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19.29,"additional_payer_notes":"APC"}]}]},{"description":"Lipoprotein bld quan part","code_information":[{"code":"83704","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":25.64,"maximum":65.99,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":34.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":63.85},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":42.74},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":42.74},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":42.74},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":65.99,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25.64,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":59.83},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34.19},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":34.87,"additional_payer_notes":"APC"}]}]},{"description":"Assay of manganese","code_information":[{"code":"83785","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":19.99,"maximum":51.43,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26.65,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":49.79},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":33.31},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":33.31},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":33.31},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":51.43,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19.99,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":46.64},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26.65},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27.18,"additional_payer_notes":"APC"}]}]},{"description":"Assay of csf protein","code_information":[{"code":"83873","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":12.9,"maximum":34.82,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17.2,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":34.82},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21.5},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21.5},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21.5},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":33.2,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.9,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30.1},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17.2},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17.54,"additional_payer_notes":"APC"}]}]},{"description":"Oligoclonal bands","code_information":[{"code":"83916","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":20.54,"maximum":52.86,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27.39,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":40.68},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":34.24},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":34.24},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":34.24},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":52.86,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20.54,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":47.93},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27.39},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27.94,"additional_payer_notes":"APC"}]}]},{"description":"Oncoprotein her-2/neu","code_information":[{"code":"83950","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":48.31,"maximum":130.33,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":64.41,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":130.33},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":80.51},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":80.51},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":80.51},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":124.31,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":48.31,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":112.72},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":64.41},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":65.7,"additional_payer_notes":"APC"}]}]},{"description":"Assay acid phosphatase","code_information":[{"code":"84060","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5.73,"maximum":14.94,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7.64,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":14.94},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":9.55},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":9.55},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":9.55},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":14.75,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5.73,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13.37},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7.64},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7.79,"additional_payer_notes":"APC"}]}]},{"description":"Assay of aldosterone","code_information":[{"code":"82088","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":30.56,"maximum":82.46,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":40.75,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":82.46},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":50.94},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":50.94},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":50.94},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":78.65,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":30.56,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":71.31},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":40.75},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":41.56,"additional_payer_notes":"APC"}]}]},{"description":"Amino acid single qual","code_information":[{"code":"82127","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":10.64,"maximum":28.07,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14.18,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":28.07},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17.73},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17.73},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17.73},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":27.37,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10.64,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24.82},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14.18},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14.46,"additional_payer_notes":"APC"}]}]},{"description":"Assay of amylase","code_information":[{"code":"82150","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4.86,"maximum":13.12,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6.48,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":13.12},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8.1},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8.1},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8.1},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":12.51,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4.86,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11.34},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6.48},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6.61,"additional_payer_notes":"APC"}]}]},{"description":"Assay of arsenic","code_information":[{"code":"82175","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":14.23,"maximum":38.38,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18.97,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":38.38},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23.71},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23.71},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23.71},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":36.61,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14.23,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33.2},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18.97},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19.35,"additional_payer_notes":"APC"}]}]},{"description":"Bilirubin total","code_information":[{"code":"82247","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3.76,"maximum":10.15,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5.02,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":10.15},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":6.28},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":6.28},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":6.28},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":9.69,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3.76,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8.79},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5.02},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5.12,"additional_payer_notes":"APC"}]}]},{"description":"Assay of bradykinin","code_information":[{"code":"82286","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3.87,"maximum":13.94,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5.16,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":13.94},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":6.45},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":6.45},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":6.45},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":9.96,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3.87,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9.03},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5.16},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5.26,"additional_payer_notes":"APC"}]}]},{"description":"Calculus analysis qual","code_information":[{"code":"82355","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8.68,"maximum":23.42,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11.58,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":23.42},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14.48},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14.48},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14.48},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":22.35,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8.68,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20.27},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11.58},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11.81,"additional_payer_notes":"APC"}]}]},{"description":"Carcinoembryonic antigen","code_information":[{"code":"82378","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":14.22,"maximum":38.38,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18.96,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":38.38},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23.7},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23.7},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23.7},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":36.59,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14.22,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33.18},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18.96},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19.34,"additional_payer_notes":"APC"}]}]},{"description":"Chemiluminescent assay","code_information":[{"code":"82397","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":10.59,"maximum":28.58,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14.12,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":28.58},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17.65},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17.65},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17.65},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":27.25,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10.59,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24.71},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14.12},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14.4,"additional_payer_notes":"APC"}]}]},{"description":"Assay rbc cholinesterase","code_information":[{"code":"82482","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7.36,"maximum":18.93,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9.81,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":15.54},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12.26},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12.26},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12.26},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":18.93,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7.36,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17.17},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9.81},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10.01,"additional_payer_notes":"APC"}]}]},{"description":"Total cortisol","code_information":[{"code":"82533","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":12.22,"maximum":33.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16.3,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":33.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20.38},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20.38},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20.38},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":31.46,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.22,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28.53},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16.3},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16.63,"additional_payer_notes":"APC"}]}]},{"description":"Assay of urine creatinine","code_information":[{"code":"82570","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3.88,"maximum":10.48,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5.18,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":10.48},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":6.48},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":6.48},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":6.48},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":10.0,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3.88,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9.07},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5.18},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5.28,"additional_payer_notes":"APC"}]}]},{"description":"Test for urine cystines","code_information":[{"code":"82615","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7.16,"maximum":18.43,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9.55,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":16.51},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11.94},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11.94},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11.94},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":18.43,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7.16,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16.71},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9.55},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9.74,"additional_payer_notes":"APC"}]}]},{"description":"El-1 fecal quantitative","code_information":[{"code":"82653","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":17.23,"maximum":44.33,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22.97,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":34.12},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28.71},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28.71},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28.71},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":44.33,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17.23,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":40.2},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22.97},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23.43,"additional_payer_notes":"APC"}]}]},{"description":"Assay of estrogen","code_information":[{"code":"82672","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":16.28,"maximum":43.92,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21.7,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":43.92},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27.13},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27.13},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27.13},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":41.88,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16.28,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37.98},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21.7},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22.13,"additional_payer_notes":"APC"}]}]},{"description":"Assay of fecal fat","code_information":[{"code":"82715","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":13.0,"maximum":44.33,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22.97,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":13.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28.71},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28.71},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28.71},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":44.33,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17.23,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":40.2},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22.97},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23.43,"additional_payer_notes":"APC"}]}]},{"description":"Assay of semen fructose","code_information":[{"code":"82757","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":12.6,"maximum":33.47,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17.34,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":12.6},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21.68},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21.68},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21.68},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":33.47,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.0,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30.35},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17.34},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17.69,"additional_payer_notes":"APC"}]}]},{"description":"Igg 1 2 3 or 4 each","code_information":[{"code":"82787","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6.02,"maximum":15.48,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8.02,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":8.5},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10.03},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10.03},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10.03},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":15.48,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6.02,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14.04},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8.02},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8.18,"additional_payer_notes":"APC"}]}]},{"description":"Assay of gastrin","code_information":[{"code":"82941","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":13.22,"maximum":35.68,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17.63,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":35.68},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22.04},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22.04},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22.04},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":34.03,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.22,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30.85},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17.63},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17.98,"additional_payer_notes":"APC"}]}]},{"description":"GTT-added samples","code_information":[{"code":"82952","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2.94,"maximum":7.92,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3.92,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7.92},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4.9},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4.9},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4.9},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2.94,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6.86},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3.92},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4.0,"additional_payer_notes":"APC"}]}]},{"description":"Assay rbc glutathione","code_information":[{"code":"82979","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7.08,"maximum":18.22,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9.44,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":13.94},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11.8},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11.8},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11.8},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":18.22,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7.08,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16.52},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9.44},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9.63,"additional_payer_notes":"APC"}]}]},{"description":"Assay of haptoglobins","code_information":[{"code":"83012","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":20.17,"maximum":51.9,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26.89,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":34.8},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":33.61},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":33.61},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":33.61},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":51.9,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20.17,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":47.06},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26.89},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27.43,"additional_payer_notes":"APC"}]}]},{"description":"Fetal hemoglobin chemical","code_information":[{"code":"83030","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8.06,"maximum":20.73,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10.74,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":16.73},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13.43},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13.43},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13.43},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":20.73,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8.06,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18.8},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10.74},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10.95,"additional_payer_notes":"APC"}]}]},{"description":"Assay of hemoglobin heat","code_information":[{"code":"83065","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6.75,"maximum":17.37,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":13.94},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11.25},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11.25},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11.25},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":17.37,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6.75,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15.75},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9.18,"additional_payer_notes":"APC"}]}]},{"description":"Assay of corticosteroids 17","code_information":[{"code":"83491","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":13.42,"maximum":35.45,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17.9,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":35.45},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22.38},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22.38},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22.38},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":34.55,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.42,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31.33},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17.9},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18.26,"additional_payer_notes":"APC"}]}]},{"description":"Immunoassay quant nos nonab","code_information":[{"code":"83520","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":12.95,"maximum":33.33,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17.27,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":26.2},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21.59},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21.59},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21.59},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":33.33,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.95,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30.22},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17.27},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17.62,"additional_payer_notes":"APC"}]}]},{"description":"Assay of idh enzyme","code_information":[{"code":"83570","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6.64,"maximum":17.89,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8.85,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":17.89},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11.06},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11.06},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11.06},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":17.08,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6.64,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15.49},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8.85},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9.03,"additional_payer_notes":"APC"}]}]},{"description":"Lactoferrin fecal (quant)","code_information":[{"code":"83631","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":14.72,"maximum":39.72,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19.63,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":39.72},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24.54},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24.54},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24.54},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":37.89,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14.72,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34.35},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19.63},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20.02,"additional_payer_notes":"APC"}]}]},{"description":"Assay of lap enzyme","code_information":[{"code":"83670","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7.36,"maximum":18.93,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9.81,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":18.54},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12.26},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12.26},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12.26},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":18.93,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7.36,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17.17},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9.81},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10.01,"additional_payer_notes":"APC"}]}]},{"description":"Assay of blood lipoprotein","code_information":[{"code":"83719","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":9.56,"maximum":24.61,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.75,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":23.53},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15.94},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15.94},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15.94},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":24.61,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9.56,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22.31},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12.75},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.0,"additional_payer_notes":"APC"}]}]},{"description":"Assay of mercury","code_information":[{"code":"83825","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":12.2,"maximum":32.89,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16.26,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":32.89},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20.33},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20.33},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20.33},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":31.38,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.2,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28.46},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16.26},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16.59,"additional_payer_notes":"APC"}]}]},{"description":"Assay myeloperoxidase","code_information":[{"code":"83876","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":38.14,"maximum":98.16,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":50.86,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":68.69},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":63.58},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":63.58},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":63.58},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":98.16,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":38.14,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":89.01},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":50.86},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":51.88,"additional_payer_notes":"APC"}]}]},{"description":"Organic acids qual each","code_information":[{"code":"83919","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":12.34,"maximum":33.3,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16.45,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":33.3},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20.56},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20.56},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20.56},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":31.75,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.34,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28.79},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16.45},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16.78,"additional_payer_notes":"APC"}]}]},{"description":"Assay of parathormone","code_information":[{"code":"83970","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":30.96,"maximum":83.53,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":41.28,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":83.53},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":51.6},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":51.6},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":51.6},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":79.67,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":30.96,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":72.24},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":41.28},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":42.11,"additional_payer_notes":"APC"}]}]},{"description":"Assay alkaline phosphatase","code_information":[{"code":"84075","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3.88,"maximum":10.48,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5.18,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":10.48},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":6.48},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":6.48},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":6.48},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":10.0,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3.88,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9.07},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5.18},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5.28,"additional_payer_notes":"APC"}]}]},{"description":"Assay of phosphorus","code_information":[{"code":"84100","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3.56,"maximum":9.6,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4.74,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":9.6},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5.93},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5.93},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5.93},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":9.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3.56,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8.3},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":4.74},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4.83,"additional_payer_notes":"APC"}]}]},{"description":"Assay of serum potassium","code_information":[{"code":"84132","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3.57,"maximum":9.31,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4.76,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":9.31},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5.95},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5.95},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5.95},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":9.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3.57,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8.33},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":4.76},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4.86,"additional_payer_notes":"APC"}]}]},{"description":"Procalcitonin (PCT)","code_information":[{"code":"84145","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":20.42,"maximum":54.22,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27.22,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":54.22},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":34.03},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":34.03},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":34.03},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":52.53,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20.42,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":47.64},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27.22},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27.76,"additional_payer_notes":"APC"}]}]},{"description":"Assay of protein other","code_information":[{"code":"84157","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3.0,"maximum":7.72,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7.43},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7.72,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3.0,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7.0},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":4.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4.08,"additional_payer_notes":"APC"}]}]},{"description":"Test RBC protoporphyrin","code_information":[{"code":"84203","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7.3,"maximum":18.8,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9.74,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":17.44},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12.18},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12.18},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12.18},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":18.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7.3,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17.05},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9.74},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9.93,"additional_payer_notes":"APC"}]}]},{"description":"Assay of endocrine hormone","code_information":[{"code":"84235","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":53.42,"maximum":137.47,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":71.23,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":105.41},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":89.04},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":89.04},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":89.04},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":137.47,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":53.42,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":124.65},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":71.23},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":72.65,"additional_payer_notes":"APC"}]}]},{"description":"Assay of silica","code_information":[{"code":"84285","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":18.91,"maximum":48.66,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25.21,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":47.64},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":31.51},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":31.51},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":31.51},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":48.66,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18.91,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":44.12},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25.21},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25.71,"additional_payer_notes":"APC"}]}]},{"description":"Chromatogram assay sugars","code_information":[{"code":"84375","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":11.77,"maximum":75.27,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":39.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":11.77},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":48.75},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":48.75},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":48.75},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":75.27,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":29.25,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":68.25},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":39.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":39.78,"additional_payer_notes":"APC"}]}]},{"description":"Assay of free testosterone","code_information":[{"code":"84402","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":19.1,"maximum":51.54,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25.47,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":51.54},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":31.84},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":31.84},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":31.84},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":49.16,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19.1,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":44.57},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25.47},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25.98,"additional_payer_notes":"APC"}]}]},{"description":"Assay of total thyroxine","code_information":[{"code":"84436","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5.15,"maximum":13.87,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6.87,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":13.87},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8.59},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8.59},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8.59},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13.26,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5.15,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12.02},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6.87},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7.01,"additional_payer_notes":"APC"}]}]},{"description":"Transferase (AST) (SGOT)","code_information":[{"code":"84450","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3.88,"maximum":10.48,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5.18,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":10.48},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":6.48},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":6.48},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":6.48},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":10.0,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3.88,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9.07},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5.18},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5.28,"additional_payer_notes":"APC"}]}]},{"description":"Assay of troponin quant","code_information":[{"code":"84484","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":9.35,"maximum":24.07,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.47,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":19.91},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15.59},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15.59},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15.59},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":24.07,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9.35,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21.82},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12.47},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.72,"additional_payer_notes":"APC"}]}]},{"description":"Assay of urine/urea-n","code_information":[{"code":"84540","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4.17,"maximum":10.73,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5.56,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":9.62},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":6.95},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":6.95},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":6.95},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":10.73,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4.17,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9.73},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5.56},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5.67,"additional_payer_notes":"APC"}]}]},{"description":"Assay of urine vma","code_information":[{"code":"84585","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":11.62,"maximum":31.37,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15.5,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":31.37},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19.38},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19.38},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19.38},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":29.92,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11.62,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27.13},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15.5},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15.81,"additional_payer_notes":"APC"}]}]},{"description":"Assay of zinc","code_information":[{"code":"84630","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8.54,"maximum":21.98,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11.39,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":20.95},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14.24},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14.24},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14.24},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":21.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8.54,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19.93},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11.39},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11.62,"additional_payer_notes":"APC"}]}]},{"description":"Bl smear w/diff wbc count","code_information":[{"code":"85007","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2.85,"maximum":7.33,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3.8,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6.96},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4.75},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4.75},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4.75},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7.33,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2.85,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6.65},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3.8},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3.88,"additional_payer_notes":"APC"}]}]},{"description":"Manual cell count each","code_information":[{"code":"85032","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3.23,"maximum":8.7,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4.31,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":8.7},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5.39},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5.39},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5.39},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":8.32,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3.23,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7.54},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":4.31},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4.4,"additional_payer_notes":"APC"}]}]},{"description":"Chromogenic substrate assay","code_information":[{"code":"85130","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8.92,"maximum":24.07,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11.89,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":24.07},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14.86},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14.86},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14.86},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":22.95,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8.92,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20.81},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11.89},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.13,"additional_payer_notes":"APC"}]}]},{"description":"Clot factor viii vw ristoctn","code_information":[{"code":"85245","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":17.2,"maximum":46.43,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22.94,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":46.43},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28.68},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28.68},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28.68},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":44.27,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17.2,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":40.15},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22.94},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23.4,"additional_payer_notes":"APC"}]}]},{"description":"Clot factor xiii fibrin scrn","code_information":[{"code":"85291","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6.83,"maximum":18.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9.11,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":18.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11.39},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11.39},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11.39},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":17.58,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6.83,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15.94},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9.11},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9.29,"additional_payer_notes":"APC"}]}]},{"description":"Clot inhibit prot s free","code_information":[{"code":"85306","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":11.49,"maximum":29.57,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15.32,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":28.91},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19.15},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19.15},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19.15},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":29.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11.49,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26.81},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15.32},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15.63,"additional_payer_notes":"APC"}]}]},{"description":"Fibrin degradation products","code_information":[{"code":"85362","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5.17,"maximum":13.94,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6.89,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":13.94},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8.61},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8.61},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8.61},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13.3,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5.17,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12.06},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6.89},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7.03,"additional_payer_notes":"APC"}]}]},{"description":"Fibrinolysins screen i&r","code_information":[{"code":"85390","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":10.46,"maximum":29.88,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15.48,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":10.46},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19.35},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19.35},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19.35},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":29.88,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11.61,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27.09},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15.48},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15.79,"additional_payer_notes":"APC"}]}]},{"description":"Heinz bodies induced","code_information":[{"code":"85445","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5.12,"maximum":13.8,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6.82,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":13.8},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8.53},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8.53},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8.53},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13.16,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5.12,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11.94},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6.82},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6.96,"additional_payer_notes":"APC"}]}]},{"description":"Wbc alkaline phosphatase","code_information":[{"code":"85540","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6.45,"maximum":17.41,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8.6,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":17.41},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10.75},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10.75},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10.75},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":16.6,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6.45,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15.05},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8.6},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8.77,"additional_payer_notes":"APC"}]}]},{"description":"Prothrombin time","code_information":[{"code":"85610","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3.22,"maximum":8.28,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4.29,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7.94},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5.36},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5.36},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5.36},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":8.28,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3.22,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7.51},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":4.29},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4.38,"additional_payer_notes":"APC"}]}]},{"description":"Thrombin time plasma","code_information":[{"code":"85670","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4.33,"maximum":11.68,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5.77,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":11.68},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7.21},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7.21},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7.21},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11.14,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4.33,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10.1},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5.77},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5.89,"additional_payer_notes":"APC"}]}]},{"description":"Allergen specific IgE","code_information":[{"code":"86003","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3.92,"maximum":10.07,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5.22,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6.56},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":6.53},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":6.53},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":6.53},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":10.07,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3.92,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9.14},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5.22},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5.32,"additional_payer_notes":"APC"}]}]},{"description":"Anca titer each antibody","code_information":[{"code":"86037","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":9.04,"maximum":23.26,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.05,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":17.89},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15.06},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15.06},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15.06},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":23.26,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9.04,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21.09},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12.05},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.29,"additional_payer_notes":"APC"}]}]},{"description":"Aqaprn-4 antb flo cytmtry ea","code_information":[{"code":"86053","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":12.05,"maximum":72.82,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":37.73,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":17.89},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":47.16},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":47.16},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":47.16},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":72.82,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":28.3,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":66.03},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12.05},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":38.48,"additional_payer_notes":"APC"}]}]},{"description":"Cell enumeration & id","code_information":[{"code":"86152","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":188.08,"maximum":497.2,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":250.78,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":497.2},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":313.48},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":313.48},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":313.48},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":484.01,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":188.08,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":438.87},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":250.78},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":255.8,"additional_payer_notes":"APC"}]}]},{"description":"Ccp antibody","code_information":[{"code":"86200","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":9.71,"maximum":26.2,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.95,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":26.2},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16.19},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16.19},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16.19},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":24.99,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9.71,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22.66},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12.95},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.21,"additional_payer_notes":"APC"}]}]},{"description":"Dgp antibody each ig class","code_information":[{"code":"86258","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":9.04,"maximum":23.26,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.05,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":17.12},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15.06},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15.06},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15.06},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":23.26,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9.04,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21.09},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11.53},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.29,"additional_payer_notes":"APC"}]}]},{"description":"Heterophile antibody screen","code_information":[{"code":"86308","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3.88,"maximum":10.48,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5.18,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":10.48},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":6.48},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":6.48},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":6.48},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":10.0,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3.88,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9.07},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5.18},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5.28,"additional_payer_notes":"APC"}]}]},{"description":"Immunoelectrophoresis assay","code_information":[{"code":"86327","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":37.4,"maximum":52.36,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":45.91},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":37.4},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":37.4},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":37.4},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":52.36}]}]},{"description":"Test for porphobilinogen","code_information":[{"code":"84106","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4.36,"maximum":11.23,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5.82,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":8.66},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7.28},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7.28},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7.28},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11.23,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4.36,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10.19},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5.82},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5.94,"additional_payer_notes":"APC"}]}]},{"description":"Assay of prealbumin","code_information":[{"code":"84134","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":10.94,"maximum":28.16,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14.59,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":11.29},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18.24},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18.24},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18.24},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":28.16,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10.94,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25.53},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14.59},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14.88,"additional_payer_notes":"APC"}]}]},{"description":"Assay of prostaglandin","code_information":[{"code":"84150","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":31.33,"maximum":80.62,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":41.77,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":50.51},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":52.21},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":52.21},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":52.21},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":80.62,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":31.33,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":73.1},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":41.77},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":42.61,"additional_payer_notes":"APC"}]}]},{"description":"Pappa serum","code_information":[{"code":"84163","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":11.29,"maximum":30.47,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15.05,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":30.47},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18.81},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18.81},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18.81},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":29.05,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11.29,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26.34},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15.05},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15.35,"additional_payer_notes":"APC"}]}]},{"description":"Assay of vitamin b-6","code_information":[{"code":"84207","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":21.08,"maximum":56.84,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":28.1,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":56.84},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":35.13},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":35.13},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":35.13},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":54.23,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21.08,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":49.18},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28.1},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":28.66,"additional_payer_notes":"APC"}]}]},{"description":"Assay of renin","code_information":[{"code":"84244","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":16.49,"maximum":44.51,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21.99,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":44.51},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27.49},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27.49},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27.49},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":42.44,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16.49,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38.48},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21.99},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22.43,"additional_payer_notes":"APC"}]}]},{"description":"Assay of urine sodium","code_information":[{"code":"84300","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3.8,"maximum":9.86,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5.06,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":9.86},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":6.33},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":6.33},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":6.33},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":9.77,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3.8,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8.86},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5.06},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5.16,"additional_payer_notes":"APC"}]}]},{"description":"Sugars multiple qual","code_information":[{"code":"84377","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4.12,"maximum":11.12,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5.5,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":11.12},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":6.88},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":6.88},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":6.88},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":10.62,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4.12,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9.63},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5.5},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5.61,"additional_payer_notes":"APC"}]}]},{"description":"Testosterone bioavailable","code_information":[{"code":"84410","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":38.46,"maximum":107.76,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":51.28,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":107.76},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":64.1},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":64.1},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":64.1},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":98.97,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":38.46,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":89.74},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":51.28},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":52.31,"additional_payer_notes":"APC"}]}]},{"description":"Assay of free thyroxine","code_information":[{"code":"84439","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6.76,"maximum":18.24,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9.02,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":18.24},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11.28},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11.28},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11.28},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":17.41,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6.76,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15.79},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9.02},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9.2,"additional_payer_notes":"APC"}]}]},{"description":"Assay of transferrin","code_information":[{"code":"84466","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":9.57,"maximum":25.85,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.76,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":25.85},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15.95},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15.95},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15.95},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":24.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9.57,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22.33},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12.76},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.02,"additional_payer_notes":"APC"}]}]},{"description":"Test feces for trypsin","code_information":[{"code":"84488","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5.48,"maximum":14.77,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7.3,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":14.77},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":9.13},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":9.13},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":9.13},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":14.09,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5.48,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12.78},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7.3},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7.45,"additional_payer_notes":"APC"}]}]},{"description":"Assay of blood/uric acid","code_information":[{"code":"84550","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3.39,"maximum":9.16,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4.52,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":9.16},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5.65},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5.65},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5.65},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":8.72,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3.39,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7.91},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":4.52},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4.61,"additional_payer_notes":"APC"}]}]},{"description":"Assay of vasopressin","code_information":[{"code":"84588","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":25.46,"maximum":68.69,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":33.94,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":68.69},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":42.43},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":42.43},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":42.43},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":65.5,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25.46,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":59.4},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33.94},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":34.62,"additional_payer_notes":"APC"}]}]},{"description":"Chorionic gonadotropin test","code_information":[{"code":"84702","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":11.29,"maximum":30.47,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15.05,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":30.47},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18.81},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18.81},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18.81},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":29.05,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11.29,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26.34},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15.05},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15.35,"additional_payer_notes":"APC"}]}]},{"description":"Manual diff wbc count b-coat","code_information":[{"code":"85009","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3.8,"maximum":9.79,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5.07,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7.52},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":6.34},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":6.34},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":6.34},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":9.79,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3.8,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8.87},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5.07},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5.17,"additional_payer_notes":"APC"}]}]},{"description":"Manual reticulocyte count","code_information":[{"code":"85044","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3.23,"maximum":8.7,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4.31,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":8.7},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5.39},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5.39},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5.39},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":8.32,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3.23,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7.54},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":4.31},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4.4,"additional_payer_notes":"APC"}]}]},{"description":"Blood clot lysis time","code_information":[{"code":"85175","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":9.22,"maximum":39.31,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":9.22},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25.46},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25.46},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25.46},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":39.31,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15.28,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35.65},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20.37},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20.78,"additional_payer_notes":"APC"}]}]},{"description":"Clot factor viii multimetric","code_information":[{"code":"85247","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":17.2,"maximum":46.43,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22.94,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":46.43},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28.68},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28.68},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28.68},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":44.27,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17.2,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":40.15},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22.94},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23.4,"additional_payer_notes":"APC"}]}]},{"description":"Clot factor wght kininogen","code_information":[{"code":"85293","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":14.2,"maximum":38.32,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18.93,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":38.32},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23.66},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23.66},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23.66},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":36.53,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14.2,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33.13},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18.93},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19.31,"additional_payer_notes":"APC"}]}]},{"description":"Factor inhibitor test","code_information":[{"code":"85335","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":9.65,"maximum":26.03,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.87,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":26.03},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16.09},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16.09},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16.09},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":24.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9.65,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22.52},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12.87},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.13,"additional_payer_notes":"APC"}]}]},{"description":"Fibrinogen test","code_information":[{"code":"85370","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":9.32,"maximum":23.99,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.43,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":16.4},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15.54},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15.54},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15.54},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":23.99,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9.32,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21.75},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12.43},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.68,"additional_payer_notes":"APC"}]}]},{"description":"Fibrinolytic plasmin","code_information":[{"code":"85400","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5.78,"maximum":17.89,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7.71,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":17.89},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":9.64},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":9.64},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":9.64},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":14.88,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5.78,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13.49},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7.71},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7.86,"additional_payer_notes":"APC"}]}]},{"description":"Hemoglobin fetal","code_information":[{"code":"85461","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7.02,"maximum":18.06,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":13.43},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11.7},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11.7},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11.7},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":18.06,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7.02,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16.38},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9.36},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9.55,"additional_payer_notes":"APC"}]}]},{"description":"Muramidase","code_information":[{"code":"85549","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":14.06,"maximum":37.94,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18.75,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":37.94},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23.44},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23.44},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23.44},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":36.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14.06,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32.81},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18.75},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19.12,"additional_payer_notes":"APC"}]}]},{"description":"Viper venom prothrombin time","code_information":[{"code":"85612","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":13.12,"maximum":33.76,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17.49,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":19.38},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21.86},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21.86},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21.86},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":33.76,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.12,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30.61},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17.49},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17.84,"additional_payer_notes":"APC"}]}]},{"description":"Thromboplastin inhibition","code_information":[{"code":"85705","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7.22,"maximum":18.59,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9.63,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":11.77},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12.04},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12.04},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12.04},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":18.59,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7.22,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16.85},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9.63},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9.82,"additional_payer_notes":"APC"}]}]},{"description":"Allg spec ige recomb ea","code_information":[{"code":"86008","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":13.45,"maximum":34.6,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17.93,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":32.89},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22.41},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22.41},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22.41},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":34.6,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.45,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31.38},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17.93},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18.29,"additional_payer_notes":"APC"}]}]},{"description":"Antinuclear antibodies (ANA)","code_information":[{"code":"86039","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8.37,"maximum":22.57,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11.16,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":22.57},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13.95},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13.95},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13.95},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":21.54,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8.37,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19.53},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11.16},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11.38,"additional_payer_notes":"APC"}]}]},{"description":"Antistreptolysin o screen","code_information":[{"code":"86063","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4.33,"maximum":11.68,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5.77,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":11.68},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7.21},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7.21},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7.21},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11.14,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4.33,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10.1},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5.77},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5.89,"additional_payer_notes":"APC"}]}]},{"description":"Cold agglutinin screen","code_information":[{"code":"86156","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6.05,"maximum":15.58,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8.07,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":11.77},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10.09},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10.09},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10.09},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":15.58,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6.05,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14.12},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8.07},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8.23,"additional_payer_notes":"APC"}]}]},{"description":"Dna antibody native","code_information":[{"code":"86225","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":10.3,"maximum":27.79,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.74,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":27.79},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17.18},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17.18},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17.18},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":26.52,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10.3,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24.05},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13.74},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14.01,"additional_payer_notes":"APC"}]}]},{"description":"Hemagglutination inhibition","code_information":[{"code":"86280","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6.14,"maximum":15.81,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":15.77},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10.24},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10.24},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10.24},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":15.81,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6.14,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14.33},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8.19},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8.35,"additional_payer_notes":"APC"}]}]},{"description":"Heterophile antibody absrbj","code_information":[{"code":"86310","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5.53,"maximum":14.92,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":14.92},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":9.21},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":9.21},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":9.21},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":14.22,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5.53,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12.9},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7.37},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7.52,"additional_payer_notes":"APC"}]}]},{"description":"Immunodiffusion nes","code_information":[{"code":"86329","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":10.54,"maximum":28.42,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14.05,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":28.42},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17.56},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17.56},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17.56},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":27.12,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10.54,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24.59},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14.05},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14.33,"additional_payer_notes":"APC"}]}]},{"description":"Islet cell antibody","code_information":[{"code":"86341","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":17.68,"maximum":45.49,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23.57,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":28.61},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":29.46},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":29.46},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":29.46},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":45.49,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17.68,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":41.25},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23.57},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":24.04,"additional_payer_notes":"APC"}]}]},{"description":"T cells total count","code_information":[{"code":"86359","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":28.3,"maximum":76.34,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":37.73,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":76.34},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":47.16},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":47.16},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":47.16},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":72.82,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":28.3,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":66.03},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37.73},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":38.48,"additional_payer_notes":"APC"}]}]},{"description":"Microsomal antibody each","code_information":[{"code":"86376","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":10.91,"maximum":29.42,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14.55,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":29.42},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18.19},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18.19},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18.19},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":28.08,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10.91,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25.46},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14.55},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14.84,"additional_payer_notes":"APC"}]}]},{"description":"Neutrlzg antb sarscov2 titer","code_information":[{"code":"86409","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":59.71,"maximum":153.65,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":79.61,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":114.64},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":99.51},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":99.51},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":99.51},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":153.65,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":59.71,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":139.32},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":105.33},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":81.2,"additional_payer_notes":"APC"}]}]},{"description":"Syphilis test non-trep qual","code_information":[{"code":"86592","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3.2,"maximum":8.64,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4.27,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":8.64},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5.34},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5.34},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5.34},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":8.24,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3.2,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7.47},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":4.27},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4.36,"additional_payer_notes":"APC"}]}]},{"description":"Blastomyces antibody","code_information":[{"code":"86612","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":9.68,"maximum":24.9,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.9,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":11.77},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16.13},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16.13},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16.13},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":24.9,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9.68,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22.58},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12.9},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.16,"additional_payer_notes":"APC"}]}]},{"description":"Chlamydia antibody","code_information":[{"code":"86631","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8.86,"maximum":22.81,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11.82,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":11.77},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14.78},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14.78},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14.78},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":22.81,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8.86,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20.69},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11.82},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.06,"additional_payer_notes":"APC"}]}]},{"description":"Encephalitis californ antbdy","code_information":[{"code":"86651","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":9.89,"maximum":25.46,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":11.77},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16.49},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16.49},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16.49},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":25.46,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9.89,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23.08},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13.19},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.45,"additional_payer_notes":"APC"}]}]},{"description":"Ehrlichia Antibody","code_information":[{"code":"86666","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7.64,"maximum":19.65,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10.18,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":11.77},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12.73},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12.73},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12.73},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":19.65,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7.64,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17.82},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10.18},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10.38,"additional_payer_notes":"APC"}]}]},{"description":"Htlv-ii antibody","code_information":[{"code":"86688","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":10.5,"maximum":28.34,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":28.34},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17.5},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17.5},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17.5},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":27.02,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10.5,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24.5},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14.28,"additional_payer_notes":"APC"}]}]},{"description":"Hiv-2 antibody","code_information":[{"code":"86702","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":10.14,"maximum":27.35,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.52,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":27.35},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16.9},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16.9},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16.9},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":26.09,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10.14,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23.66},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13.52},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.79,"additional_payer_notes":"APC"}]}]},{"description":"Influenza virus antibody","code_information":[{"code":"86710","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":10.16,"maximum":27.43,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.55,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":27.43},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16.94},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16.94},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16.94},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":26.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10.16,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23.71},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13.55},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.82,"additional_payer_notes":"APC"}]}]},{"description":"Mumps antibody","code_information":[{"code":"86735","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":9.79,"maximum":26.4,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.05,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":26.4},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16.31},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16.31},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16.31},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":25.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9.79,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22.84},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13.05},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.31,"additional_payer_notes":"APC"}]}]},{"description":"Rickettsia Antibody","code_information":[{"code":"86757","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":14.51,"maximum":39.17,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19.35,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":39.17},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24.19},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24.19},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24.19},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":37.35,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14.51,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33.86},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19.35},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19.74,"additional_payer_notes":"APC"}]}]},{"description":"Toxoplasma antibody","code_information":[{"code":"86777","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":10.79,"maximum":29.12,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14.39,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":29.12},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17.99},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17.99},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17.99},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":27.77,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10.79,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25.18},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14.39},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14.68,"additional_payer_notes":"APC"}]}]},{"description":"Yersinia antibody","code_information":[{"code":"86793","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":9.89,"maximum":25.46,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":11.77},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16.49},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16.49},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16.49},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":25.46,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9.89,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23.08},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13.19},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.45,"additional_payer_notes":"APC"}]}]},{"description":"Cytotoxic antibody screening","code_information":[{"code":"86808","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":22.26,"maximum":60.05,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":29.68,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":60.05},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":37.1},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":37.1},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":37.1},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":57.28,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22.26,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":51.94},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29.68},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":30.27,"additional_payer_notes":"APC"}]}]},{"description":"Hla class i&ii antibody qual","code_information":[{"code":"86828","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":48.14,"maximum":123.89,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":64.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":80.1},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":80.24},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":80.24},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":80.24},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":123.89,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":48.14,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":112.33},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":64.19},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":65.47,"additional_payer_notes":"APC"}]}]},{"description":"RBC antibody screen","code_information":[{"code":"86850","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7.75,"maximum":99.48,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":51.54,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7.75},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12.21},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12.21},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12.21},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":99.48,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":38.66,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17.1},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9.77},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":52.57,"additional_payer_notes":"APC"}]}]},{"description":"Blood typing rbc antigens","code_information":[{"code":"86905","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3.83,"maximum":684.27,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":354.54,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7.75},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4.79},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4.79},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4.79},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":684.27,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":265.91,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6.7},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3.83},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":361.63,"additional_payer_notes":"APC"}]}]},{"description":"Stool cultr aerobic bact ea","code_information":[{"code":"87046","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7.08,"maximum":19.09,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9.44,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":19.09},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11.8},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11.8},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11.8},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":18.22,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7.08,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16.52},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9.44},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9.63,"additional_payer_notes":"APC"}]}]},{"description":"Culture of specimen by kit","code_information":[{"code":"87084","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":15.24,"maximum":52.25,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27.07,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":15.24},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":33.84},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":33.84},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":33.84},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":52.25,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20.3,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":47.37},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27.07},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27.61,"additional_payer_notes":"APC"}]}]},{"description":"Mycoplasma","code_information":[{"code":"87109","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":11.54,"maximum":29.7,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15.39,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":20.16},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19.24},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19.24},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19.24},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":29.7,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11.54,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26.93},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15.39},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15.7,"additional_payer_notes":"APC"}]}]},{"description":"Dna/rna amplified probe","code_information":[{"code":"87150","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":26.32,"maximum":71.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":35.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":71.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43.86},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43.86},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43.86},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":67.72,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26.32,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":61.41},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35.09},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":35.79,"additional_payer_notes":"APC"}]}]},{"description":"Macroscopic exam parasite","code_information":[{"code":"87169","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3.23,"maximum":8.64,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4.31,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":8.64},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5.39},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5.39},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5.39},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":8.32,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3.23,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7.54},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":4.31},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4.4,"additional_payer_notes":"APC"}]}]},{"description":"Microbe susceptible mlc","code_information":[{"code":"87187","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":20.96,"maximum":77.53,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":40.17,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":20.96},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":50.21},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":50.21},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":50.21},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":77.53,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":30.13,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":70.3},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":40.17},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":40.97,"additional_payer_notes":"APC"}]}]},{"description":"Smear wet mount saline/ink","code_information":[{"code":"87210","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4.36,"maximum":11.23,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5.82,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":8.64},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7.28},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7.28},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7.28},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11.23,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4.36,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10.19},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5.82},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5.94,"additional_payer_notes":"APC"}]}]},{"description":"Adenovirus ag if","code_information":[{"code":"87260","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":10.82,"maximum":27.85,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14.43,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":24.26},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18.04},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18.04},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18.04},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":27.85,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10.82,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25.25},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14.43},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14.72,"additional_payer_notes":"APC"}]}]},{"description":"Herpes simplex 1 ag if","code_information":[{"code":"87274","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8.98,"maximum":24.26,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11.98,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":24.26},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14.98},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14.98},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14.98},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":23.12,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8.98,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20.97},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11.98},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.22,"additional_payer_notes":"APC"}]}]},{"description":"Treponema pallidum ag if","code_information":[{"code":"87285","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":9.14,"maximum":24.26,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.18,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":24.26},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15.23},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15.23},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15.23},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":23.51,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9.14,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21.32},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12.18},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.42,"additional_payer_notes":"APC"}]}]},{"description":"Cryptococcus neoform ag ia","code_information":[{"code":"87327","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":10.06,"maximum":25.9,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.42,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":24.26},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16.78},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16.78},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16.78},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":25.9,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10.06,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23.49},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13.42},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.69,"additional_payer_notes":"APC"}]}]},{"description":"H pylori ag ia","code_information":[{"code":"87339","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":12.0,"maximum":30.88,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":24.26},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":30.88,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.0,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28.0},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16.32,"additional_payer_notes":"APC"}]}]},{"description":"Hiv-2 ag ia","code_information":[{"code":"87391","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":16.42,"maximum":42.27,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21.9,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":35.69},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27.38},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27.38},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27.38},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":42.27,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16.42,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38.33},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21.9},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22.34,"additional_payer_notes":"APC"}]}]},{"description":"Ag detect nos ia mult","code_information":[{"code":"87449","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8.98,"maximum":24.26,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11.98,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":24.26},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14.98},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14.98},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14.98},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":23.12,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8.98,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20.97},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11.98},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.22,"additional_payer_notes":"APC"}]}]},{"description":"Lyme dis dna amp probe","code_information":[{"code":"87476","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":26.32,"maximum":71.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":35.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":71.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43.86},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43.86},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43.86},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":67.72,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26.32,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":61.41},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35.09},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":35.79,"additional_payer_notes":"APC"}]}]},{"description":"Insulin antibodies","code_information":[{"code":"86337","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":16.06,"maximum":43.32,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21.41,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":43.32},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26.76},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26.76},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26.76},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":41.32,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16.06,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37.47},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21.41},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21.84,"additional_payer_notes":"APC"}]}]},{"description":"Mononuclear cell antigen","code_information":[{"code":"86356","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":20.08,"maximum":54.18,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26.78,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":54.18},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":33.48},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":33.48},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":33.48},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":51.69,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20.08,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":46.87},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26.78},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27.32,"additional_payer_notes":"APC"}]}]},{"description":"Muscle-specific kinase antb","code_information":[{"code":"86366","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":13.8,"maximum":35.51,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18.4,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":27.55},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":35.51,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.8,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32.2},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18.4},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18.77,"additional_payer_notes":"APC"}]}]},{"description":"Particle agglut antbdy titr","code_information":[{"code":"86406","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7.98,"maximum":20.54,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10.64,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":14.16},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13.3},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13.3},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13.3},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":20.54,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7.98,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18.62},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10.64},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10.85,"additional_payer_notes":"APC"}]}]},{"description":"Bacterium antibody","code_information":[{"code":"86609","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":9.66,"maximum":24.86,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.88,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":11.77},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16.1},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16.1},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16.1},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":24.86,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9.66,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22.54},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12.88},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.14,"additional_payer_notes":"APC"}]}]},{"description":"Campylobacter antibody","code_information":[{"code":"86625","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":9.84,"maximum":25.32,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.12,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":11.77},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16.4},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16.4},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16.4},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":25.32,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9.84,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22.96},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13.12},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.38,"additional_payer_notes":"APC"}]}]},{"description":"Cmv antibody igm","code_information":[{"code":"86645","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":11.77,"maximum":32.52,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16.85,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":11.77},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21.06},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21.06},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21.06},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":32.52,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.64,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29.49},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16.85},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17.19,"additional_payer_notes":"APC"}]}]},{"description":"Epstein-barr nuclear antigen","code_information":[{"code":"86664","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":11.47,"maximum":30.95,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15.29,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":30.95},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19.11},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19.11},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19.11},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":29.51,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11.47,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26.76},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15.29},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15.6,"additional_payer_notes":"APC"}]}]},{"description":"Hemophilus influenza antibdy","code_information":[{"code":"86684","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":11.88,"maximum":32.05,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15.84,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":32.05},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19.8},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19.8},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19.8},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":30.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11.88,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27.72},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15.84},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16.16,"additional_payer_notes":"APC"}]}]},{"description":"Histoplasma antibody","code_information":[{"code":"86698","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":10.34,"maximum":26.61,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.79,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":22.72},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17.24},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17.24},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17.24},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":26.61,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10.34,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24.13},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13.79},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14.07,"additional_payer_notes":"APC"}]}]},{"description":"Hepatitis a antibody","code_information":[{"code":"86708","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":9.29,"maximum":25.06,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.39,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":25.06},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15.49},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15.49},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15.49},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":23.91,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9.29,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21.68},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12.39},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.64,"additional_payer_notes":"APC"}]}]},{"description":"Lymph choriomeningitis ab","code_information":[{"code":"86727","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":9.65,"maximum":24.84,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.87,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":11.77},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16.09},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16.09},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16.09},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":24.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9.65,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22.52},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12.87},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.13,"additional_payer_notes":"APC"}]}]},{"description":"Protozoa antibody nos","code_information":[{"code":"86753","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":9.29,"maximum":23.91,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.39,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":11.77},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15.49},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15.49},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15.49},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":23.91,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9.29,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21.68},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12.39},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.64,"additional_payer_notes":"APC"}]}]},{"description":"Shigella antibody","code_information":[{"code":"86771","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":18.36,"maximum":47.25,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":24.48,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":22.72},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":30.6},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":30.6},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":30.6},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":47.25,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18.36,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":42.84},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24.48},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":24.97,"additional_payer_notes":"APC"}]}]},{"description":"West Nile Virus Antibody","code_information":[{"code":"86789","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":10.79,"maximum":29.12,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14.39,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":29.12},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17.99},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17.99},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17.99},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":27.77,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10.79,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25.18},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14.39},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14.68,"additional_payer_notes":"APC"}]}]},{"description":"Lymphocytotoxicity assay","code_information":[{"code":"86806","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":35.69,"maximum":96.3,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":47.59,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":96.3},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":59.49},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":59.49},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":59.49},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":91.85,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":35.69,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":83.28},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":47.59},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":48.54,"additional_payer_notes":"APC"}]}]},{"description":"Hla x-math non-cytotoxic","code_information":[{"code":"86825","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":82.12,"maximum":211.32,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":109.49,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":162.53},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":136.86},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":136.86},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":136.86},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":211.32,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":82.12,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":191.61},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":109.49},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":111.68,"additional_payer_notes":"APC"}]}]},{"description":"Hla class i semiquant panel","code_information":[{"code":"86834","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":268.17,"maximum":723.53,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":357.56,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":723.53},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":446.95},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":446.95},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":446.95},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":690.09,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":268.17,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":625.73},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":357.56},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":364.71,"additional_payer_notes":"APC"}]}]},{"description":"Blood type antigen donor ea","code_information":[{"code":"86902","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6.35,"maximum":684.27,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":354.54,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7.75},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7.94},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7.94},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7.94},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":684.27,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":265.91,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11.11},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6.35},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":361.63,"additional_payer_notes":"APC"}]}]},{"description":"Blood culture for bacteria","code_information":[{"code":"87040","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7.74,"maximum":20.9,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10.32,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":20.9},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12.9},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12.9},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12.9},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":19.92,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7.74,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18.06},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10.32},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10.53,"additional_payer_notes":"APC"}]}]},{"description":"Culture Aerobic Identify","code_information":[{"code":"87077","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6.06,"maximum":16.33,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8.08,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":16.33},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10.1},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10.1},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10.1},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":15.59,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6.06,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14.14},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8.08},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8.24,"additional_payer_notes":"APC"}]}]},{"description":"Fungi identification yeast","code_information":[{"code":"87106","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7.74,"maximum":20.9,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10.32,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":20.9},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12.9},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12.9},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12.9},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":19.92,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7.74,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18.06},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10.32},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10.53,"additional_payer_notes":"APC"}]}]},{"description":"Culture type immunologic","code_information":[{"code":"87147","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3.88,"maximum":10.48,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5.18,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":10.48},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":6.48},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":6.48},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":6.48},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":10.0,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3.88,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9.07},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5.18},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5.28,"additional_payer_notes":"APC"}]}]},{"description":"Dark field examination","code_information":[{"code":"87166","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8.48,"maximum":22.85,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11.3,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":22.85},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14.13},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14.13},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14.13},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":21.81,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8.48,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19.78},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11.3},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11.53,"additional_payer_notes":"APC"}]}]},{"description":"Microbe susceptible enzyme","code_information":[{"code":"87185","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3.56,"maximum":9.62,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4.75,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":9.62},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5.94},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5.94},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5.94},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":9.17,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3.56,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8.31},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":4.75},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4.84,"additional_payer_notes":"APC"}]}]},{"description":"Smear special stain","code_information":[{"code":"87207","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4.49,"maximum":12.12,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5.99,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":12.12},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7.49},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7.49},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7.49},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4.49,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10.48},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5.99},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6.11,"additional_payer_notes":"APC"}]}]},{"description":"Virus inoculation shell via","code_information":[{"code":"87254","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":14.67,"maximum":39.59,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19.56,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":39.59},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24.45},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24.45},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24.45},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":37.75,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14.67,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34.23},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19.56},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19.95,"additional_payer_notes":"APC"}]}]},{"description":"Cryptosporidium ag if","code_information":[{"code":"87272","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8.98,"maximum":24.26,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11.98,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":24.26},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14.98},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14.98},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14.98},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":23.12,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8.98,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20.97},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11.98},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.22,"additional_payer_notes":"APC"}]}]},{"description":"Pneumocystis carinii ag if","code_information":[{"code":"87281","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8.98,"maximum":24.26,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11.98,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":24.26},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14.98},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14.98},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14.98},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":23.12,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8.98,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20.97},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11.98},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.22,"additional_payer_notes":"APC"}]}]},{"description":"Chylmd trach ag ia","code_information":[{"code":"87320","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":11.25,"maximum":28.95,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":24.26},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18.75},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18.75},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18.75},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":28.95,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11.25,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26.25},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15.3,"additional_payer_notes":"APC"}]}]},{"description":"Entamoeb hist group ag ia","code_information":[{"code":"87337","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8.98,"maximum":24.26,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11.98,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":24.26},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14.98},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14.98},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14.98},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":23.12,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8.98,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20.97},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11.98},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.22,"additional_payer_notes":"APC"}]}]},{"description":"Hiv-1 ag w/hiv-1 & hiv-2 ab","code_information":[{"code":"87389","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":18.06,"maximum":48.72,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":24.08,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":48.72},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":30.1},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":30.1},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":30.1},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":46.47,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18.06,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":42.14},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24.08},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":24.56,"additional_payer_notes":"APC"}]}]},{"description":"Sarscov & inf vir a&b ag ia","code_information":[{"code":"87428","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":45.96,"maximum":135.66,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":70.29,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":45.96},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":87.86},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":87.86},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":87.86},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":135.66,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":52.72,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":123.01},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":73.57},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":71.7,"additional_payer_notes":"APC"}]}]},{"description":"Bartonella dna quant","code_information":[{"code":"87472","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":32.13,"maximum":86.68,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":42.84,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":86.68},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":53.55},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":53.55},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":53.55},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":82.68,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":32.13,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":74.97},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":42.84},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":43.7,"additional_payer_notes":"APC"}]}]},{"description":"Chylmd trach dna dir probe","code_information":[{"code":"87490","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":17.06,"maximum":43.91,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22.75,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":40.58},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28.44},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28.44},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28.44},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":43.91,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17.06,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":39.81},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22.75},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23.2,"additional_payer_notes":"APC"}]}]},{"description":"Vanomycin dna amp probe","code_information":[{"code":"87500","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":26.32,"maximum":71.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":35.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":71.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43.86},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43.86},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43.86},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":67.72,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26.32,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":61.41},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35.09},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":35.79,"additional_payer_notes":"APC"}]}]},{"description":"Gardner vag dna amp probe","code_information":[{"code":"87511","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":26.32,"maximum":71.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":35.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":71.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43.86},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43.86},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43.86},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":67.72,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26.32,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":61.41},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35.09},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":35.79,"additional_payer_notes":"APC"}]}]},{"description":"Hepatitis d quantification","code_information":[{"code":"87523","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":32.13,"maximum":82.68,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":42.84,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":64.16},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":53.55},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":53.55},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":53.55},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":82.68,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":32.13,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":74.97},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":42.84},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":43.7,"additional_payer_notes":"APC"}]}]},{"description":"Hhv-6 dna amp probe","code_information":[{"code":"87532","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":26.32,"maximum":71.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":35.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":71.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43.86},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43.86},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43.86},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":67.72,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26.32,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":61.41},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35.09},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":35.79,"additional_payer_notes":"APC"}]}]},{"description":"Legion pneumo dna dir prob","code_information":[{"code":"87540","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":15.04,"maximum":40.58,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20.05,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":40.58},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25.06},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25.06},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25.06},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":38.7,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15.04,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35.09},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20.05},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20.45,"additional_payer_notes":"APC"}]}]},{"description":"M.tuberculo dna quant","code_information":[{"code":"87557","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":32.13,"maximum":86.68,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":42.84,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":86.68},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":53.55},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":53.55},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":53.55},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":82.68,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":32.13,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":74.97},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":42.84},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":43.7,"additional_payer_notes":"APC"}]}]},{"description":"M.pneumon dna quant","code_information":[{"code":"87582","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":84.49,"maximum":584.06,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":302.62,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":84.49},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":378.28},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":378.28},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":378.28},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":584.06,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":226.96,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":529.59},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":302.62},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":308.67,"additional_payer_notes":"APC"}]}]},{"description":"Hpv types 16 & 18 only","code_information":[{"code":"87625","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":30.41,"maximum":78.26,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":40.55,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":71.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":50.69},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":50.69},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":50.69},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":78.26,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":30.41,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":70.96},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":40.55},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":41.36,"additional_payer_notes":"APC"}]}]},{"description":"Sarscov2&inf a&b&rsv amp prb","code_information":[{"code":"87637","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":106.97,"maximum":275.28,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":142.63,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":211.87},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":178.29},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":178.29},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":178.29},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":275.28,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":106.97,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":249.6},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":142.6},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":145.48,"additional_payer_notes":"APC"}]}]},{"description":"Trichomonas vaginalis amplif","code_information":[{"code":"87661","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":26.32,"maximum":71.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":35.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":71.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43.86},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43.86},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43.86},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":67.72,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26.32,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":61.41},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35.09},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":35.79,"additional_payer_notes":"APC"}]}]},{"description":"Clostridium toxin a w/optic","code_information":[{"code":"87803","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":12.0,"maximum":30.88,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":24.26},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":30.88,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.0,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28.0},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16.32,"additional_payer_notes":"APC"}]}]},{"description":"N. gonorrhoeae assay w/optic","code_information":[{"code":"87850","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":18.42,"maximum":47.4,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":24.56,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":24.26},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":30.7},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":30.7},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":30.7},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":47.4,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18.42,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":42.98},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24.56},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25.05,"additional_payer_notes":"APC"}]}]},{"description":"Sialidase enzyme assay","code_information":[{"code":"87905","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":9.16,"maximum":24.72,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.22,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":24.72},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15.28},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15.28},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15.28},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":23.58,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9.16,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21.39},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12.22},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.46,"additional_payer_notes":"APC"}]}]},{"description":"Cytopath c/v thin layer redo","code_information":[{"code":"88143","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":17.28,"maximum":44.47,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23.04,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":40.98},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28.8},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28.8},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28.8},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":44.47,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17.28,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":40.32},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23.04},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23.5,"additional_payer_notes":"APC"}]}]},{"description":"Cytopath tbs c/v redo","code_information":[{"code":"88165","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":21.4,"maximum":81.48,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":42.22,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":21.4},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":52.78},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":52.78},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":52.78},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":81.48,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":31.66,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":73.89},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":42.22},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":43.06,"additional_payer_notes":"APC"}]}]},{"description":"Tissue culture bone marrow","code_information":[{"code":"88237","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":100.79,"maximum":277.44,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":143.75,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":100.79},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":179.69},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":179.69},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":179.69},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":277.44,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":107.81,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":251.56},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":143.75},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":146.62,"additional_payer_notes":"APC"}]}]},{"description":"Chromosome analysis 15-20","code_information":[{"code":"88262","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":94.12,"maximum":252.2,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":125.49,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":252.2},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":156.86},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":156.86},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":156.86},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":242.2,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":94.12,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":219.61},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":125.49},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":128.0,"additional_payer_notes":"APC"}]}]},{"description":"Cytogenetics 25-99","code_information":[{"code":"88274","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":31.78,"maximum":81.79,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":42.38,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":70.45},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":52.98},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":52.98},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":52.98},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":81.79,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":31.78,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":74.17},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":42.38},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":43.23,"additional_payer_notes":"APC"}]}]},{"description":"Bilirubin total transcut","code_information":[{"code":"88720","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3.76,"maximum":10.15,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5.02,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":10.15},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":6.28},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":6.28},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":6.28},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":9.69,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3.76,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8.79},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5.02},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5.12,"additional_payer_notes":"APC"}]}]},{"description":"Specimen fat stain","code_information":[{"code":"89125","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4.41,"maximum":11.35,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5.88,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":8.74},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7.35},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7.35},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7.35},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11.35,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4.41,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10.29},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5.88},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6.0,"additional_payer_notes":"APC"}]}]},{"description":"Sperm antibody test","code_information":[{"code":"89325","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8.0,"maximum":21.59,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10.67,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":21.59},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13.34},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13.34},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13.34},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":20.59,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8.0,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18.67},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10.67},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10.88,"additional_payer_notes":"APC"}]}]},{"description":"Scr c/v cyto,thinlayer,rescr","code_information":[{"code":"G0144","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":32.98,"maximum":84.86,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":43.97,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":43.24},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":54.96},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":54.96},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":54.96},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":84.86,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":32.98,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":76.95},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":43.97},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":44.85,"additional_payer_notes":"APC"}]}]},{"description":"EIA HIV-1/HIV-2 screen","code_information":[{"code":"G0432","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":14.68,"maximum":37.77,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19.57,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":27.74},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24.46},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24.46},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24.46},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":37.77,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14.68,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34.25},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19.57},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19.96,"additional_payer_notes":"APC"}]}]},{"description":"Drug test def 8-14 classes","code_information":[{"code":"G0481","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":117.44,"maximum":302.22,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":156.59,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":182.7},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":195.74},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":195.74},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":195.74},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":302.22,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":117.44,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":274.03},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":156.59},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":159.72,"additional_payer_notes":"APC"}]}]},{"description":"Hair analysis","code_information":[{"code":"P2031","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4.95,"maximum":9.07,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":9.07},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":6.19},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":6.19},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":6.19},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8.66},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":4.95}]}]},{"description":"Pinworm examinations","code_information":[{"code":"Q0113","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3.2,"maximum":10.94,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4.27,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":10.94},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5.34},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5.34},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5.34},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":8.24,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3.2,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7.47},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":4.27},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4.36,"additional_payer_notes":"APC"}]}]},{"description":"Us leiomyomata ablate >200","code_information":[{"code":"0072T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2401.4,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3201.87,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6179.61,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2401.4,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3265.91,"additional_payer_notes":"APC"}]}]},{"description":"Perq sacral augmt bilat inj","code_information":[{"code":"0201T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":13851.98,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Njx paravert w/us lumb/sac","code_information":[{"code":"0218T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":2334.0,"payers_information":[{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Trluml perip athrc brchiocph","code_information":[{"code":"0237T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8563.85,"maximum":27583.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11418.47,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":22037.64,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8563.85,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":27583.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11646.84,"additional_payer_notes":"APC"}]}]},{"description":"Implt/rpl crtd sns dev gen","code_information":[{"code":"0268T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":43285.0,"maximum":44873.0,"payers_information":[{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":44873.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":44873.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":44873.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":43285.0}]}]},{"description":"Extraosseous joint stblztion","code_information":[{"code":"0335T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":13851.98,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Trnscrv uterin fibroid abltj","code_information":[{"code":"0404T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":16106.0,"maximum":16106.0,"payers_information":[{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0}]}]},{"description":"Repos car modulj tranvns elt","code_information":[{"code":"0415T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":465.35,"maximum":3030.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":620.47,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1197.51,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":465.35,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":632.88,"additional_payer_notes":"APC"}]}]},{"description":"Onco prst8 3 gene ur alg","code_information":[{"code":"0005U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":570.0,"maximum":1466.8,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":760.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1128.96},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":950.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":950.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":950.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1466.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":570.0,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1330.0},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":760.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":775.2,"additional_payer_notes":"APC"}]}]},{"description":"Rx mntr lc-ms/ms oral fluid","code_information":[{"code":"0011U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":85.82,"maximum":220.85,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":114.43,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":169.99},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":143.04},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":143.04},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":143.04},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":220.85,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":85.82,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":200.25},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":114.43},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":116.72,"additional_payer_notes":"APC"}]}]},{"description":"Trnsplj rnl meas cd154+cll","code_information":[{"code":"0018M","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":480.55,"maximum":1236.61,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":640.73,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":948.76},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":800.91},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":800.91},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":800.91},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1236.61,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":480.55,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1121.28},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":640.73},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":653.54,"additional_payer_notes":"APC"}]}]},{"description":"Glyca nuc mr spectrsc quan","code_information":[{"code":"0024U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":25.64,"maximum":65.99,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":34.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":52.08},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":42.74},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":42.74},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":42.74},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":65.99,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25.64,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":59.83},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34.19},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":34.87,"additional_payer_notes":"APC"}]}]},{"description":"Htr2a htr2c genes","code_information":[{"code":"0033U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":349.62,"maximum":611.84,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":519.35},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":437.03},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":437.03},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":437.03},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":611.84},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":349.62}]}]},{"description":"B brgdrferi antb 5 prtn igm","code_information":[{"code":"0041U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":12.91,"maximum":33.22,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17.21,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21.51},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21.51},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21.51},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":33.22,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.91,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30.12},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17.21},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17.55,"additional_payer_notes":"APC"}]}]},{"description":"Npm1 gene analysis quan","code_information":[{"code":"0049U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":246.49,"maximum":786.34,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":407.43,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":366.19},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":509.29},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":509.29},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":509.29},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":786.34,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":305.57,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":713.0},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":246.49},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":415.58,"additional_payer_notes":"APC"}]}]},{"description":"Chylmd pneum dna amp probe","code_information":[{"code":"87486","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":26.32,"maximum":71.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":35.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":71.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43.86},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43.86},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43.86},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":67.72,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26.32,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":61.41},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35.09},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":35.79,"additional_payer_notes":"APC"}]}]},{"description":"Cytomeg dna quant","code_information":[{"code":"87497","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":32.13,"maximum":86.68,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":42.84,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":86.68},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":53.55},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":53.55},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":53.55},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":82.68,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":32.13,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":74.97},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":42.84},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":43.7,"additional_payer_notes":"APC"}]}]},{"description":"Iadna-dna/rna probe tq 12-25","code_information":[{"code":"87507","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":312.58,"maximum":843.37,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":416.78,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":843.37},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":520.98},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":520.98},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":520.98},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":804.39,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":312.58,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":729.37},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":416.78},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":425.12,"additional_payer_notes":"APC"}]}]},{"description":"Hepatitis c probe&rvrs trnsc","code_information":[{"code":"87521","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":26.32,"maximum":71.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":35.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":71.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43.86},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43.86},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43.86},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":67.72,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26.32,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":61.41},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35.09},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":35.79,"additional_payer_notes":"APC"}]}]},{"description":"Hsv dna quant","code_information":[{"code":"87530","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":32.13,"maximum":86.68,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":42.84,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":86.68},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":53.55},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":53.55},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":53.55},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":82.68,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":32.13,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":74.97},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":42.84},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":43.7,"additional_payer_notes":"APC"}]}]},{"description":"Hiv-2 probe&revrse trnscripj","code_information":[{"code":"87538","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":26.32,"maximum":71.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":35.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":71.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43.86},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43.86},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43.86},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":67.72,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26.32,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":61.41},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35.09},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":35.79,"additional_payer_notes":"APC"}]}]},{"description":"M.tuberculo dna dir probe","code_information":[{"code":"87555","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":20.16,"maximum":51.88,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26.88,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":40.58},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":33.6},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":33.6},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":33.6},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":51.88,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20.16,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":47.04},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26.88},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27.42,"additional_payer_notes":"APC"}]}]},{"description":"M.pneumon dna dir probe","code_information":[{"code":"87580","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":15.04,"maximum":40.58,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20.05,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":40.58},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25.06},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25.06},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25.06},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":38.7,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15.04,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35.09},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20.05},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20.45,"additional_payer_notes":"APC"}]}]},{"description":"Hpv low-risk types","code_information":[{"code":"87623","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":26.32,"maximum":71.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":35.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":71.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43.86},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43.86},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43.86},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":67.72,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26.32,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":61.41},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35.09},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":35.79,"additional_payer_notes":"APC"}]}]},{"description":"Sars-cov-2 covid-19 amp prb","code_information":[{"code":"87635","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":38.48,"maximum":99.03,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":51.31,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":76.22},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":64.14},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":64.14},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":64.14},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":99.03,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":38.48,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":89.79},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":51.31},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":52.34,"additional_payer_notes":"APC"}]}]},{"description":"Strep b dna amp probe","code_information":[{"code":"87653","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":26.32,"maximum":71.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":35.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":71.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43.86},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43.86},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43.86},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":67.72,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26.32,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":61.41},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35.09},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":35.79,"additional_payer_notes":"APC"}]}]},{"description":"Detect agnt mult dna ampli","code_information":[{"code":"87801","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":52.65,"maximum":142.03,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":70.2,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":142.03},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":87.75},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":87.75},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":87.75},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":135.49,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":52.65,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":122.85},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":70.2},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":71.6,"additional_payer_notes":"APC"}]}]},{"description":"Chylmd trach assay w/optic","code_information":[{"code":"87810","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":24.26,"maximum":68.11,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":35.29,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":24.26},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":44.11},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":44.11},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":44.11},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":68.11,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26.47,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":61.76},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35.29},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":36.0,"additional_payer_notes":"APC"}]}]},{"description":"Phenotype dna hiv w/culture","code_information":[{"code":"87903","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":366.5,"maximum":988.79,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":488.66,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":988.79},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":610.83},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":610.83},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":610.83},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":943.11,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":366.5,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":855.16},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":488.66},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":498.43,"additional_payer_notes":"APC"}]}]},{"description":"Sex chromatin identification","code_information":[{"code":"88140","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5.99,"maximum":16.19,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7.99,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":16.19},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":9.99},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":9.99},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":9.99},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":15.42,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5.99,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13.98},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7.99},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8.15,"additional_payer_notes":"APC"}]}]},{"description":"Cytopath c/v index add-on","code_information":[{"code":"88155","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":10.99,"maximum":28.27,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14.65,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":12.12},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18.31},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18.31},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18.31},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":28.27,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10.99,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25.64},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14.65},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14.94,"additional_payer_notes":"APC"}]}]},{"description":"Tissue culture skin/biopsy","code_information":[{"code":"88233","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":100.79,"maximum":271.61,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":140.73,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":100.79},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":175.91},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":175.91},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":175.91},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":271.61,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":105.55,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":246.28},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":140.73},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":143.54,"additional_payer_notes":"APC"}]}]},{"description":"Chromosome analysis 100","code_information":[{"code":"88249","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":129.88,"maximum":350.42,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":173.17,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":350.42},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":216.46},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":216.46},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":216.46},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":334.22,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":129.88,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":303.05},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":173.17},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":176.63,"additional_payer_notes":"APC"}]}]},{"description":"Cytogenetics 3-5","code_information":[{"code":"88272","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":30.52,"maximum":78.55,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":40.7,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":51.25},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":50.88},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":50.88},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":50.88},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":78.55,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":30.52,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":71.23},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":40.7},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":41.51,"additional_payer_notes":"APC"}]}]},{"description":"Protein western blot tissue","code_information":[{"code":"88371","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":22.23,"maximum":44.96,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":44.96},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27.79},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27.79},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27.79},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38.9},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22.23}]}]},{"description":"Leukocyte assessment fecal","code_information":[{"code":"89055","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3.2,"maximum":8.64,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4.27,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":8.64},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5.34},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5.34},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5.34},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":8.24,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3.2,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7.47},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":4.27},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4.36,"additional_payer_notes":"APC"}]}]},{"description":"Semen anal sperm detection","code_information":[{"code":"89321","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":9.04,"maximum":24.38,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.05,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":24.38},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15.06},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15.06},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15.06},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":23.26,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9.04,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21.09},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12.05},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.29,"additional_payer_notes":"APC"}]}]},{"description":"Screen cerv/vag thin layer","code_information":[{"code":"G0123","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":15.2,"maximum":40.98,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20.26,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":40.98},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25.33},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25.33},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25.33},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":39.1,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15.2,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35.46},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20.26},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20.67,"additional_payer_notes":"APC"}]}]},{"description":"Hpv combo assay ca screen","code_information":[{"code":"G0476","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":26.32,"maximum":71.52,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":35.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":71.52},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43.86},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43.86},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43.86},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":67.72,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26.32,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":61.41},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35.09},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":35.79,"additional_payer_notes":"APC"}]}]},{"description":"Cephalin floculation test","code_information":[{"code":"P2028","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3.71,"maximum":9.55,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4.95,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":9.07},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":6.19},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":6.19},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":6.19},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":9.55,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3.71,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8.66},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":4.95},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5.05,"additional_payer_notes":"APC"}]}]},{"description":"Wet mounts/ w preparations","code_information":[{"code":"Q0111","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8.64,"maximum":35.78,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18.54,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":8.64},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22.74},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22.74},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22.74},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":35.78,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.9,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31.83},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15.12},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18.91,"additional_payer_notes":"APC"}]}]},{"description":"Bone srgry cmptr ct/mri imag","code_information":[{"code":"0055T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":2334.0,"payers_information":[{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Exc rectal tumor endoscopic","code_information":[{"code":"0184T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4503.59,"maximum":11589.23,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6004.78,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11589.23,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4503.59,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6124.88,"additional_payer_notes":"APC"}]}]},{"description":"Njx paravert w/us lumb/sac","code_information":[{"code":"0216T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":656.13,"maximum":3030.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":874.84,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1688.44,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":656.13,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":892.34,"additional_payer_notes":"APC"}]}]},{"description":"Trluml perip athrc renal art","code_information":[{"code":"0234T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8563.85,"maximum":27583.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11418.47,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":22037.64,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8563.85,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":27583.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11646.84,"additional_payer_notes":"APC"}]}]},{"description":"Implt/rpl crtd sns dev total","code_information":[{"code":"0266T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":43285.0,"maximum":44873.0,"payers_information":[{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":44873.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":44873.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":44873.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":43285.0}]}]},{"description":"Tempr","code_information":[{"code":"0278T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":95.45,"maximum":2334.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":127.27,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":245.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":95.45,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":129.82,"additional_payer_notes":"APC"}]}]},{"description":"Rmvl car modulj tranvns elt","code_information":[{"code":"0413T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2772.2,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3696.26,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7133.79,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2772.2,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3770.19,"additional_payer_notes":"APC"}]}]},{"description":"Ehrlicha chaffeensis amp prb","code_information":[{"code":"87484","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":26.32,"maximum":67.72,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":35.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":51.96},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43.86},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43.86},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43.86},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":67.72,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26.32,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":61.41},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35.09},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":35.79,"additional_payer_notes":"APC"}]}]},{"description":"Cytomeg dna dir probe","code_information":[{"code":"87495","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":22.52,"maximum":57.96,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":30.03,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":40.58},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":37.54},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":37.54},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":37.54},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":57.96,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22.52,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":52.55},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30.03},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":30.63,"additional_payer_notes":"APC"}]}]},{"description":"Nfct agent detection gi","code_information":[{"code":"87505","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":96.22,"maximum":259.61,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":128.29,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":259.61},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":160.36},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":160.36},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":160.36},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":247.6,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":96.22,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":224.51},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":128.29},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":130.86,"additional_payer_notes":"APC"}]}]},{"description":"Hepatitis b dna quant","code_information":[{"code":"87517","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":32.13,"maximum":86.68,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":42.84,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":86.68},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":53.55},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":53.55},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":53.55},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":82.68,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":32.13,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":74.97},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":42.84},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":43.7,"additional_payer_notes":"APC"}]}]},{"description":"Hsv dna dir probe","code_information":[{"code":"87528","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":15.04,"maximum":40.58,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20.05,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":40.58},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25.06},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25.06},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25.06},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":38.7,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15.04,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35.09},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20.05},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20.45,"additional_payer_notes":"APC"}]}]},{"description":"Hiv-1 quant&revrse trnscrpj","code_information":[{"code":"87536","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":63.82,"maximum":172.2,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":85.1,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":172.2},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":106.38},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":106.38},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":106.38},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":164.24,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":63.82,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":148.93},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":85.1},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":86.8,"additional_payer_notes":"APC"}]}]},{"description":"Mycobacteria dna amp probe","code_information":[{"code":"87551","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":36.18,"maximum":93.1,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":48.24,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":71.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":60.3},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":60.3},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":60.3},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":93.1,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":36.18,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":84.42},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":48.24},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":49.2,"additional_payer_notes":"APC"}]}]},{"description":"M. genitalium amp probe","code_information":[{"code":"87563","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":26.32,"maximum":67.72,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":35.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":52.12},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43.86},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43.86},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43.86},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":67.72,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26.32,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":61.41},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35.09},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":35.79,"additional_payer_notes":"APC"}]}]},{"description":"Orthopoxvirus amp prb each","code_information":[{"code":"87593","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":38.48,"maximum":99.03,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":51.31,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":73.88},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":64.14},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":64.14},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":64.14},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":99.03,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":38.48,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":89.79},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":51.17},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":52.34,"additional_payer_notes":"APC"}]}]},{"description":"Resp virus 12-25 targets","code_information":[{"code":"87633","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":312.58,"maximum":843.37,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":416.78,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":843.37},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":520.98},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":520.98},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":520.98},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":804.39,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":312.58,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":729.37},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":416.78},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":425.12,"additional_payer_notes":"APC"}]}]},{"description":"Strep a dna amp probe","code_information":[{"code":"87651","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":26.32,"maximum":71.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":35.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":71.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43.86},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43.86},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43.86},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":67.72,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26.32,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":61.41},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35.09},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":35.79,"additional_payer_notes":"APC"}]}]},{"description":"Detect agent nos dna quant","code_information":[{"code":"87799","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":32.13,"maximum":86.68,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":42.84,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":86.68},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":53.55},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":53.55},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":53.55},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":82.68,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":32.13,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":74.97},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":42.84},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":43.7,"additional_payer_notes":"APC"}]}]},{"description":"Trichomonas assay w/optic","code_information":[{"code":"87808","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":11.47,"maximum":29.51,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15.29,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":24.26},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19.11},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19.11},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19.11},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":29.51,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11.47,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26.76},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15.29},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15.6,"additional_payer_notes":"APC"}]}]},{"description":"Genotype dna hiv reverse t","code_information":[{"code":"87901","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":193.09,"maximum":520.94,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":257.45,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":520.94},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":321.81},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":321.81},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":321.81},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":496.88,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":193.09,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":450.54},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":257.45},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":262.6,"additional_payer_notes":"APC"}]}]},{"description":"Nfct agt gntyp alys sarscov2","code_information":[{"code":"87913","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":193.09,"maximum":496.88,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":257.45,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":381.23},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":321.81},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":321.81},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":321.81},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":496.88,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":193.09,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":450.54},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":257.45},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":262.6,"additional_payer_notes":"APC"}]}]},{"description":"Cytopath c/v auto redo","code_information":[{"code":"88152","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":20.73,"maximum":53.35,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27.64,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":21.4},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":34.55},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":34.55},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":34.55},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":53.35,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20.73,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":48.37},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27.64},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":28.19,"additional_payer_notes":"APC"}]}]},{"description":"Cytopath c/v auto fluid redo","code_information":[{"code":"88175","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":19.96,"maximum":53.35,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26.61,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":53.35},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":33.26},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":33.26},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":33.26},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":51.36,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19.96,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":46.57},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26.61},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27.14,"additional_payer_notes":"APC"}]}]},{"description":"Chromosome analysis 20-25","code_information":[{"code":"88245","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":129.88,"maximum":334.22,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":173.17,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":301.21},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":216.46},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":216.46},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":216.46},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":334.22,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":129.88,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":303.05},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":173.17},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":176.63,"additional_payer_notes":"APC"}]}]},{"description":"Chromosome analys amniotic","code_information":[{"code":"88269","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":130.24,"maximum":336.56,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":173.66,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":336.56},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":217.08},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":217.08},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":217.08},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":335.16,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":130.24,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":303.91},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":173.66},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":177.13,"additional_payer_notes":"APC"}]}]},{"description":"Chromosome count additional","code_information":[{"code":"88285","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":20.18,"maximum":51.94,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26.91,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":38.45},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":33.64},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":33.64},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":33.64},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":51.94,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20.18,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":47.09},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26.91},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27.45,"additional_payer_notes":"APC"}]}]},{"description":"Body fluid cell count","code_information":[{"code":"89050","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3.54,"maximum":9.58,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4.72,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":9.58},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5.9},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5.9},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5.9},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":9.11,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3.54,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8.26},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":4.72},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4.81,"additional_payer_notes":"APC"}]}]},{"description":"Semen analysis w/count","code_information":[{"code":"89310","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6.46,"maximum":17.44,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8.61,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":17.44},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10.76},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10.76},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10.76},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":16.62,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6.46,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15.07},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8.61},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8.78,"additional_payer_notes":"APC"}]}]},{"description":"Semen analysis","code_information":[{"code":"G0027","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4.88,"maximum":13.15,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6.5,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":13.15},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8.13},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8.13},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8.13},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":12.54,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4.88,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11.38},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6.5},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6.63,"additional_payer_notes":"APC"}]}]},{"description":"CBC/diffwbc w/o platelet","code_information":[{"code":"G0306","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5.83,"maximum":15.72,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7.77,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":15.72},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":9.71},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":9.71},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":9.71},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":15.0,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5.83,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13.6},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7.77},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7.93,"additional_payer_notes":"APC"}]}]},{"description":"Hep c screen high risk/other","code_information":[{"code":"G0472","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":28.88,"maximum":89.46,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":46.35,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":28.88},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":57.94},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":57.94},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":57.94},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":89.46,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":34.76,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":81.11},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":46.35},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":47.28,"additional_payer_notes":"APC"}]}]},{"description":"Drug test def simple all cl","code_information":[{"code":"G0659","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":46.6,"maximum":119.93,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":62.14,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":118.55},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":77.68},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":77.68},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":77.68},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":119.93,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":46.6,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":108.75},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":62.14},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":63.38,"additional_payer_notes":"APC"}]}]},{"description":"Catheterize for urine spec","code_information":[{"code":"P9612","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3.0,"maximum":18.03,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9.34,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4.45},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11.36},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11.36},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11.36},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":18.03,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7.0,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15.91},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9.53,"additional_payer_notes":"APC"}]}]},{"description":"COVID-19 lab test non-CDC","code_information":[{"code":"U0002","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":38.48,"maximum":99.03,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":51.31,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":76.22},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":64.14},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":64.14},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":64.14},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":99.03,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":38.48,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":89.79},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":51.31},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":52.34,"additional_payer_notes":"APC"}]}]},{"description":"Remove Lumb Artif Disc Addl","code_information":[{"code":"0164T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":2334.0,"payers_information":[{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Njx paravert w/us cer/thor","code_information":[{"code":"0214T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":2334.0,"payers_information":[{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Plmt post facet implt addl","code_information":[{"code":"0222T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":2334.0,"payers_information":[{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Im b1 mrw cel ther xcl hrvst","code_information":[{"code":"0264T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3231.05,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4308.07,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":8314.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3231.05,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4394.23,"additional_payer_notes":"APC"}]}]},{"description":"Perq lamot/lam crv/thrc","code_information":[{"code":"0274T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Ins bone device for rsa","code_information":[{"code":"0347T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":43.76,"maximum":2334.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":58.35,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":112.62,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":43.76,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":59.52,"additional_payer_notes":"APC"}]}]},{"description":"Insj/rplc car modulj vnt elt","code_information":[{"code":"0411T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6138.95,"maximum":27583.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8185.27,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":15797.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6138.95,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":27583.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8348.97,"additional_payer_notes":"APC"}]}]},{"description":"Dx mammo incl cad bi","code_information":[{"code":"77066","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":146.4,"maximum":146.4,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":146.4}]},{"setting":"outpatient","billing_class":"facility","modifier_code":["TC"],"minimum":79.11,"maximum":203.58,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":105.48,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":203.58,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":79.11,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":107.59,"additional_payer_notes":"APC"}]}]},{"description":"Insj/rplc nstim apnea sen ld","code_information":[{"code":"0425T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":18364.0,"maximum":18364.0,"payers_information":[{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0}]}]},{"description":"Repos nstim apnea sensing ld","code_information":[{"code":"0433T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8770.0,"maximum":8770.0,"payers_information":[{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0}]}]},{"description":"Vein byp fem-tibial peroneal","code_information":[{"code":"35585","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Art byp axillary-pop-tibial","code_information":[{"code":"35623","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Art byp aortobi-iliac","code_information":[{"code":"35638","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Art byp femoral-femoral","code_information":[{"code":"35661","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Exploration carotid artery","code_information":[{"code":"35701","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Revise graft w/vein","code_information":[{"code":"35879","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4127.91,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5503.89,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":10622.5,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4127.91,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5613.96,"additional_payer_notes":"APC"}]}]},{"description":"Place needle in vein","code_information":[{"code":"36000","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Place catheter in artery","code_information":[{"code":"36015","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Place catheter in artery","code_information":[{"code":"36218","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Place cath intracranial art","code_information":[{"code":"36228","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Ins cath ren art 2nd+ bilat","code_information":[{"code":"36254","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2342.32,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3123.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6027.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2342.32,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3185.56,"additional_payer_notes":"APC"}]}]},{"description":"Bl exchange/transfuse non-nb","code_information":[{"code":"36455","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":327.28,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":436.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":842.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":327.28,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":445.1,"additional_payer_notes":"APC"}]}]},{"description":"Endovenous laser vein addon","code_information":[{"code":"36479","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Apheresis selective","code_information":[{"code":"36516","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3231.05,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4308.07,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":8314.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3231.05,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4394.23,"additional_payer_notes":"APC"}]}]},{"description":"Insert tunneled cv cath","code_information":[{"code":"36563","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4127.91,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5503.89,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":10622.5,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4127.91,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5613.96,"additional_payer_notes":"APC"}]}]},{"description":"Repair tunneled cv cath","code_information":[{"code":"36576","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1167.76,"maximum":4106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1557.01,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3005.03,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1167.76,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1588.15,"additional_payer_notes":"APC"}]}]},{"description":"Removal tunneled cv cath","code_information":[{"code":"36589","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":465.35,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":620.47,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1197.51,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":465.35,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":632.88,"additional_payer_notes":"APC"}]}]},{"description":"Insertion catheter artery","code_information":[{"code":"36640","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2342.32,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3123.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6027.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2342.32,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3185.56,"additional_payer_notes":"APC"}]}]},{"description":"Av fusion/forearm vein","code_information":[{"code":"36820","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4127.91,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5503.89,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":10622.5,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4127.91,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5613.96,"additional_payer_notes":"APC"}]}]},{"description":"Artery to vein shunt","code_information":[{"code":"36835","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2342.32,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3123.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6027.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2342.32,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3185.56,"additional_payer_notes":"APC"}]}]},{"description":"Splice spleen/kidney veins","code_information":[{"code":"37181","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Ins endovas vena cava filtr","code_information":[{"code":"37191","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4127.91,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5503.89,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":10622.5,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4127.91,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5613.96,"additional_payer_notes":"APC"}]}]},{"description":"Thromblytic art/ven therapy","code_information":[{"code":"37213","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2342.32,"maximum":6027.57,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3123.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6027.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2342.32,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3185.56,"additional_payer_notes":"APC"}]}]},{"description":"Iliac revasc add-on","code_information":[{"code":"37222","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5512.0,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0}]}]},{"description":"Tib/per revasc w/stent","code_information":[{"code":"37230","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8923.0,"maximum":27583.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":10765.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":8923.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":10765.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":27583.0}]}]},{"description":"Open/perq place stent same","code_information":[{"code":"37238","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":27583.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11418.47,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":22037.64,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8563.85,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":27583.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11646.84,"additional_payer_notes":"APC"}]}]},{"description":"Endoscopy ligate perf veins","code_information":[{"code":"37500","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0}]}]},{"description":"Ligation of neck artery","code_information":[{"code":"37615","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2342.32,"maximum":6027.57,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3123.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6027.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2342.32,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3185.56,"additional_payer_notes":"APC"}]}]},{"description":"Ligate/strip short leg vein","code_information":[{"code":"37718","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2342.32,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3123.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6027.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2342.32,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3185.56,"additional_payer_notes":"APC"}]}]},{"description":"Ligate/divide/excise vein","code_information":[{"code":"37785","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2342.32,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3123.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6027.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2342.32,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3185.56,"additional_payer_notes":"APC"}]}]},{"description":"Laparoscopy splenectomy","code_information":[{"code":"38120","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":20292.15,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10514.07,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":20292.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7885.55,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10724.35,"additional_payer_notes":"APC"}]}]},{"description":"Wash harvest stem cells","code_information":[{"code":"38209","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":327.28,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":436.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":842.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":327.28,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":445.1,"additional_payer_notes":"APC"}]}]},{"description":"Bone marrow biopsy","code_information":[{"code":"38221","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1225.21,"maximum":4106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1633.61,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3152.87,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1225.21,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1666.28,"additional_payer_notes":"APC"}]}]},{"description":"Drainage lymph node lesion","code_information":[{"code":"38305","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2154.81,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2873.08,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5545.05,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2154.81,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2930.54,"additional_payer_notes":"APC"}]}]},{"description":"Biopsy/removal lymph nodes","code_information":[{"code":"38520","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2904.59,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3872.79,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7474.49,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2904.59,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3950.25,"additional_payer_notes":"APC"}]}]},{"description":"Insj/rplc nstim apnea pls gn","code_information":[{"code":"0427T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":44873.0,"maximum":44873.0,"payers_information":[{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":44873.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":44873.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":44873.0}]}]},{"description":"Abltj perc uxtr/perph nrv","code_information":[{"code":"0440T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1448.59,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1931.46,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3727.72,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1448.59,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1970.09,"additional_payer_notes":"APC"}]}]},{"description":"Rmvl/rplc nstim apnea pls gn","code_information":[{"code":"0431T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":44873.0,"maximum":44873.0,"payers_information":[{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":44873.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":44873.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":44873.0}]}]},{"description":"Laparoscopy lymph node biop","code_information":[{"code":"38570","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4484.77,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5979.69,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5257.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11540.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4484.77,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6099.28,"additional_payer_notes":"APC"}]}]},{"description":"Remove armpit lymph nodes","code_information":[{"code":"38745","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4484.77,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5979.69,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5257.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11540.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4484.77,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6099.28,"additional_payer_notes":"APC"}]}]},{"description":"Mediastinoscpy w/medstnl bx","code_information":[{"code":"39401","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4484.77,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5979.69,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5257.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11540.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4484.77,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6099.28,"additional_payer_notes":"APC"}]}]},{"description":"Resect diaphragm simple","code_information":[{"code":"39560","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5257.0,"maximum":6462.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5257.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6462.0}]}]},{"description":"Reconstruct lip with flap","code_information":[{"code":"40527","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":11300.84,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Repair cleft lip/nasal","code_information":[{"code":"40720","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2459.51,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3279.35,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6329.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2459.51,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3344.94,"additional_payer_notes":"APC"}]}]},{"description":"Biopsy of mouth lesion","code_information":[{"code":"40808","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":400.09,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":533.45,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1029.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":400.09,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":544.12,"additional_payer_notes":"APC"}]}]},{"description":"Repair mouth laceration","code_information":[{"code":"40830","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":175.7,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":234.27,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":452.14,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":175.7,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":238.96,"additional_payer_notes":"APC"}]}]},{"description":"Drainage of mouth lesion","code_information":[{"code":"41000","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":400.09,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":533.45,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1029.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":400.09,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":544.12,"additional_payer_notes":"APC"}]}]},{"description":"Drainage of mouth lesion","code_information":[{"code":"41016","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":11300.84,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Excision of tongue lesion","code_information":[{"code":"41112","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2459.51,"maximum":6329.15,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3279.35,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6329.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2459.51,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3344.94,"additional_payer_notes":"APC"}]}]},{"description":"Removal of tongue","code_information":[{"code":"41140","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Tongue to lip surgery","code_information":[{"code":"41510","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2459.51,"maximum":6329.15,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3279.35,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6329.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2459.51,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3344.94,"additional_payer_notes":"APC"}]}]},{"description":"Excision gum each quadrant","code_information":[{"code":"41820","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2459.51,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3279.35,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6329.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2459.51,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3344.94,"additional_payer_notes":"APC"}]}]},{"description":"Removal of gum tissue","code_information":[{"code":"41830","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2459.51,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3279.35,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6329.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2459.51,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3344.94,"additional_payer_notes":"APC"}]}]},{"description":"Excision lesion mouth roof","code_information":[{"code":"42104","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2459.51,"maximum":6329.15,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3279.35,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6329.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2459.51,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3344.94,"additional_payer_notes":"APC"}]}]},{"description":"Repair palate","code_information":[{"code":"42182","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":11300.84,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Lengthening of palate","code_information":[{"code":"42227","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Drainage of salivary gland","code_information":[{"code":"42310","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":400.09,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":533.45,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1029.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":400.09,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":544.12,"additional_payer_notes":"APC"}]}]},{"description":"Drainage of salivary cyst","code_information":[{"code":"42409","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2459.51,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3279.35,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6329.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2459.51,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3344.94,"additional_payer_notes":"APC"}]}]},{"description":"Repair salivary duct","code_information":[{"code":"42500","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":11300.84,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Dilation of salivary duct","code_information":[{"code":"42660","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":400.09,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":533.45,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1029.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":400.09,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":544.12,"additional_payer_notes":"APC"}]}]},{"description":"Biopsy of upper nose/throat","code_information":[{"code":"42806","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2459.51,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3279.35,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6329.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2459.51,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3344.94,"additional_payer_notes":"APC"}]}]},{"description":"Removal of tonsils","code_information":[{"code":"42826","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2459.51,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3279.35,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6329.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2459.51,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3344.94,"additional_payer_notes":"APC"}]}]},{"description":"Excision of tonsil tags","code_information":[{"code":"42860","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2459.51,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3279.35,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6329.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2459.51,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3344.94,"additional_payer_notes":"APC"}]}]},{"description":"Surgical opening of throat","code_information":[{"code":"42955","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1151.01,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1534.69,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2961.94,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1151.01,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1565.38,"additional_payer_notes":"APC"}]}]},{"description":"Incision of esophagus","code_information":[{"code":"43020","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1151.01,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1534.69,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2961.94,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1151.01,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1565.38,"additional_payer_notes":"APC"}]}]},{"description":"Removal of esophagus","code_information":[{"code":"43113","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Removal of esophagus pouch","code_information":[{"code":"43130","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Esophagoscp guide wire dilat","code_information":[{"code":"43196","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1423.51,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1898.01,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3663.16,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1423.51,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1935.97,"additional_payer_notes":"APC"}]}]},{"description":"Esoph optical endomicroscopy","code_information":[{"code":"43206","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1423.51,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1898.01,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3663.16,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1423.51,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1935.97,"additional_payer_notes":"APC"}]}]},{"description":"Esophagoscopy snare les remv","code_information":[{"code":"43217","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1423.51,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1898.01,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3663.16,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1423.51,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1935.97,"additional_payer_notes":"APC"}]}]},{"description":"Egd diagnostic brush wash","code_information":[{"code":"43235","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":672.83,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":897.11,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1731.42,"additional_payer_notes":"APC"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1484.0},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":672.83,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":915.05,"additional_payer_notes":"APC"}]}]},{"description":"Egd injection varices","code_information":[{"code":"43243","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1423.51,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1898.01,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3663.16,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1423.51,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1935.97,"additional_payer_notes":"APC"}]}]},{"description":"Egd remove lesion snare","code_information":[{"code":"43251","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1423.51,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1898.01,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3663.16,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1423.51,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1935.97,"additional_payer_notes":"APC"}]}]},{"description":"Radiographic procedure","code_information":[{"code":"76499","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":64.56,"maximum":183.45,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":86.08,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":183.45},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":166.13,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":64.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":87.8,"additional_payer_notes":"APC"}]}]},{"description":"Us abdl aorta screen aaa","code_information":[{"code":"76706","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":77.56,"maximum":199.58,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":103.41,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":80.67},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":199.58,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":77.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":105.48,"additional_payer_notes":"APC"}]}]},{"description":"Endo cholangiopancreatograph","code_information":[{"code":"43261","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2860.11,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3813.48,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7360.02,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2860.11,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3889.75,"additional_payer_notes":"APC"}]}]},{"description":"Ercp duct stent placement","code_information":[{"code":"43274","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":11589.23,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6004.78,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11589.23,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4503.59,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6124.88,"additional_payer_notes":"APC"}]}]},{"description":"Lap paraesoph her rpr w/mesh","code_information":[{"code":"43282","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":20292.15,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10514.07,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":20292.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7885.55,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10724.35,"additional_payer_notes":"APC"}]}]},{"description":"Tracheo-esophagoplasty cong","code_information":[{"code":"43314","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Transab esoph hiat hern rpr","code_information":[{"code":"43333","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5257.0,"maximum":6462.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5257.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6462.0}]}]},{"description":"Surgical opening esophagus","code_information":[{"code":"43351","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Repair esophagus opening","code_information":[{"code":"43420","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2459.51,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3279.35,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6329.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2459.51,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3344.94,"additional_payer_notes":"APC"}]}]},{"description":"Surgical repair of stomach","code_information":[{"code":"43501","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Removal of stomach","code_information":[{"code":"43621","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Vagotomy & pylorus repair","code_information":[{"code":"43641","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Lap place gastr adj device","code_information":[{"code":"43770","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":20292.15,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10514.07,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":20292.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7885.55,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10724.35,"additional_payer_notes":"APC"}]}]},{"description":"Fusion of stomach and bowel","code_information":[{"code":"43820","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Gastroplasty duodenal switch","code_information":[{"code":"43845","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Impl/redo electrd antrum","code_information":[{"code":"43881","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Insert needle cath bowel","code_information":[{"code":"44015","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Excision of bowel lesion(s)","code_information":[{"code":"44111","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Enterectomy cadaver donor","code_information":[{"code":"44132","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Partial removal of colon","code_information":[{"code":"44143","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Removal of colon/ileostomy","code_information":[{"code":"44156","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Lap enterectomy","code_information":[{"code":"44202","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5257.0,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5257.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0}]}]},{"description":"Lap colectomy w/proctectomy","code_information":[{"code":"44211","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5257.0,"maximum":6462.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5257.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6462.0}]}]},{"description":"Revision of ileostomy","code_information":[{"code":"44314","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2628.85,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3505.13,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6764.9,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2628.85,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3575.23,"additional_payer_notes":"APC"}]}]},{"description":"Small bowel endoscopy/biopsy","code_information":[{"code":"44361","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1423.51,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1898.01,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3663.16,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1423.51,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1935.97,"additional_payer_notes":"APC"}]}]},{"description":"Small bowel endoscopy","code_information":[{"code":"44373","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1423.51,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1898.01,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3663.16,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1423.51,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1935.97,"additional_payer_notes":"APC"}]}]},{"description":"Small bowel endoscopy","code_information":[{"code":"44384","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1423.51,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1898.01,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3663.16,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1423.51,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1935.97,"additional_payer_notes":"APC"}]}]},{"description":"Colonoscopy w/snare","code_information":[{"code":"44394","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":887.71,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1183.61,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2284.37,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":887.71,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1207.28,"additional_payer_notes":"APC"}]}]},{"description":"Colonoscopy w/decompression","code_information":[{"code":"44408","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":689.87,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":919.83,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1775.27,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":689.87,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":938.23,"additional_payer_notes":"APC"}]}]},{"description":"Repair bowel opening","code_information":[{"code":"44625","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Intraop colon lavage add-on","code_information":[{"code":"44701","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Repair of mesentery","code_information":[{"code":"44850","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Partial proctectomy","code_information":[{"code":"45113","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Excision of rectal prolapse","code_information":[{"code":"45130","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Proctosigmoidoscopy dx","code_information":[{"code":"45300","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":689.87,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":919.83,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1775.27,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":689.87,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":938.23,"additional_payer_notes":"APC"}]}]},{"description":"Proctosigmoidoscopy ablate","code_information":[{"code":"45320","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2059.07,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2745.43,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5298.68,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2059.07,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2800.34,"additional_payer_notes":"APC"}]}]},{"description":"Supchrdl njx rxw/o supply","code_information":[{"code":"0465T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":1887.0,"payers_information":[{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0}]}]},{"description":"Ntrapx c ffr w/3d funcjl map","code_information":[{"code":"0523T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":2334.0,"payers_information":[{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Evac meibomian glnd heat bi","code_information":[{"code":"0563T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":43.76,"maximum":2334.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":58.35,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":112.62,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":43.76,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":59.52,"additional_payer_notes":"APC"}]}]},{"description":"Tmpst auto tube dlvr sys","code_information":[{"code":"0583T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1151.01,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1534.69,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2961.94,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1151.01,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1565.38,"additional_payer_notes":"APC"}]}]},{"description":"Perq njx algc ct lmbr 1st","code_information":[{"code":"0629T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":9524.15,"maximum":24508.8,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12698.86,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":24508.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9524.15,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12952.84,"additional_payer_notes":"APC"}]}]},{"description":"Egd flx transnasal tube/cath","code_information":[{"code":"0654T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2860.11,"maximum":7360.02,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3813.48,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7360.02,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2860.11,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3889.75,"additional_payer_notes":"APC"}]}]},{"description":"Car acous wavfrm rec cad rsk","code_information":[{"code":"0716T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":43.76,"maximum":2334.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":58.35,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":112.62,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":43.76,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":59.52,"additional_payer_notes":"APC"}]}]},{"description":"Breath tst attain/anal c-14","code_information":[{"code":"78267","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8.3,"maximum":21.35,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11.06,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":15.91},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13.83},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13.83},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13.83},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":21.35,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8.3,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19.36},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11.28,"additional_payer_notes":"APC"}]}]},{"description":"Sigmoidoscopy w/submuc inj","code_information":[{"code":"45335","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":689.87,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":919.83,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1775.27,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":689.87,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":938.23,"additional_payer_notes":"APC"}]}]},{"description":"Sigmoidoscopy w/resection","code_information":[{"code":"45349","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2059.07,"maximum":5298.68,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2745.43,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5298.68,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2059.07,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2800.34,"additional_payer_notes":"APC"}]}]},{"description":"Colonoscopy w/lesion removal","code_information":[{"code":"45385","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":887.71,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1183.61,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2284.37,"additional_payer_notes":"APC"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1543.0},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":887.71,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1207.28,"additional_payer_notes":"APC"}]}]},{"description":"Lap removal of rectum","code_information":[{"code":"45395","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Repair of rectum","code_information":[{"code":"45505","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2059.07,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2745.43,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5298.68,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2059.07,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2800.34,"additional_payer_notes":"APC"}]}]},{"description":"Repair rect/bladder fistula","code_information":[{"code":"45800","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Surg dx exam anorectal","code_information":[{"code":"45990","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2059.07,"maximum":5298.68,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2745.43,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5298.68,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2059.07,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2800.34,"additional_payer_notes":"APC"}]}]},{"description":"Incision of anal septum","code_information":[{"code":"46070","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2059.07,"maximum":5298.68,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2745.43,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5298.68,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2059.07,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2800.34,"additional_payer_notes":"APC"}]}]},{"description":"Remove int/ext hem 1 group","code_information":[{"code":"46255","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2059.07,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2745.43,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5298.68,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2059.07,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2800.34,"additional_payer_notes":"APC"}]}]},{"description":"Remove anal fist complex","code_information":[{"code":"46280","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2059.07,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2745.43,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5298.68,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2059.07,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2800.34,"additional_payer_notes":"APC"}]}]},{"description":"Anoscopy and dilation","code_information":[{"code":"46604","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":887.71,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1183.61,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2284.37,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":887.71,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1207.28,"additional_payer_notes":"APC"}]}]},{"description":"Anoscopy","code_information":[{"code":"46615","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2059.07,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2745.43,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5298.68,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2059.07,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2800.34,"additional_payer_notes":"APC"}]}]},{"description":"Rep perf anoper/vestib fistu","code_information":[{"code":"46716","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Repair of anal sphincter","code_information":[{"code":"46750","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2059.07,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2745.43,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5298.68,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2059.07,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2800.34,"additional_payer_notes":"APC"}]}]},{"description":"Cryosurgery anal lesion(s)","code_information":[{"code":"46916","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":148.84,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":198.45,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":383.01,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":148.84,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":202.42,"additional_payer_notes":"APC"}]}]},{"description":"Remove by ligat int hem grps","code_information":[{"code":"46946","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2059.07,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2745.43,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5298.68,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2059.07,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2800.34,"additional_payer_notes":"APC"}]}]},{"description":"Partial removal of liver","code_information":[{"code":"47120","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Partial removal donor liver","code_information":[{"code":"47142","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Repair liver wound","code_information":[{"code":"47360","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Percut ablate liver rf","code_information":[{"code":"47382","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4484.77,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5979.69,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5257.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11540.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4484.77,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6099.28,"additional_payer_notes":"APC"}]}]},{"description":"Laparo cholecystoenterostomy","code_information":[{"code":"47570","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5257.0,"maximum":6462.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5257.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6462.0}]}]},{"description":"Bile duct revision","code_information":[{"code":"47701","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Fuse bile ducts and bowel","code_information":[{"code":"47760","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Drainage of abdomen","code_information":[{"code":"48000","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Partial removal of pancreas","code_information":[{"code":"48145","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Pancreas removal/transplant","code_information":[{"code":"48160","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Fuse Pancreas and Bowel","code_information":[{"code":"48548","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Reopening of abdomen","code_information":[{"code":"49002","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Laparoscopy aspiration","code_information":[{"code":"49322","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4484.77,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5979.69,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5257.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11540.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4484.77,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6099.28,"additional_payer_notes":"APC"}]}]},{"description":"Remove foreign body adbomen","code_information":[{"code":"49402","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2656.06,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3541.41,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6834.92,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2656.06,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3612.24,"additional_payer_notes":"APC"}]}]},{"description":"Ins tun ip cath for dial opn","code_information":[{"code":"49421","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2656.06,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3541.41,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6834.92,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2656.06,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3612.24,"additional_payer_notes":"APC"}]}]},{"description":"Removal of shunt","code_information":[{"code":"49429","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2342.32,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3123.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6027.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2342.32,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3185.56,"additional_payer_notes":"APC"}]}]},{"description":"Drug screen amphetamines 1/2","code_information":[{"code":"80324","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":35.06,"maximum":35.06,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":35.06}]}]},{"description":"Benzodiazepines1-12","code_information":[{"code":"80346","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":35.06,"maximum":35.06,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":35.06}]}]},{"description":"Drug screening methadone","code_information":[{"code":"80358","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":35.06,"maximum":35.06,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":35.06}]}]},{"description":"Sedative hypnotics","code_information":[{"code":"80368","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":35.06,"maximum":35.06,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":35.06}]}]},{"description":"Drug/substance nos 7/more","code_information":[{"code":"80377","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":35.06,"maximum":35.06,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":35.06}]}]},{"description":"Path clin consltj sf 5-20","code_information":[{"code":"80503","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":34.57,"maximum":99.48,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":51.54,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":34.57},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":99.48,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":38.66,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":50.75},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":52.57,"additional_payer_notes":"APC"}]}]},{"description":"Urinalysis","code_information":[{"code":"81005","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1.63,"maximum":4.39,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2.17,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4.39},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2.71},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2.71},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2.71},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1.63,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3.8},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2.17},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2.21,"additional_payer_notes":"APC"}]}]},{"description":"Hpa-3 genotyping","code_information":[{"code":"81107","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":91.66,"maximum":235.88,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":122.22,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":224.14},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":152.78},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":152.78},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":152.78},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":235.88,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":91.66,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":213.89},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":122.22},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":124.66,"additional_payer_notes":"APC"}]}]},{"description":"DMD dup/delet analysis","code_information":[{"code":"81161","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":208.18,"maximum":538.47,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":279.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":208.18},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":348.75},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":348.75},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":348.75},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":538.47,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":209.25,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":488.25},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":279.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":284.58,"additional_payer_notes":"APC"}]}]},{"description":"Abl1 gene","code_information":[{"code":"81170","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":225.0,"maximum":579.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":300.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":489.48},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":375.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":375.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":375.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":579.0,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":225.0,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":525.0},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":300.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":306.0,"additional_payer_notes":"APC"}]}]},{"description":"Atxn1 gene detc abnor allele","code_information":[{"code":"81178","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":102.75,"maximum":264.41,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":137.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":203.51},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":171.25},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":171.25},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":171.25},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":264.41,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":102.75,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":239.75},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":137.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":139.74,"additional_payer_notes":"APC"}]}]},{"description":"Cacna1a gen known famil vrnt","code_information":[{"code":"81186","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":138.9,"maximum":357.44,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":185.2,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":275.11},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":231.5},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":231.5},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":231.5},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":357.44,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":138.9,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":324.1},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":185.2},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":188.9,"additional_payer_notes":"APC"}]}]},{"description":"Ntrk translocation analysis","code_information":[{"code":"81194","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":388.71,"maximum":1000.28,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":518.28,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":769.9},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":647.85},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":647.85},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":647.85},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1000.28,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":388.71,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":906.99},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":518.28},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":528.65,"additional_payer_notes":"APC"}]}]},{"description":"Bcr/abl1 gene major bp","code_information":[{"code":"81206","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":122.97,"maximum":331.78,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":163.96,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":331.78},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":204.95},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":204.95},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":204.95},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":316.44,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":122.97,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":286.93},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":163.96},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":167.24,"additional_payer_notes":"APC"}]}]},{"description":"Brca2 gene known fam variant","code_information":[{"code":"81217","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":138.29,"maximum":724.23,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":375.25,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":138.29},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":469.06},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":469.06},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":469.06},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":724.23,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":281.44,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":656.69},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":375.25},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":382.76,"additional_payer_notes":"APC"}]}]},{"description":"Cyp2c19 gene com variants","code_information":[{"code":"81225","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":218.52,"maximum":562.32,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":291.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":432.79},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":364.2},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":364.2},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":364.2},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":562.32,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":218.52,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":509.88},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":291.36},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":297.19,"additional_payer_notes":"APC"}]}]},{"description":"Btk gene common variants","code_information":[{"code":"81233","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":131.55,"maximum":338.52,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":175.4,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":260.56},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":219.25},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":219.25},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":219.25},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":338.52,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":131.55,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":306.95},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":175.4},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":178.91,"additional_payer_notes":"APC"}]}]},{"description":"F5 gene","code_information":[{"code":"81241","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":55.03,"maximum":141.6,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":73.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":123.65},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":91.71},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":91.71},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":91.71},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":141.6,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":55.03,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":128.4},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":73.37},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":74.84,"additional_payer_notes":"APC"}]}]},{"description":"G6pd full gene sequence","code_information":[{"code":"81249","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":450.0,"maximum":1158.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":600.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":891.29},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":750.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":750.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":750.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1158.0,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":450.0,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1050.0},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":600.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":612.0,"additional_payer_notes":"APC"}]}]},{"description":"Hba1/hba2 gene","code_information":[{"code":"81257","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":76.7,"maximum":197.36,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":102.26,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":151.91},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":127.83},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":127.83},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":127.83},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":197.36,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":76.7,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":178.96},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":102.26},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":104.31,"additional_payer_notes":"APC"}]}]},{"description":"Str markers specimen anal","code_information":[{"code":"81265","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":174.8,"maximum":449.83,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":233.07,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":435.16},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":291.34},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":291.34},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":291.34},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":449.83,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":174.8,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":407.87},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":233.07},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":237.73,"additional_payer_notes":"APC"}]}]},{"description":"Kit gene analys d816 variant","code_information":[{"code":"81273","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":93.65,"maximum":241.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":124.87,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":185.5},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":156.09},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":156.09},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":156.09},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":241.0,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":93.65,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":218.52},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":124.87},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":127.37,"additional_payer_notes":"APC"}]}]},{"description":"Fxn gene detc abnor alleles","code_information":[{"code":"81284","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":102.75,"maximum":264.41,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":137.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":203.51},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":171.25},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":171.25},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":171.25},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":264.41,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":102.75,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":239.75},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":137.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":139.74,"additional_payer_notes":"APC"}]}]},{"description":"Mlh1 gene full seq","code_information":[{"code":"81292","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":506.55,"maximum":1303.52,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":675.4,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":958.51},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":844.25},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":844.25},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":844.25},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1303.52,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":506.55,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1181.95},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":675.4},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":688.91,"additional_payer_notes":"APC"}]}]},{"description":"Msh6 gene dup/delete variant","code_information":[{"code":"81300","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":178.5,"maximum":459.34,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":238.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":239.82},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":297.5},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":297.5},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":297.5},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":459.34,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":178.5,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":416.5},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":238.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":242.76,"additional_payer_notes":"APC"}]}]},{"description":"Palb2 gene known famil vrnt","code_information":[{"code":"81308","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":226.01,"maximum":581.61,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":301.35,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":447.65},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":376.69},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":376.69},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":376.69},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":581.61,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":226.01,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":527.36},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":301.35},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":307.38,"additional_payer_notes":"APC"}]}]},{"description":"Pml/raralpha 1 breakpoint","code_information":[{"code":"81316","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":155.48,"maximum":639.85,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":207.31,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":639.85},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":259.14},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":259.14},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":259.14},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":400.11,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":155.48,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":362.79},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":207.31},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":211.46,"additional_payer_notes":"APC"}]}]},{"description":"Pmp22 gene dup/delet","code_information":[{"code":"81324","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":568.77,"maximum":1463.63,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":758.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1126.51},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":947.95},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":947.95},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":947.95},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1463.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":568.77,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1327.13},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":758.36},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":773.53,"additional_payer_notes":"APC"}]}]},{"description":"Insj impltbl glucose sensor","code_information":[{"code":"0446T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":7942.1,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4115.08,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7942.1,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3086.31,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4197.38,"additional_payer_notes":"APC"}]}]},{"description":"Replace duod/jej tube perc","code_information":[{"code":"49451","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":672.83,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":897.11,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1731.42,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":672.83,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":915.05,"additional_payer_notes":"APC"}]}]},{"description":"Rpr ing hernia init reduce","code_information":[{"code":"49500","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":12358.4,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6403.32,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":12358.4,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4802.49,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6531.38,"additional_payer_notes":"APC"}]}]},{"description":"Rpr rem hernia init reduce","code_information":[{"code":"49550","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2656.06,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3541.41,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6834.92,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2656.06,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3612.24,"additional_payer_notes":"APC"}]}]},{"description":"Repair umbilical lesion","code_information":[{"code":"49611","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Abdomen surgery procedure","code_information":[{"code":"49999","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":672.83,"maximum":13249.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":897.11,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":13249.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":10779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":13249.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1731.42,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":672.83,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":915.05,"additional_payer_notes":"APC"}]}]},{"description":"Removal of kidney stone","code_information":[{"code":"50075","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Renal biopsy open","code_information":[{"code":"50205","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Removal of kidney lesion","code_information":[{"code":"50280","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Prep renal graft/ureteral","code_information":[{"code":"50329","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Change stent via transureth","code_information":[{"code":"50385","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1550.71,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2067.62,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3990.5,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1550.71,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2108.97,"additional_payer_notes":"APC"}]}]},{"description":"Revision of kidney/ureter","code_information":[{"code":"50405","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0}]}]},{"description":"Close kidney-skin fistula","code_information":[{"code":"50520","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2959.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0}]}]},{"description":"Laparo Radical Nephrectomy","code_information":[{"code":"50545","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5257.0,"maximum":6462.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5257.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6462.0}]}]},{"description":"Kidney endoscopy & treatment","code_information":[{"code":"50557","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7022.52,"maximum":18071.3,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9363.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":18071.3,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7022.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9550.63,"additional_payer_notes":"APC"}]}]},{"description":"Kidney endoscopy & treatment","code_information":[{"code":"50580","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3579.0,"maximum":10235.57,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5303.4,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":10235.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3977.55,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5409.47,"additional_payer_notes":"APC"}]}]},{"description":"Removal of ureter stone","code_information":[{"code":"50620","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Plmt ureteral stent prq","code_information":[{"code":"50693","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2614.94,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3486.59,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6729.12,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2614.94,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3556.32,"additional_payer_notes":"APC"}]}]},{"description":"Release/revise ureter","code_information":[{"code":"50725","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Reimplant ureter in bladder","code_information":[{"code":"50782","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Revise urine flow","code_information":[{"code":"50830","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Laparoscopy ureterolithotomy","code_information":[{"code":"50945","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4484.77,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5979.69,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5257.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11540.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4484.77,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6099.28,"additional_payer_notes":"APC"}]}]},{"description":"Ureter endoscopy & treatment","code_information":[{"code":"50961","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3977.55,"maximum":10235.57,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5303.4,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":10235.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3977.55,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5409.47,"additional_payer_notes":"APC"}]}]},{"description":"Incise bladder/drain ureter","code_information":[{"code":"51045","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1550.71,"maximum":4106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2067.62,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3990.5,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1550.71,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2108.97,"additional_payer_notes":"APC"}]}]},{"description":"Removal of bladder cyst","code_information":[{"code":"51500","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4484.77,"maximum":11540.8,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5979.69,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5257.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11540.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4484.77,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6099.28,"additional_payer_notes":"APC"}]}]},{"description":"Removal of bladder","code_information":[{"code":"51570","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Injection for bladder x-ray","code_information":[{"code":"51600","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Change of bladder tube","code_information":[{"code":"51710","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":517.28,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":689.7,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1331.13,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":517.28,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":703.5,"additional_payer_notes":"APC"}]}]},{"description":"Urine flow measurement","code_information":[{"code":"51736","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":98.7,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":131.6,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":253.99,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":98.7,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":134.23,"additional_payer_notes":"APC"}]}]},{"description":"Revision of urinary tract","code_information":[{"code":"51820","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Cystoscopy","code_information":[{"code":"52000","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":517.28,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":689.7,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1331.13,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":517.28,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":703.5,"additional_payer_notes":"APC"}]}]},{"description":"Cystoscopy and treatment","code_information":[{"code":"52234","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2614.94,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3486.59,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6729.12,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2614.94,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3556.32,"additional_payer_notes":"APC"}]}]},{"description":"Cystoscopy and treatment","code_information":[{"code":"52276","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1550.71,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2067.62,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3990.5,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1550.71,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2108.97,"additional_payer_notes":"APC"}]}]},{"description":"Cystoscopy and treatment","code_information":[{"code":"52300","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2614.94,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3486.59,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6729.12,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2614.94,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3556.32,"additional_payer_notes":"APC"}]}]},{"description":"Cystoscopy stone removal","code_information":[{"code":"52325","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3977.55,"maximum":10235.57,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5303.4,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":10235.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3977.55,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5409.47,"additional_payer_notes":"APC"}]}]},{"description":"Cysto/uretero stricture tx","code_information":[{"code":"52344","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2614.94,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3486.59,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6729.12,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2614.94,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3556.32,"additional_payer_notes":"APC"}]}]},{"description":"Scr mammo bi incl cad","code_information":[{"code":"77067","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":120.9,"maximum":120.9,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":120.9}]},{"setting":"outpatient","billing_class":"facility","modifier_code":["TC"],"minimum":65.36,"maximum":168.18,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":87.14,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":168.18,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":65.36,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":88.88,"additional_payer_notes":"APC"}]}]},{"description":"Insj/rplcmt iims eltrd only","code_information":[{"code":"0526T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6138.95,"maximum":27583.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8185.27,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":15797.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6138.95,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":27583.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8348.97,"additional_payer_notes":"APC"}]}]},{"description":"Insj/rplcmt icds ss eltrd","code_information":[{"code":"0571T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":23285.27,"maximum":59920.75,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":31047.02,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":54996.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":54996.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":54996.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":59920.75,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23285.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":51942.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":31667.96,"additional_payer_notes":"APC"}]}]},{"description":"Insj iris prosth sec io lens","code_information":[{"code":"0618T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":15691.0,"maximum":16106.0,"payers_information":[{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0}]}]},{"description":"Tcat rmvl/dblk icar mas perq","code_information":[{"code":"0644T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4222.18,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5629.58,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":10865.09,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4222.18,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5742.17,"additional_payer_notes":"APC"}]}]},{"description":"Colonic lavage 35+l water","code_information":[{"code":"0736T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":95.45,"maximum":2334.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":127.27,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":245.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":95.45,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":129.82,"additional_payer_notes":"APC"}]}]},{"description":"Cysto/uretero w/lithotripsy","code_information":[{"code":"52356","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3977.55,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5303.4,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":10235.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3977.55,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5409.47,"additional_payer_notes":"APC"}]}]},{"description":"Remove prostate regrowth","code_information":[{"code":"52630","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3977.55,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5303.4,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":10235.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3977.55,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5409.47,"additional_payer_notes":"APC"}]}]},{"description":"Incision of urethra","code_information":[{"code":"53020","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1550.71,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2067.62,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3990.5,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1550.71,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2108.97,"additional_payer_notes":"APC"}]}]},{"description":"Removal of urethra","code_information":[{"code":"53215","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3977.55,"maximum":10235.57,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5303.4,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":10235.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3977.55,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5409.47,"additional_payer_notes":"APC"}]}]},{"description":"Removal of urethra gland","code_information":[{"code":"53270","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2614.94,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3486.59,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6729.12,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2614.94,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3556.32,"additional_payer_notes":"APC"}]}]},{"description":"Reconstruction of urethra","code_information":[{"code":"53430","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3977.55,"maximum":10235.57,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5303.4,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":10235.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3977.55,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5409.47,"additional_payer_notes":"APC"}]}]},{"description":"Remov/replc ur sphinctr comp","code_information":[{"code":"53448","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2959.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0}]}]},{"description":"Repair of urethra injury","code_information":[{"code":"53515","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3977.55,"maximum":10235.57,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5303.4,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":10235.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3977.55,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5409.47,"additional_payer_notes":"APC"}]}]},{"description":"Dilation of urethra","code_information":[{"code":"53661","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":98.7,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":131.6,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":253.99,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":98.7,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":134.23,"additional_payer_notes":"APC"}]}]},{"description":"Slitting of prepuce","code_information":[{"code":"54001","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1550.71,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2067.62,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3990.5,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1550.71,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2108.97,"additional_payer_notes":"APC"}]}]},{"description":"Biopsy of penis","code_information":[{"code":"54100","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1225.21,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1633.61,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3152.87,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1225.21,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1666.28,"additional_payer_notes":"APC"}]}]},{"description":"Remove penis & nodes","code_information":[{"code":"54130","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Revision of penis","code_information":[{"code":"54435","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2614.94,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3486.59,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6729.12,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2614.94,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3556.32,"additional_payer_notes":"APC"}]}]},{"description":"Orchiectomy partial","code_information":[{"code":"54522","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2614.94,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3486.59,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6729.12,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2614.94,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3556.32,"additional_payer_notes":"APC"}]}]},{"description":"Orchiopexy (Fowler-Stephens)","code_information":[{"code":"54650","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2656.06,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3541.41,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6834.92,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2656.06,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3612.24,"additional_payer_notes":"APC"}]}]},{"description":"Biopsy of epididymis","code_information":[{"code":"54800","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1225.21,"maximum":4106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1633.61,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3152.87,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1225.21,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1666.28,"additional_payer_notes":"APC"}]}]},{"description":"Drainage of hydrocele","code_information":[{"code":"55000","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":525.32,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":700.42,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1351.81,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":525.32,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":714.43,"additional_payer_notes":"APC"}]}]},{"description":"Revision of scrotum","code_information":[{"code":"55175","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2614.94,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3486.59,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6729.12,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2614.94,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3556.32,"additional_payer_notes":"APC"}]}]},{"description":"Revise spermatic cord veins","code_information":[{"code":"55530","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2614.94,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3486.59,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6729.12,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2614.94,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3556.32,"additional_payer_notes":"APC"}]}]},{"description":"Remove sperm pouch lesion","code_information":[{"code":"55680","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2614.94,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3486.59,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6729.12,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2614.94,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3556.32,"additional_payer_notes":"APC"}]}]},{"description":"Extensive prostate surgery","code_information":[{"code":"55812","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Extensive prostate surgery","code_information":[{"code":"55862","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Place needles pelvic for rt","code_information":[{"code":"55920","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3710.98,"maximum":9549.58,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4947.97,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":9549.58,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3710.98,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5046.93,"additional_payer_notes":"APC"}]}]},{"description":"Destroy vulva lesions sim","code_information":[{"code":"56501","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1530.61,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2040.81,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3938.76,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1530.61,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2081.63,"additional_payer_notes":"APC"}]}]},{"description":"Extensive vulva surgery","code_information":[{"code":"56632","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":27583.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":27583.0}]}]},{"description":"Repair clitoris","code_information":[{"code":"56805","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2401.4,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3201.87,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6179.61,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2401.4,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3265.91,"additional_payer_notes":"APC"}]}]},{"description":"I & d vag hematoma non-ob","code_information":[{"code":"57023","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2154.81,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2873.08,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5545.05,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2154.81,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2930.54,"additional_payer_notes":"APC"}]}]},{"description":"Remove vagina wall complete","code_information":[{"code":"57110","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Insert pessary/other device","code_information":[{"code":"57160","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":149.98,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":199.97,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":385.94,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":149.98,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":203.97,"additional_payer_notes":"APC"}]}]},{"description":"Repair rectum & vagina","code_information":[{"code":"57250","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3710.98,"maximum":9549.58,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4947.97,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":9549.58,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3710.98,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5046.93,"additional_payer_notes":"APC"}]}]},{"description":"Colpopexy intraperitoneal","code_information":[{"code":"57283","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5501.01,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7334.68,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":14155.93,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5501.01,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7481.37,"additional_payer_notes":"APC"}]}]},{"description":"Comprehen metabolic panel","code_information":[{"code":"80053","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7.92,"maximum":21.4,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10.56,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":21.4},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13.2},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13.2},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13.2},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":20.38,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7.92,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18.48},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10.56},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10.77,"additional_payer_notes":"APC"}]}]},{"description":"Drug assay adalimumab","code_information":[{"code":"80145","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":28.93,"maximum":74.44,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":38.57,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":57.3},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":48.21},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":48.21},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":48.21},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":74.44,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":28.93,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":67.5},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38.57},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":39.34,"additional_payer_notes":"APC"}]}]},{"description":"Asy carbamazepin 10,11-epxid","code_information":[{"code":"80161","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":13.98,"maximum":35.98,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18.64,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":27.71},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23.3},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23.3},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23.3},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":35.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.98,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32.62},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18.64},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19.01,"additional_payer_notes":"APC"}]}]},{"description":"Assay of gentamicin","code_information":[{"code":"80170","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":12.28,"maximum":33.16,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16.38,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":33.16},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20.48},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20.48},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20.48},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":31.61,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.28,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28.67},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16.38},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16.71,"additional_payer_notes":"APC"}]}]},{"description":"Drug scrn quan mycophenolate","code_information":[{"code":"80180","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":13.54,"maximum":36.52,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18.05,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":36.52},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22.56},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22.56},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22.56},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":34.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.54,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31.59},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18.05},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18.41,"additional_payer_notes":"APC"}]}]},{"description":"Drug assay itraconzaole","code_information":[{"code":"80189","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":20.33,"maximum":52.32,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27.11,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":40.27},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":33.89},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":33.89},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":33.89},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":52.32,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20.33,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":47.44},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27.11},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27.65,"additional_payer_notes":"APC"}]}]},{"description":"Drug screen quant tiagabine","code_information":[{"code":"80199","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":20.33,"maximum":52.32,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27.11,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":36.53},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":33.89},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":33.89},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":33.89},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":52.32,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20.33,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":47.44},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27.11},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27.65,"additional_payer_notes":"APC"}]}]},{"description":"Plastic surgery neck","code_information":[{"code":"15819","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3579.0,"maximum":4761.0,"payers_information":[{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0}]}]},{"description":"Drug assay infliximab","code_information":[{"code":"80230","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":28.93,"maximum":74.44,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":38.57,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":57.3},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":48.21},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":48.21},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":48.21},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":74.44,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":28.93,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":67.5},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38.57},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":39.34,"additional_payer_notes":"APC"}]}]},{"description":"Drug screen quantalcohols","code_information":[{"code":"80320","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":35.06,"maximum":35.06,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":35.06}]}]},{"description":"Antipsychotics nos 1-3","code_information":[{"code":"80342","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":35.06,"maximum":35.06,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":35.06}]}]},{"description":"Heroin metabolite","code_information":[{"code":"80356","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":35.06,"maximum":35.06,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":35.06}]}]},{"description":"Drug screening pregabalin","code_information":[{"code":"80366","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":35.06,"maximum":35.06,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":35.06}]}]},{"description":"Drug/substance nos 1-3","code_information":[{"code":"80375","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":35.06,"maximum":35.06,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":35.06}]}]},{"description":"CRH stimulation panel","code_information":[{"code":"80412","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":601.22,"maximum":1547.13,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":801.62,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":667.01},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1002.03},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1002.03},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1002.03},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1547.13,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":601.22,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1402.84},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":801.62},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":817.65,"additional_payer_notes":"APC"}]}]},{"description":"Glucagon tolerance panel","code_information":[{"code":"80424","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":37.88,"maximum":102.19,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":50.5,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":102.19},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":63.13},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":63.13},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":63.13},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":97.46,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":37.88,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":88.38},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":50.5},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":51.51,"additional_payer_notes":"APC"}]}]},{"description":"TRH stimulation panel","code_information":[{"code":"80438","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":37.81,"maximum":102.01,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":50.41,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":102.01},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":63.01},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":63.01},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":63.01},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":97.29,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":37.81,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":88.22},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":50.41},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":51.42,"additional_payer_notes":"APC"}]}]},{"description":"1st plmt drug elut oc ins","code_information":[{"code":"0444T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":2334.0,"payers_information":[{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Insj aqueous drg dev io rsvr","code_information":[{"code":"0474T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0}]}]},{"description":"Revise vag graft via vagina","code_information":[{"code":"57295","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2401.4,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3201.87,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6179.61,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2401.4,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3265.91,"additional_payer_notes":"APC"}]}]},{"description":"Removal of cervix","code_information":[{"code":"57530","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3388.0,"maximum":9549.58,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4947.97,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":9549.58,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3710.98,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5046.93,"additional_payer_notes":"APC"}]}]},{"description":"Revision of cervix","code_information":[{"code":"57700","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2401.4,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3201.87,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6179.61,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2401.4,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3265.91,"additional_payer_notes":"APC"}]}]},{"description":"Myomectomy abdom complex","code_information":[{"code":"58146","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0}]}]},{"description":"Vag hyst including t/o","code_information":[{"code":"58262","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3710.98,"maximum":9549.58,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4947.97,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":9549.58,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3710.98,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5046.93,"additional_payer_notes":"APC"}]}]},{"description":"Vag hyst incl t/o complex","code_information":[{"code":"58291","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3710.98,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4947.97,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":9549.58,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3710.98,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5046.93,"additional_payer_notes":"APC"}]}]},{"description":"Catheter for hysterography","code_information":[{"code":"58340","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Repair of ruptured uterus","code_information":[{"code":"58520","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Lap Radical Hyst","code_information":[{"code":"58548","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0}]}]},{"description":"Hysteroscopy resect septum","code_information":[{"code":"58560","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3710.98,"maximum":9549.58,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4947.97,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":9549.58,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3710.98,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5046.93,"additional_payer_notes":"APC"}]}]},{"description":"Tlh w/t/o uterus over 250 g","code_information":[{"code":"58573","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":20292.15,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10514.07,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":20292.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7885.55,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10724.35,"additional_payer_notes":"APC"}]}]},{"description":"Laparoscopy remove adnexa","code_information":[{"code":"58661","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4484.77,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5979.69,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5257.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11540.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4484.77,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6099.28,"additional_payer_notes":"APC"}]}]},{"description":"Removal of ovary/tube(s)","code_information":[{"code":"58720","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0}]}]},{"description":"Drain ovary abscess open","code_information":[{"code":"58820","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2401.4,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3201.87,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6179.61,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2401.4,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3265.91,"additional_payer_notes":"APC"}]}]},{"description":"Resect ovarian malignancy","code_information":[{"code":"58950","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0}]}]},{"description":"Retrieval of oocyte","code_information":[{"code":"58970","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":683.26,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":911.02,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1758.27,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":683.26,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":929.24,"additional_payer_notes":"APC"}]}]},{"description":"Fetal contract stress test","code_information":[{"code":"59020","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":149.98,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":199.97,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":385.94,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":149.98,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":203.97,"additional_payer_notes":"APC"}]}]},{"description":"Treat ectopic pregnancy","code_information":[{"code":"59151","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4484.77,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5979.69,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5257.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11540.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4484.77,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6099.28,"additional_payer_notes":"APC"}]}]},{"description":"Obstetrical care","code_information":[{"code":"59409","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2401.4,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3201.87,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6179.61,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2401.4,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3265.91,"additional_payer_notes":"APC"}]}]},{"description":"Cesarean delivery only","code_information":[{"code":"59514","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3388.0,"maximum":4106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0}]}]},{"description":"Attempted vbac after care","code_information":[{"code":"59622","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Abortion","code_information":[{"code":"59851","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3388.0,"maximum":4106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0}]}]},{"description":"Fetal invas px w/us","code_information":[{"code":"59897","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":149.98,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":199.97,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":385.94,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":149.98,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":203.97,"additional_payer_notes":"APC"}]}]},{"description":"Partial removal of thyroid","code_information":[{"code":"60220","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4484.77,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5979.69,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5257.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11540.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4484.77,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6099.28,"additional_payer_notes":"APC"}]}]},{"description":"Remove thyroid duct lesion","code_information":[{"code":"60280","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4484.77,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5979.69,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5257.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11540.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4484.77,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6099.28,"additional_payer_notes":"APC"}]}]},{"description":"Removal of thymus gland","code_information":[{"code":"60521","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Twist drill hole","code_information":[{"code":"61105","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3388.0,"maximum":4106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0}]}]},{"description":"Pierce skull for drainage","code_information":[{"code":"61156","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Open skull for drainage","code_information":[{"code":"61313","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6779.0,"maximum":8333.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0}]}]},{"description":"Decompress eye socket","code_information":[{"code":"61330","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2459.51,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3279.35,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6329.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2459.51,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3344.94,"additional_payer_notes":"APC"}]}]},{"description":"Removal of skull lesion","code_information":[{"code":"61500","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6779.0,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0}]}]},{"description":"Autol cell implt adps hrvg","code_information":[{"code":"0565T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":2334.0,"payers_information":[{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Perq impltj/rplcmt isdns ptn","code_information":[{"code":"0587T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2959.0,"maximum":12165.93,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6303.59,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":12165.93,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4727.69,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6429.66,"additional_payer_notes":"APC"}]}]},{"description":"Insertion of iris prosthesis","code_information":[{"code":"0616T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7529.0,"maximum":7791.0,"payers_information":[{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0}]}]},{"description":"Perq njx algc ct lmbr ea","code_information":[{"code":"0630T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":2334.0,"payers_information":[{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Tprnl focal abltj mal prst8","code_information":[{"code":"0655T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3977.55,"maximum":10235.57,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5303.4,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":10235.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3977.55,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5409.47,"additional_payer_notes":"APC"}]}]},{"description":"Prq elc nrv stim cn wo implt","code_information":[{"code":"0720T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":4761.0,"payers_information":[{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0}]}]},{"description":"Perq dev soft tiss 1st imag","code_information":[{"code":"10035","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":525.32,"maximum":3030.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":700.42,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1351.81,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":525.32,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":714.43,"additional_payer_notes":"APC"}]}]},{"description":"Remove brain lining lesion","code_information":[{"code":"61519","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6779.0,"maximum":8333.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0}]}]},{"description":"Implant brain electrodes","code_information":[{"code":"61533","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6779.0,"maximum":8333.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0}]}]},{"description":"Incision of brain tissue","code_information":[{"code":"61541","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6779.0,"maximum":8333.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0}]}]},{"description":"Incise skull/sutures","code_information":[{"code":"61556","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6779.0,"maximum":8333.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0}]}]},{"description":"Remove foreign body brain","code_information":[{"code":"61570","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6779.0,"maximum":8333.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0}]}]},{"description":"Orbitocranial approach/skull","code_information":[{"code":"61584","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6779.0,"maximum":8333.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0}]}]},{"description":"Transcondylar approach/skull","code_information":[{"code":"61597","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6779.0,"maximum":8333.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0}]}]},{"description":"Transect artery sinus","code_information":[{"code":"61611","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3388.0,"maximum":4106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0}]}]},{"description":"Transcath occlusion non-cns","code_information":[{"code":"61626","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":27583.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11418.47,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":22037.64,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8563.85,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":27583.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11646.84,"additional_payer_notes":"APC"}]}]},{"description":"Evasc prlng admn rx agnt add","code_information":[{"code":"61651","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6019.0,"maximum":7398.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":7398.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6019.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":7398.0}]}]},{"description":"Brain aneurysm repr complx","code_information":[{"code":"61698","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6779.0,"maximum":8333.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0}]}]},{"description":"Incise skull/brain surgery","code_information":[{"code":"61720","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":16752.93,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8680.28,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":16752.93,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6510.21,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8853.88,"additional_payer_notes":"APC"}]}]},{"description":"Scan proc spinal","code_information":[{"code":"61783","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Implant neuroelectrodes","code_information":[{"code":"61850","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Implant neurostim arrays","code_information":[{"code":"61886","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8923.0,"maximum":58906.76,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":30521.64,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":10765.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":8923.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":10765.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":54996.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":54996.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":54996.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":58906.76,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22891.23,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":51942.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":31132.07,"additional_payer_notes":"APC"}]}]},{"description":"Repair skull cavity lesion","code_information":[{"code":"62120","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6779.0,"maximum":8333.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0}]}]},{"description":"Repair of skull with graft","code_information":[{"code":"62147","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6779.0,"maximum":8333.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0}]}]},{"description":"Establish brain cavity shunt","code_information":[{"code":"62190","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Replace/revise brain shunt","code_information":[{"code":"62230","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":16752.93,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8680.28,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":16752.93,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6510.21,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8853.88,"additional_payer_notes":"APC"}]}]},{"description":"Needle biopsy spinal cord","code_information":[{"code":"62269","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1225.21,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1633.61,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3152.87,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1225.21,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1666.28,"additional_payer_notes":"APC"}]}]},{"description":"Percutaneous diskectomy","code_information":[{"code":"62287","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1448.59,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1931.46,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3727.72,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1448.59,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1970.09,"additional_payer_notes":"APC"}]}]},{"description":"Myelography lumbar injection","code_information":[{"code":"62305","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":581.54,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":775.38,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1496.49,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":581.54,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":790.89,"additional_payer_notes":"APC"}]}]},{"description":"Analyze spine infus pump","code_information":[{"code":"62367","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":227.84,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":303.79,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":586.32,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":227.84,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":309.87,"additional_payer_notes":"APC"}]}]},{"description":"Remove lamina/facets lumbar","code_information":[{"code":"63012","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Laminotomy single lumbar","code_information":[{"code":"63042","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"C-laminoplasty w/graft/plate","code_information":[{"code":"63051","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6779.0,"maximum":8333.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0}]}]},{"description":"Spine disk surgery thorax","code_information":[{"code":"63077","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6779.0,"maximum":8333.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0}]}]},{"description":"Remove vert body dcmprn lmbr","code_information":[{"code":"63090","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6779.0,"maximum":8333.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0}]}]},{"description":"Incise spine nrv half segmnt","code_information":[{"code":"63185","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6779.0,"maximum":27583.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":27583.0}]}]},{"description":"Excise intraspinl lesion crv","code_information":[{"code":"63265","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Bx/exc xdrl spine lesn crvl","code_information":[{"code":"63275","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6779.0,"maximum":8333.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0}]}]},{"description":"Bx/exc idrl imed lesn cervl","code_information":[{"code":"63285","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6779.0,"maximum":8333.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0}]}]},{"description":"Remov vert xdrl bdy lmbr/sac","code_information":[{"code":"63303","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6779.0,"maximum":8333.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0}]}]},{"description":"Srs spinal lesion","code_information":[{"code":"63620","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3388.0,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0}]}]},{"description":"Insrt/redo spine n generator","code_information":[{"code":"63685","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8923.0,"maximum":58906.76,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":30521.64,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":10765.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":8923.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":10765.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":44873.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":44873.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":44873.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":58906.76,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22891.23,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":43285.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":31132.07,"additional_payer_notes":"APC"}]}]},{"description":"Graft repair of spine defect","code_information":[{"code":"63710","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Insj stablj dev w/o dcmprn","code_information":[{"code":"22869","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":9524.15,"maximum":24508.8,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12698.86,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":24508.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9524.15,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12952.84,"additional_payer_notes":"APC"}]}]},{"description":"N block inj brachial plexus","code_information":[{"code":"64415","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":656.13,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":874.84,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1688.44,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":656.13,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":892.34,"additional_payer_notes":"APC"}]}]},{"description":"N block inj paracervical","code_information":[{"code":"64435","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":523.65,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":698.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1347.51,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":523.65,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":712.16,"additional_payer_notes":"APC"}]}]},{"description":"Pvb thoracic single inj site","code_information":[{"code":"64461","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":523.65,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":698.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1347.51,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":523.65,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":712.16,"additional_payer_notes":"APC"}]}]},{"description":"Tap block uni by infusion","code_information":[{"code":"64487","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Inj paravert f jnt l/s 3 lev","code_information":[{"code":"64495","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":433.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":433.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Implant neuroelectrodes","code_information":[{"code":"64561","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4727.69,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6303.59,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":12165.93,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4727.69,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6429.66,"additional_payer_notes":"APC"}]}]},{"description":"Revise/remove neuroelectrode","code_information":[{"code":"64585","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2593.52,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3458.03,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6674.0,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2593.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3527.19,"additional_payer_notes":"APC"}]}]},{"description":"Chemodenerv musc migraine","code_information":[{"code":"64615","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":227.71,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":303.61,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":585.96,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":227.71,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":309.68,"additional_payer_notes":"APC"}]}]},{"description":"Remove skin nerve lesion","code_information":[{"code":"64774","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1448.59,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1931.46,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3727.72,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1448.59,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1970.09,"additional_payer_notes":"APC"}]}]},{"description":"Remove skin nerve lesion","code_information":[{"code":"64788","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1448.59,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1931.46,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3727.72,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1448.59,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1970.09,"additional_payer_notes":"APC"}]}]},{"description":"Sympathectomy digital artery","code_information":[{"code":"64820","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1448.59,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1931.46,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3727.72,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1448.59,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1970.09,"additional_payer_notes":"APC"}]}]},{"description":"Repair of hand or foot nerve","code_information":[{"code":"64836","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2534.21,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3378.94,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6521.36,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2534.21,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3446.52,"additional_payer_notes":"APC"}]}]},{"description":"Repair of low back nerves","code_information":[{"code":"64862","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2534.21,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3378.94,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6521.36,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2534.21,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3446.52,"additional_payer_notes":"APC"}]}]},{"description":"Nerve graft head/neck <=4 cm","code_information":[{"code":"64885","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":16752.93,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8680.28,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":16752.93,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6510.21,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8853.88,"additional_payer_notes":"APC"}]}]},{"description":"Nerve graft arm/leg <=4 cm","code_information":[{"code":"64897","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":16752.93,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8680.28,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":16752.93,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6510.21,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8853.88,"additional_payer_notes":"APC"}]}]},{"description":"Nervous system surgery","code_information":[{"code":"64999","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":227.71,"maximum":13249.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":303.61,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":13249.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":10779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":13249.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":585.96,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":227.71,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":309.68,"additional_payer_notes":"APC"}]}]},{"description":"Remove eye/revise socket","code_information":[{"code":"65114","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2916.44,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3888.58,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7504.96,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2916.44,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3966.35,"additional_payer_notes":"APC"}]}]},{"description":"Remove foreign body from eye","code_information":[{"code":"65205","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":98.7,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":131.6,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":253.99,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":98.7,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":134.23,"additional_payer_notes":"APC"}]}]},{"description":"Repair of eye wound","code_information":[{"code":"65272","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1763.69,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2351.59,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4538.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1763.69,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2398.62,"additional_payer_notes":"APC"}]}]},{"description":"Biopsy of cornea","code_information":[{"code":"65410","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1763.69,"maximum":4538.57,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2351.59,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4538.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1763.69,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2398.62,"additional_payer_notes":"APC"}]}]},{"description":"Corneal transplant","code_information":[{"code":"65710","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3947.51,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5263.35,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":10158.27,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3947.51,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5368.62,"additional_payer_notes":"APC"}]}]},{"description":"Corneal tissue transplant","code_information":[{"code":"65767","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0}]}]},{"description":"Ocular reconst transplant","code_information":[{"code":"65781","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3947.51,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5263.35,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":10158.27,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3947.51,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5368.62,"additional_payer_notes":"APC"}]}]},{"description":"Trabeculoplasty laser surg","code_information":[{"code":"65855","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":408.01,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":544.01,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1049.93,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":408.01,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":554.89,"additional_payer_notes":"APC"}]}]},{"description":"Remove blood clot from eye","code_information":[{"code":"65930","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1712.02,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2282.69,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4405.59,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1712.02,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2328.34,"additional_payer_notes":"APC"}]}]},{"description":"Incision of eye","code_information":[{"code":"66172","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1712.02,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2282.69,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4405.59,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1712.02,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2328.34,"additional_payer_notes":"APC"}]}]},{"description":"Repair/graft eye lesion","code_information":[{"code":"66225","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3947.51,"maximum":10158.27,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5263.35,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":10158.27,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3947.51,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5368.62,"additional_payer_notes":"APC"}]}]},{"description":"Removal of iris","code_information":[{"code":"66635","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1712.02,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2282.69,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4405.59,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1712.02,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2328.34,"additional_payer_notes":"APC"}]}]},{"description":"Revision of iris","code_information":[{"code":"66761","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":408.01,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":544.01,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1049.93,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":408.01,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":554.89,"additional_payer_notes":"APC"}]}]},{"description":"Removal of lens material","code_information":[{"code":"66850","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1712.02,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2282.69,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4405.59,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1712.02,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2328.34,"additional_payer_notes":"APC"}]}]},{"description":"Insert lens prosthesis","code_information":[{"code":"66985","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1712.02,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2282.69,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4405.59,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1712.02,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2328.34,"additional_payer_notes":"APC"}]}]},{"description":"Implant eye drug system","code_information":[{"code":"67027","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8923.0,"maximum":26635.93,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13801.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":10765.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":8923.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":10765.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":26635.93,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10350.75,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14077.02,"additional_payer_notes":"APC"}]}]},{"description":"Vit for macular hole","code_information":[{"code":"67042","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3066.31,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4088.41,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7890.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3066.31,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4170.17,"additional_payer_notes":"APC"}]}]},{"description":"Release encircling material","code_information":[{"code":"67115","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3066.31,"maximum":7890.63,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4088.41,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7890.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3066.31,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4170.17,"additional_payer_notes":"APC"}]}]},{"description":"Treatment of choroid lesion","code_information":[{"code":"67220","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":408.01,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":544.01,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1049.93,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":408.01,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":554.89,"additional_payer_notes":"APC"}]}]},{"description":"Eye surgery procedure","code_information":[{"code":"67299","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1712.02,"maximum":13249.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2282.69,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":13249.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":10779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":13249.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4405.59,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1712.02,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2328.34,"additional_payer_notes":"APC"}]}]},{"description":"Rerevise eye muscles add-on","code_information":[{"code":"67332","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Explore/biopsy eye socket","code_information":[{"code":"67400","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2916.44,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3888.58,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7504.96,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2916.44,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3966.35,"additional_payer_notes":"APC"}]}]},{"description":"Explore/drain eye socket","code_information":[{"code":"67440","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2916.44,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3888.58,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7504.96,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2916.44,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3966.35,"additional_payer_notes":"APC"}]}]},{"description":"Decompress optic nerve","code_information":[{"code":"67570","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2916.44,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3888.58,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7504.96,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2916.44,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3966.35,"additional_payer_notes":"APC"}]}]},{"description":"Remove eyelid lesion(s)","code_information":[{"code":"67808","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1763.69,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2351.59,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4538.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1763.69,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2398.62,"additional_payer_notes":"APC"}]}]},{"description":"Closure of eyelid by suture","code_information":[{"code":"67875","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":739.52,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":986.02,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1903.02,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":739.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1005.74,"additional_payer_notes":"APC"}]}]},{"description":"Repair eyelid defect","code_information":[{"code":"67906","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2916.44,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3888.58,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7504.96,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2916.44,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3966.35,"additional_payer_notes":"APC"}]}]},{"description":"Repair eyelid defect","code_information":[{"code":"67917","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1763.69,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2351.59,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4538.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1763.69,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2398.62,"additional_payer_notes":"APC"}]}]},{"description":"Revision of eyelid","code_information":[{"code":"67950","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1763.69,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2351.59,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4538.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1763.69,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2398.62,"additional_payer_notes":"APC"}]}]},{"description":"Incise/drain eyelid lining","code_information":[{"code":"68020","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":739.52,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":986.02,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1903.02,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":739.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1005.74,"additional_payer_notes":"APC"}]}]},{"description":"Revise/graft eyelid lining","code_information":[{"code":"68320","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1763.69,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2351.59,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4538.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1763.69,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2398.62,"additional_payer_notes":"APC"}]}]},{"description":"Revise eyelid lining","code_information":[{"code":"68362","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1763.69,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2351.59,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4538.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1763.69,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2398.62,"additional_payer_notes":"APC"}]}]},{"description":"Biopsy of tear gland","code_information":[{"code":"68510","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1763.69,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2351.59,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4538.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1763.69,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2398.62,"additional_payer_notes":"APC"}]}]},{"description":"Create tear sac drain","code_information":[{"code":"68720","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2916.44,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3888.58,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7504.96,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2916.44,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3966.35,"additional_payer_notes":"APC"}]}]},{"description":"Probe nasolacrimal duct","code_information":[{"code":"68811","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1763.69,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2351.59,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4538.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1763.69,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2398.62,"additional_payer_notes":"APC"}]}]},{"description":"Extensive ear canal surgery","code_information":[{"code":"69150","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":11300.84,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Revise external ear","code_information":[{"code":"69300","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2459.51,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3279.35,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6329.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2459.51,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3344.94,"additional_payer_notes":"APC"}]}]},{"description":"Create eardrum opening","code_information":[{"code":"69436","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1151.01,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1534.69,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2961.94,"additional_payer_notes":"APC"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2909.0},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1151.01,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1565.38,"additional_payer_notes":"APC"}]}]},{"description":"Remove part of temporal bone","code_information":[{"code":"69535","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Mastoid surgery revision","code_information":[{"code":"69604","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Rebuild eardrum structures","code_information":[{"code":"69637","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Revise middle ear bone","code_information":[{"code":"69660","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Implant/replace hearing aid","code_information":[{"code":"69710","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0}]}]},{"description":"Middle ear surgery procedure","code_information":[{"code":"69799","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":175.7,"maximum":13249.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":234.27,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":13249.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":10779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":13249.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":452.14,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":175.7,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":238.96,"additional_payer_notes":"APC"}]}]},{"description":"Inner ear surgery procedure","code_information":[{"code":"69949","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":175.7,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":234.27,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":452.14,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":175.7,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":238.96,"additional_payer_notes":"APC"}]}]},{"description":"Left hrt cath w/ventrclgrphy","code_information":[{"code":"93452","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2404.97,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3206.62,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6188.79,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2404.97,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3270.76,"additional_payer_notes":"APC"}]}]},{"description":"R&l hrt art/ventricle angio","code_information":[{"code":"93460","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2404.97,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3206.62,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6188.79,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2404.97,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3270.76,"additional_payer_notes":"APC"}]}]},{"description":"Perc d-e cor stent ather br","code_information":[{"code":"C9603","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Bone graft peri each addl","code_information":[{"code":"D3429","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5512.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0}]}]},{"description":"Metabolic panel ionized ca","code_information":[{"code":"80047","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":10.3,"maximum":26.5,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.73,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":17.11},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17.16},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17.16},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17.16},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":26.5,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10.3,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24.03},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13.73},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14.0,"additional_payer_notes":"APC"}]}]},{"description":"Insj stablj dev w/dcmprn","code_information":[{"code":"22867","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":13007.15,"maximum":33471.73,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17342.86,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":33471.73,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13007.15,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17689.72,"additional_payer_notes":"APC"}]}]},{"description":"Analgesics non-opioid 1 or 2","code_information":[{"code":"80329","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":35.06,"maximum":35.06,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":35.06}]}]},{"description":"Cannabinoids synthetic 1-3","code_information":[{"code":"80350","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":35.06,"maximum":35.06,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":35.06}]}]},{"description":"Methylphenidate","code_information":[{"code":"80360","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":35.06,"maximum":35.06,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":35.06}]}]},{"description":"Stimulants synthetic","code_information":[{"code":"80371","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":35.06,"maximum":35.06,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":35.06}]}]},{"description":"Path clin consltj high 41-60","code_information":[{"code":"80505","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":126.39,"maximum":325.23,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":168.51,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":138.59},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":325.23,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":126.39,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":152.32},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":171.88,"additional_payer_notes":"APC"}]}]},{"description":"Microscopic exam of urine","code_information":[{"code":"81015","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2.29,"maximum":6.18,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3.05,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6.18},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3.81},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3.81},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3.81},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5.89,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2.29,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5.34},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3.05},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3.11,"additional_payer_notes":"APC"}]}]},{"description":"Hpa-5 genotyping","code_information":[{"code":"81109","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":91.66,"maximum":235.88,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":122.22,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":224.14},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":152.78},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":152.78},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":152.78},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":235.88,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":91.66,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":213.89},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":122.22},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":124.66,"additional_payer_notes":"APC"}]}]},{"description":"Brca1&2 gene full seq alys","code_information":[{"code":"81163","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":351.0,"maximum":936.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":468.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":695.2},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":585.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":585.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":585.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":903.24,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":351.0,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":819.0},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":936.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":477.36,"additional_payer_notes":"APC"}]}]},{"description":"Aff2 gene charac alleles","code_information":[{"code":"81172","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":206.12,"maximum":530.42,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":274.83,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":408.24},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":343.54},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":343.54},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":343.54},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":530.42,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":206.12,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":480.95},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":274.83},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":280.33,"additional_payer_notes":"APC"}]}]},{"description":"Atxn3 gene detc abnor allele","code_information":[{"code":"81180","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":102.75,"maximum":264.41,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":137.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":203.51},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":171.25},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":171.25},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":171.25},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":264.41,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":102.75,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":239.75},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":137.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":139.74,"additional_payer_notes":"APC"}]}]},{"description":"Cstb gene detc abnor allele","code_information":[{"code":"81188","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":102.75,"maximum":264.41,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":137.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":203.51},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":171.25},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":171.25},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":171.25},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":264.41,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":102.75,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":239.75},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":137.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":139.74,"additional_payer_notes":"APC"}]}]},{"description":"Aspa gene","code_information":[{"code":"81200","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":35.44,"maximum":91.19,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":47.25,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":70.19},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":59.06},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":59.06},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":59.06},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":91.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":35.44,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":82.69},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":47.25},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":48.2,"additional_payer_notes":"APC"}]}]},{"description":"Bcr/abl1 gene other bp","code_information":[{"code":"81208","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":160.96,"maximum":414.22,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":214.62,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":325.46},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":268.28},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":268.28},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":268.28},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":414.22,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":160.96,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":375.59},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":214.62},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":218.91,"additional_payer_notes":"APC"}]}]},{"description":"Calr gene com variants","code_information":[{"code":"81219","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":91.22,"maximum":246.12,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":121.63,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":246.12},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":152.04},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":152.04},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":152.04},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":234.75,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":91.22,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":212.85},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":121.63},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":124.06,"additional_payer_notes":"APC"}]}]},{"description":"Cyp2c9 gene com variants","code_information":[{"code":"81227","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":131.11,"maximum":337.38,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":174.81,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":259.67},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":218.51},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":218.51},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":218.51},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":337.38,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":131.11,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":305.92},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":174.81},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":178.31,"additional_payer_notes":"APC"}]}]},{"description":"Egfr gene com variants","code_information":[{"code":"81235","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":243.44,"maximum":626.44,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":324.58,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":489.48},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":405.73},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":405.73},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":405.73},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":626.44,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":243.44,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":568.02},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":324.58},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":331.07,"additional_payer_notes":"APC"}]}]},{"description":"Fmr1 gene detection","code_information":[{"code":"81243","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":42.78,"maximum":110.09,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":57.04,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":84.73},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":71.3},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":71.3},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":71.3},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":110.09,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":42.78,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":99.82},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":57.04},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":58.18,"additional_payer_notes":"APC"}]}]},{"description":"Gba gene","code_information":[{"code":"81251","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":35.44,"maximum":91.19,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":47.25,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":70.19},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":59.06},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":59.06},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":59.06},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":91.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":35.44,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":82.69},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":47.25},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":48.2,"additional_payer_notes":"APC"}]}]},{"description":"Hba1/hba2 full gene sequence","code_information":[{"code":"81259","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":450.0,"maximum":1158.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":600.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":891.29},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":750.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":750.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":750.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1158.0,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":450.0,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1050.0},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":600.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":612.0,"additional_payer_notes":"APC"}]}]},{"description":"Chimerism anal no cell selec","code_information":[{"code":"81267","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":155.6,"maximum":419.78,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":207.46,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":419.78},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":259.33},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":259.33},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":259.33},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":400.4,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":155.6,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":363.06},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":207.46},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":211.61,"additional_payer_notes":"APC"}]}]},{"description":"Kras gene variants exon 2","code_information":[{"code":"81275","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":144.94,"maximum":372.97,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":193.25,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":292.93},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":241.56},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":241.56},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":241.56},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":372.97,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":144.94,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":338.19},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":193.25},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":197.12,"additional_payer_notes":"APC"}]}]},{"description":"Fxn gene full gene sequence","code_information":[{"code":"81286","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":206.12,"maximum":530.42,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":274.83,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":408.24},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":343.54},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":343.54},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":343.54},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":530.42,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":206.12,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":480.95},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":274.83},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":280.33,"additional_payer_notes":"APC"}]}]},{"description":"Mlh1 gene dup/delete variant","code_information":[{"code":"81294","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":151.8,"maximum":390.63,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":202.4,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":282.82},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":253.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":253.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":253.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":390.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":151.8,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":354.2},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":202.4},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":206.45,"additional_payer_notes":"APC"}]}]},{"description":"Mecp2 gene full seq","code_information":[{"code":"81302","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":395.9,"maximum":1018.79,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":527.87,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":784.13},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":659.84},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":659.84},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":659.84},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1018.79,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":395.9,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":923.77},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":527.87},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":538.43,"additional_payer_notes":"APC"}]}]},{"description":"Npm1 gene","code_information":[{"code":"81310","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":184.89,"maximum":475.78,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":246.52,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":366.58},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":308.15},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":308.15},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":308.15},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":475.78,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":184.89,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":431.41},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":246.52},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":251.45,"additional_payer_notes":"APC"}]}]},{"description":"Pms2 known familial variants","code_information":[{"code":"81318","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":248.25,"maximum":638.83,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":331.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":273.82},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":413.75},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":413.75},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":413.75},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":638.83,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":248.25,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":579.25},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":331.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":337.62,"additional_payer_notes":"APC"}]}]},{"description":"Pmp22 gene known fam variant","code_information":[{"code":"81326","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":34.95,"maximum":89.94,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":46.6,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":78.52},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":58.25},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":58.25},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":58.25},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":89.94,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":34.95,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":81.55},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":46.6},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":47.53,"additional_payer_notes":"APC"}]}]},{"description":"Remvl insj impltbl gluc sens","code_information":[{"code":"0448T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":7942.1,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4115.08,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7942.1,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3086.31,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4197.38,"additional_payer_notes":"APC"}]}]},{"description":"Gingivectomy/plasty rest","code_information":[{"code":"D4212","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2459.51,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3279.35,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6329.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2459.51,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3344.94,"additional_payer_notes":"APC"}]}]},{"description":"Osseous surg 1 to 3 teeth","code_information":[{"code":"D4261","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2459.51,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3279.35,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6329.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2459.51,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3344.94,"additional_payer_notes":"APC"}]}]},{"description":"Mesial/distal wedge proc","code_information":[{"code":"D4274","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":479.59,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":639.45,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1234.13,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":479.59,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":652.24,"additional_payer_notes":"APC"}]}]},{"description":"Surgical place mini implant","code_information":[{"code":"D6013","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5512.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0}]}]},{"description":"Rem imp tooth w mucoper flp","code_information":[{"code":"D7210","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1151.01,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1534.69,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2961.94,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1151.01,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1565.38,"additional_payer_notes":"APC"}]}]},{"description":"Primary closure sinus perf","code_information":[{"code":"D7261","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":479.59,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":639.45,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1234.13,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":479.59,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":652.24,"additional_payer_notes":"APC"}]}]},{"description":"Exfoliative cytolog collect","code_information":[{"code":"D7287","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5512.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0}]}]},{"description":"Alveoplasty w/ extraction","code_information":[{"code":"D7310","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1151.01,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1534.69,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2961.94,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1151.01,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1565.38,"additional_payer_notes":"APC"}]}]},{"description":"Excision benign lesion compl","code_information":[{"code":"D7412","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1151.01,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1534.69,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2961.94,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1151.01,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1565.38,"additional_payer_notes":"APC"}]}]},{"description":"Rem nonodonto cyst to 1.25cm","code_information":[{"code":"D7460","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":479.59,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":639.45,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1234.13,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":479.59,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":652.24,"additional_payer_notes":"APC"}]}]},{"description":"I&d absc intraoral soft tiss","code_information":[{"code":"D7510","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":525.32,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":700.42,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1351.81,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":525.32,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":714.43,"additional_payer_notes":"APC"}]}]},{"description":"Maxilla open reduct simple","code_information":[{"code":"D7610","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5512.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0}]}]},{"description":"Open reduc compd alveolus fx","code_information":[{"code":"D7770","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":11300.84,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Tmj cutting of a muscle","code_information":[{"code":"D7856","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5512.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0}]}]},{"description":"Tmj arthroscopy disc reposit","code_information":[{"code":"D7874","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Collect & appl blood product","code_information":[{"code":"D7921","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5512.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0}]}]},{"description":"Reconstruct midface no graft","code_information":[{"code":"D7948","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5512.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0}]}]},{"description":"Excision hyperplastic tissue","code_information":[{"code":"D7970","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5512.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0}]}]},{"description":"Dental coronoidectomy","code_information":[{"code":"D7991","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5512.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0}]}]},{"description":"Laparoscopy islet cell trans","code_information":[{"code":"G0342","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8923.0,"maximum":10765.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":10765.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":8923.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":10765.0}]}]},{"description":"Place perm pacing cardiovert","code_information":[{"code":"G0448","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":9356.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0}]}]},{"description":"Lobar lung transplantation","code_information":[{"code":"S2060","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5512.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0}]}]},{"description":"LAUP","code_information":[{"code":"S2080","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5512.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0}]}]},{"description":"Minimally invasive direct co","code_information":[{"code":"S2205","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5512.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0}]}]},{"description":"Arthroscopy, shoulder, surgi","code_information":[{"code":"S2300","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5512.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0}]}]},{"description":"Fetal surg sacrococ teratoma","code_information":[{"code":"S2405","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5512.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0}]}]},{"description":"Dx lmbr spi pnxr w/fluor/ct","code_information":[{"code":"62328","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":523.65,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":698.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1347.51,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":523.65,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":712.16,"additional_payer_notes":"APC"}]}]},{"description":"Regn cell tx scldr hands","code_information":[{"code":"0489T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Nsl/sins ndsc total","code_information":[{"code":"31253","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5235.45,"maximum":13472.56,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6980.6,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":7398.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6019.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":7398.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13472.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5235.45,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7120.21,"additional_payer_notes":"APC"}]}]},{"description":"Evasc rpr a-ao ndgft","code_information":[{"code":"34701","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":9356.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0}]}]},{"description":"Removal complete iims","code_information":[{"code":"0530T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2772.2,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3696.26,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7133.79,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2772.2,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3770.19,"additional_payer_notes":"APC"}]}]},{"description":"Removal ss dfb electrode","code_information":[{"code":"0573T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2772.2,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3696.26,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7133.79,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2772.2,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3770.19,"additional_payer_notes":"APC"}]}]},{"description":"Temp fml iu valve-pmp rplcmt","code_information":[{"code":"0597T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":517.28,"maximum":3030.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":689.7,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1331.13,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":517.28,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":703.5,"additional_payer_notes":"APC"}]}]},{"description":"Evasc ven artlz tibl/prnl vn","code_information":[{"code":"0620T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":26827.0,"maximum":84083.89,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":43566.78,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":84083.89,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":32675.09,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":27583.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":44438.12,"additional_payer_notes":"APC"}]}]},{"description":"Arthrd si jt prq iartic impl","code_information":[{"code":"0775T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":26827.0,"maximum":26827.0,"payers_information":[{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0}]}]},{"description":"Injection ext venography","code_information":[{"code":"36005","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Establish access to artery","code_information":[{"code":"36140","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Place cath carotid/inom art","code_information":[{"code":"36222","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2342.32,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3123.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6027.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2342.32,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3185.56,"additional_payer_notes":"APC"}]}]},{"description":"Ins cath abd/l-ext art 2nd","code_information":[{"code":"36246","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Revision of infusion pump","code_information":[{"code":"36261","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2772.2,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3696.26,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7133.79,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2772.2,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3770.19,"additional_payer_notes":"APC"}]}]},{"description":"Endovenous mchnchem 1st vein","code_information":[{"code":"36473","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2342.32,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3123.09,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6027.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2342.32,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3185.56,"additional_payer_notes":"APC"}]}]},{"description":"External cannula declotting","code_information":[{"code":"36860","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1167.76,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1557.01,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3005.03,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1167.76,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1588.15,"additional_payer_notes":"APC"}]}]},{"description":"Balo angiop ctr dialysis seg","code_information":[{"code":"36907","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":2334.0,"payers_information":[{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Fem/popl revas w/tla","code_information":[{"code":"37224","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6019.0,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":7398.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6019.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":7398.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0}]}]},{"description":"Tib/per revasc add-on","code_information":[{"code":"37232","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5512.0,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0}]}]},{"description":"Vasc embolize/occlude venous","code_information":[{"code":"37241","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":27583.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11418.47,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":22037.64,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8563.85,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":27583.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11646.84,"additional_payer_notes":"APC"}]}]},{"description":"Penile venous occlusion","code_information":[{"code":"37790","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2614.94,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3486.59,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6729.12,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2614.94,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3556.32,"additional_payer_notes":"APC"}]}]},{"description":"Repair lip","code_information":[{"code":"40650","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":400.09,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":533.45,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1029.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":400.09,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":544.12,"additional_payer_notes":"APC"}]}]},{"description":"Lip surgery procedure","code_information":[{"code":"40799","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":175.7,"maximum":13249.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":234.27,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":13249.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":10779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":13249.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":452.14,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":175.7,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":238.96,"additional_payer_notes":"APC"}]}]},{"description":"Excise/repair mouth lesion","code_information":[{"code":"40812","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1151.01,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1534.69,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2961.94,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1151.01,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1565.38,"additional_payer_notes":"APC"}]}]},{"description":"Reconstruction of mouth","code_information":[{"code":"40840","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":11300.84,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Drainage of mouth lesion","code_information":[{"code":"41006","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1151.01,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1534.69,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2961.94,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1151.01,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1565.38,"additional_payer_notes":"APC"}]}]},{"description":"Drainage of mouth lesion","code_information":[{"code":"41018","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1151.01,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1534.69,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2961.94,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1151.01,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1565.38,"additional_payer_notes":"APC"}]}]},{"description":"Excision of tongue lesion","code_information":[{"code":"41114","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2459.51,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3279.35,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6329.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2459.51,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3344.94,"additional_payer_notes":"APC"}]}]},{"description":"Esophagoscopy rigid trnso","code_information":[{"code":"43180","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":11300.84,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Esophagosc flex trnsn biopsy","code_information":[{"code":"43198","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":672.83,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":897.11,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1731.42,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":672.83,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":915.05,"additional_payer_notes":"APC"}]}]},{"description":"Esophagoscop mucosal resect","code_information":[{"code":"43211","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1423.51,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1898.01,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3663.16,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1423.51,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1935.97,"additional_payer_notes":"APC"}]}]},{"description":"Esoph endoscopy dilation","code_information":[{"code":"43226","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1423.51,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1898.01,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3663.16,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1423.51,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1935.97,"additional_payer_notes":"APC"}]}]},{"description":"Endoscopic us exam esoph","code_information":[{"code":"43237","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1423.51,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1898.01,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3663.16,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1423.51,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1935.97,"additional_payer_notes":"APC"}]}]},{"description":"Egd dilate stricture","code_information":[{"code":"43245","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1423.51,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1898.01,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3663.16,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1423.51,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1935.97,"additional_payer_notes":"APC"}]}]},{"description":"Egd us transmural injxn/mark","code_information":[{"code":"43253","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1423.51,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1898.01,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3663.16,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1423.51,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1935.97,"additional_payer_notes":"APC"}]}]},{"description":"Ercp sphincter pressure meas","code_information":[{"code":"43263","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1423.51,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1898.01,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3663.16,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1423.51,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1935.97,"additional_payer_notes":"APC"}]}]},{"description":"Ercp stent exchange w/dilate","code_information":[{"code":"43276","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":11589.23,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6004.78,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11589.23,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4503.59,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6124.88,"additional_payer_notes":"APC"}]}]},{"description":"Rmvl esophgl sphnctr dev","code_information":[{"code":"43285","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4484.77,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5979.69,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11540.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4484.77,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6099.28,"additional_payer_notes":"APC"}]}]},{"description":"Revise gastric port open","code_information":[{"code":"43886","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2628.85,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3505.13,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6764.9,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2628.85,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3575.23,"additional_payer_notes":"APC"}]}]},{"description":"Proctosigmoidoscopy w/bx","code_information":[{"code":"45305","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":887.71,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1183.61,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2284.37,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":887.71,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1207.28,"additional_payer_notes":"APC"}]}]},{"description":"Proctosigmoidoscopy W/Stent","code_information":[{"code":"45327","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":11589.23,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6004.78,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11589.23,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4503.59,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6124.88,"additional_payer_notes":"APC"}]}]},{"description":"Sigmoidoscopy w/tumr remove","code_information":[{"code":"45338","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":887.71,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1183.61,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2284.37,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":887.71,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1207.28,"additional_payer_notes":"APC"}]}]},{"description":"Diagnostic colonoscopy","code_information":[{"code":"45378","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":689.87,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":919.83,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1775.27,"additional_payer_notes":"APC"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1543.0},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":689.87,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":938.23,"additional_payer_notes":"APC"}]}]},{"description":"Colonoscopy w/ablation","code_information":[{"code":"45388","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":887.71,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1183.61,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2284.37,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":887.71,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1207.28,"additional_payer_notes":"APC"}]}]},{"description":"Anus surgery procedure","code_information":[{"code":"46999","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":689.87,"maximum":13249.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":919.83,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":13249.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":10779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":13249.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1775.27,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":689.87,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":938.23,"additional_payer_notes":"APC"}]}]},{"description":"Exc abd tum over 10 cm","code_information":[{"code":"49205","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":17314.0,"maximum":18364.0,"payers_information":[{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0}]}]},{"description":"Correction hallux valgus","code_information":[{"code":"28295","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Laryngoplasty medialization","code_information":[{"code":"31591","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Core ndl bx lng/med perq","code_information":[{"code":"32408","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1225.21,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1633.61,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3152.87,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1225.21,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1666.28,"additional_payer_notes":"APC"}]}]},{"description":"Liver dis 10 assays w/ash","code_information":[{"code":"0002M","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":377.55,"maximum":971.56,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":503.4,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":747.79},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":629.25},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":629.25},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":629.25},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":971.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":377.55,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":880.95},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":513.47,"additional_payer_notes":"APC"}]}]},{"description":"Rx test prsmv ur w/def conf","code_information":[{"code":"0007U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":85.82,"maximum":220.85,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":114.43,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":169.99},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":143.04},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":143.04},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":143.04},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":220.85,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":85.82,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":200.25},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":114.43},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":116.72,"additional_payer_notes":"APC"}]}]},{"description":"Adrnl cortcl tum bchm asy 25","code_information":[{"code":"0015M","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":979.03,"maximum":2519.36,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1305.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1939.08},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1631.71},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1631.71},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1631.71},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2519.36,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":979.03,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2284.4},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1305.37},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1331.48,"additional_payer_notes":"APC"}]}]},{"description":"Onc rna tiss predict alg","code_information":[{"code":"0019U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2756.25,"maximum":7092.75,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3675.0,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4593.75},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4593.75},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4593.75},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7092.75,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2756.25,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6431.25},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3675.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3748.5,"additional_payer_notes":"APC"}]}]},{"description":"Jak2 gene trgt seq alys","code_information":[{"code":"0027U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":91.43,"maximum":235.29,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":121.91,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":223.6},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":152.39},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":152.39},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":152.39},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":235.29,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":91.43,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":213.34},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":135.46},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":124.35,"additional_payer_notes":"APC"}]}]},{"description":"Xome tum & nml spec seq alys","code_information":[{"code":"0036U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3585.0,"maximum":9225.4,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4780.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7100.54},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5975.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5975.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5975.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":9225.4,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3585.0,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8365.0},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":4780.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4875.6,"additional_payer_notes":"APC"}]}]},{"description":"Tbrf b grp antb 4 prtn igg","code_information":[{"code":"0044U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":11.14,"maximum":28.68,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14.86,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18.58},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18.58},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18.58},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":28.68,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11.14,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26.01},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14.86},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15.16,"additional_payer_notes":"APC"}]}]},{"description":"Lpoprtn bld w/5 maj classes","code_information":[{"code":"0052U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":25.4,"maximum":65.35,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":33.86,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":50.29},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":42.33},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":42.33},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":42.33},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":65.35,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25.4,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":59.26},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33.86},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":34.54,"additional_payer_notes":"APC"}]}]},{"description":"Mech remov tunneled cv cath","code_information":[{"code":"36595","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2342.32,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3123.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6027.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2342.32,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3185.56,"additional_payer_notes":"APC"}]}]},{"description":"Insert needle bone cavity","code_information":[{"code":"36680","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":331.39,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":441.86,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":852.79,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":331.39,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":450.7,"additional_payer_notes":"APC"}]}]},{"description":"Insertion of cannula(s)","code_information":[{"code":"36823","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0}]}]},{"description":"Thrmbc/nfs dialysis circuit","code_information":[{"code":"36905","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8563.85,"maximum":27583.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11418.47,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":22037.64,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8563.85,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":27583.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11646.84,"additional_payer_notes":"APC"}]}]},{"description":"Trluml balo angiop 1st vein","code_information":[{"code":"37248","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4222.18,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5629.58,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":10865.09,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4222.18,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5742.17,"additional_payer_notes":"APC"}]}]},{"description":"Abltj mal prst8 tiss hifu","code_information":[{"code":"55880","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7022.52,"maximum":18071.3,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9363.37,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":18071.3,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7022.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9550.63,"additional_payer_notes":"APC"}]}]},{"description":"Closure of vagina","code_information":[{"code":"57120","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3710.98,"maximum":9549.58,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4947.97,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":9549.58,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3710.98,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5046.93,"additional_payer_notes":"APC"}]}]},{"description":"Treat vaginal bleeding","code_information":[{"code":"57180","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":149.98,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":199.97,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":385.94,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":149.98,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":203.97,"additional_payer_notes":"APC"}]}]},{"description":"Extensive repair of vagina","code_information":[{"code":"57265","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3710.98,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4947.97,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":9549.58,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3710.98,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5046.93,"additional_payer_notes":"APC"}]}]},{"description":"Repair paravag defect vag","code_information":[{"code":"57285","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5501.01,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7334.68,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":14155.93,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5501.01,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7481.37,"additional_payer_notes":"APC"}]}]},{"description":"Neuro autism 32 amines alg","code_information":[{"code":"0063U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":562.5,"maximum":1447.5,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":750.0,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":937.5},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":937.5},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":937.5},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1447.5,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":562.5,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1312.5},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":750.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":765.0,"additional_payer_notes":"APC"}]}]},{"description":"Cyp2d6 full gene sequence","code_information":[{"code":"0071U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":301.35,"maximum":1158.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":600.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":447.65},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":750.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":750.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":750.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1158.0,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":450.0,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1050.0},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":301.35},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":612.0,"additional_payer_notes":"APC"}]}]},{"description":"Onc lng 5 clin rsk factr alg","code_information":[{"code":"0080U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2640.0,"maximum":6793.6,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3520.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5228.84},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4400.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4400.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4400.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6793.6,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2640.0,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6160.0},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3520.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3590.4,"additional_payer_notes":"APC"}]}]},{"description":"Onc cutan mlnma mrna 23 gene","code_information":[{"code":"0090U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1462.5,"maximum":3763.5,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1950.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2896.67},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2437.5},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2437.5},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2437.5},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3763.5,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1462.5,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3412.5},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1950.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1989.0,"additional_payer_notes":"APC"}]}]},{"description":"Hered ova ca pnl 24 genes","code_information":[{"code":"0103U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1117.98,"maximum":3365.82,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1743.95,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2590.58},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2179.94},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2179.94},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2179.94},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3365.82,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1307.96,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3051.91},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1117.98},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1778.83,"additional_payer_notes":"APC"}]}]},{"description":"Iadi 16s&18s rrna genes","code_information":[{"code":"0112U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":267.1,"maximum":687.33,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":356.13,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":445.16},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":445.16},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":445.16},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":687.33,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":267.1,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":623.23},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":356.13},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":363.25,"additional_payer_notes":"APC"}]}]},{"description":"Onc b cll lymphm mrna 58 gen","code_information":[{"code":"0120U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1882.66,"maximum":4844.71,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2510.21,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3728.84},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3137.76},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3137.76},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3137.76},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4844.71,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1882.66,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":4392.87},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2789.12},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2560.41,"additional_payer_notes":"APC"}]}]},{"description":"Hered prst8 ca rltd do 11","code_information":[{"code":"0133U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":517.72,"maximum":1332.26,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":690.29,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":862.86},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":862.86},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":862.86},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1332.26,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":517.72,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1208.01},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":690.29},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":704.1,"additional_payer_notes":"APC"}]}]},{"description":"Nfct ds bact&fng gram neg","code_information":[{"code":"0142U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":117.56,"maximum":302.53,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":156.75,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":232.84},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":195.94},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":195.94},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":195.94},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":302.53,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":117.56,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":274.31},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":156.75},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":159.88,"additional_payer_notes":"APC"}]}]},{"description":"Msh2 mrna seq alys","code_information":[{"code":"0159U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":212.16,"maximum":545.96,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":282.88,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":420.22},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":353.6},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":353.6},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":353.6},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":545.96,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":212.16,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":495.04},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":282.88},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":288.54,"additional_payer_notes":"APC"}]}]},{"description":"Nudt15&tpmt gene com vrnt","code_information":[{"code":"0169U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":349.63,"maximum":899.71,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":466.17,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":692.47},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":582.71},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":582.71},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":582.71},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":899.71,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":349.63,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":815.8},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":466.17},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":475.49,"additional_payer_notes":"APC"}]}]},{"description":"Onc brst ca dna pik3ca 11","code_information":[{"code":"0177U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":206.12,"maximum":530.42,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":274.83,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":408.24},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":343.54},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":343.54},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":343.54},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":530.42,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":206.12,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":480.95},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":246.52},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":280.33,"additional_payer_notes":"APC"}]}]},{"description":"Fut1 gnotyp fut1 exon 4","code_information":[{"code":"0185U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":138.9,"maximum":357.44,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":185.2,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":275.11},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":231.5},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":231.5},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":231.5},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":357.44,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":138.9,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":324.1},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":185.2},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":188.9,"additional_payer_notes":"APC"}]}]},{"description":"Jr gnotyp abcg2 exons 2-26","code_information":[{"code":"0193U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":212.16,"maximum":545.96,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":282.88,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":420.22},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":353.6},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":353.6},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":353.6},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":545.96,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":212.16,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":495.04},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":282.88},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":288.54,"additional_payer_notes":"APC"}]}]},{"description":"Yt gnotyp ache exon 2","code_information":[{"code":"0201U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":138.9,"maximum":357.44,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":185.2,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":275.11},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":231.5},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":231.5},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":231.5},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":357.44,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":138.9,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":324.1},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":185.2},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":188.9,"additional_payer_notes":"APC"}]}]},{"description":"Onc pan-tum dna&rna gnrj seq","code_information":[{"code":"0211U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3675.0,"maximum":16318.15,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8455.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":12559.64},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10568.75},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10568.75},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10568.75},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":16318.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6341.25,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14796.25},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3675.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8624.1,"additional_payer_notes":"APC"}]}]},{"description":"Nfct agt hiv gnrj seq alys","code_information":[{"code":"0219U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":543.75,"maximum":1399.25,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":725.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1076.96},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":906.25},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":906.25},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":906.25},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1399.25,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":543.75,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1268.75},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":725.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":739.5,"additional_payer_notes":"APC"}]}]},{"description":"Rx asy prsmv 30+rx/metablt","code_information":[{"code":"0227U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":46.6,"maximum":119.93,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":62.14,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":92.32},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":77.68},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":77.68},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":77.68},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":119.93,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":46.6,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":108.75},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":62.14},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":63.38,"additional_payer_notes":"APC"}]}]},{"description":"Pten full gene analysis","code_information":[{"code":"0235U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":450.0,"maximum":1158.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":600.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":891.29},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":750.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":750.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":750.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1158.0,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":450.0,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1050.0},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":600.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":612.0,"additional_payer_notes":"APC"}]}]},{"description":"Ob pe biochem assay pgf alg","code_information":[{"code":"0243U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":48.31,"maximum":124.31,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":64.41,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":95.69},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":80.51},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":80.51},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":80.51},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":124.31,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":48.31,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":112.72},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":64.41},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":65.7,"additional_payer_notes":"APC"}]}]},{"description":"Hepcidin-25 elisa serum/plsm","code_information":[{"code":"0251U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":12.95,"maximum":33.33,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17.27,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":25.66},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21.59},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21.59},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21.59},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":33.33,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.95,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30.22},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17.27},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17.62,"additional_payer_notes":"APC"}]}]},{"description":"Neph ckd nuc mrs meas gfr","code_information":[{"code":"0259U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":39.53,"maximum":101.73,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":52.71,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":78.3},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":65.89},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":65.89},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":65.89},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":101.73,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":39.53,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":92.24},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":52.71},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":53.76,"additional_payer_notes":"APC"}]}]},{"description":"Rare do id opt gen mapg&seq","code_information":[{"code":"0267U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5054.5,"maximum":13006.91,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6739.33,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":9979.27},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8424.16},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8424.16},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8424.16},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13006.91,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5054.5,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11793.83},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6739.33},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6874.12,"additional_payer_notes":"APC"}]}]},{"description":"Hem heprn nduc trmbctpna srm","code_information":[{"code":"0275U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":13.78,"maximum":35.45,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":27.28},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22.96},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22.96},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22.96},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":35.45,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.78,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32.15},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18.37},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18.74,"additional_payer_notes":"APC"}]}]},{"description":"Vw factor type 2b eval plsm","code_information":[{"code":"0283U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":13.8,"maximum":35.51,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18.4,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":27.34},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":35.51,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.8,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32.2},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18.4},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18.77,"additional_payer_notes":"APC"}]}]},{"description":"Psyc mood do mrna 144 genes","code_information":[{"code":"0291U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1316.25,"maximum":3387.15,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1755.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2628.29},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2193.75},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2193.75},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2193.75},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3387.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1316.25,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3071.25},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1755.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1790.1,"additional_payer_notes":"APC"}]}]},{"description":"Onc pan tum whl gen opt mapg","code_information":[{"code":"0299U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1397.42,"maximum":3596.01,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1863.22,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2790.35},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2329.03},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2329.03},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2329.03},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3596.01,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1397.42,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3260.64},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1863.22},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1900.48,"additional_payer_notes":"APC"}]}]},{"description":"Onc mrd nxt-gnrj alys sbsq","code_information":[{"code":"0307U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":595.87,"maximum":1533.37,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":794.49,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1189.84},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":993.11},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":993.11},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":993.11},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1533.37,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":595.87,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1390.36},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":794.49},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":810.38,"additional_payer_notes":"APC"}]}]},{"description":"Onc cutan sq cll ca mrna 40","code_information":[{"code":"0315U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6375.0,"maximum":16405.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8500.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":12729.6},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10625.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10625.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10625.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":16405.0,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6375.0,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14875.0},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8500.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8670.0,"additional_payer_notes":"APC"}]}]},{"description":"Iadna cns pthgn next gen seq","code_information":[{"code":"0323U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1594.65,"maximum":4103.57,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2126.2,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3148.38},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2657.75},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2657.75},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2657.75},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4103.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1594.65,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3720.85},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2126.2},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2168.72,"additional_payer_notes":"APC"}]}]},{"description":"Onc lvr surveilanc hcc cfdna","code_information":[{"code":"0333U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":496.74,"maximum":1278.28,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":662.32,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":991.88},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":827.9},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":827.9},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":827.9},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1278.28,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":496.74,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1159.06},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":662.32},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":675.57,"additional_payer_notes":"APC"}]}]},{"description":"Ftl aneup dna seq cmpr alys","code_information":[{"code":"0341U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1425.15,"maximum":3667.39,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1900.2,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2845.74},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2375.25},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2375.25},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2375.25},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3667.39,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1425.15,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3325.35},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1900.2},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1938.2,"additional_payer_notes":"APC"}]}]},{"description":"Rx metab/pcx dna 27 gen alys","code_information":[{"code":"0350U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1002.07,"maximum":2578.65,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1336.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1978.42},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1670.11},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1670.11},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1670.11},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2578.65,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1002.07,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2338.16},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1336.09},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1362.81,"additional_payer_notes":"APC"}]}]},{"description":"Onc pap thyr ca rna 82&10","code_information":[{"code":"0362U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2700.0,"maximum":6948.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3600.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5391.36},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4500.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4500.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4500.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6948.0,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2700.0,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6300.0},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3600.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3672.0,"additional_payer_notes":"APC"}]}]},{"description":"Iadna surg wnd pthgn 34&21","code_information":[{"code":"0370U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":416.78,"maximum":729.37,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":624.18},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":520.98},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":520.98},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":520.98},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":729.37},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":416.78}]}]},{"description":"Laryngoplasty laryngeal sten","code_information":[{"code":"31551","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Largsc w/laser dstrj les","code_information":[{"code":"31572","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2765.81,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3687.74,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7117.34,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2765.81,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3761.5,"additional_payer_notes":"APC"}]}]},{"description":"Dilate esophagus 1/mult pass","code_information":[{"code":"43450","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":672.83,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":897.11,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1731.42,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":672.83,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":915.05,"additional_payer_notes":"APC"}]}]},{"description":"Withdrawal of arterial blood","code_information":[{"code":"36600","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":98.7,"maximum":2334.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":131.6,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":253.99,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":98.7,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":134.23,"additional_payer_notes":"APC"}]}]},{"description":"Intro cath dialysis circuit","code_information":[{"code":"36901","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1167.76,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1557.01,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3005.03,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1167.76,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1588.15,"additional_payer_notes":"APC"}]}]},{"description":"Dialysis circuit embolj","code_information":[{"code":"36909","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":2334.0,"payers_information":[{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Reconstruction tongue fold","code_information":[{"code":"41520","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2459.51,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3279.35,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6329.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2459.51,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3344.94,"additional_payer_notes":"APC"}]}]},{"description":"Excision of gum lesion","code_information":[{"code":"41822","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1151.01,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1534.69,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2961.94,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1151.01,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1565.38,"additional_payer_notes":"APC"}]}]},{"description":"Gum graft","code_information":[{"code":"41870","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1151.01,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1534.69,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2961.94,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1151.01,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1565.38,"additional_payer_notes":"APC"}]}]},{"description":"Rfc1 repeat xpnsj vrnt alys","code_information":[{"code":"0378U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":102.75,"maximum":264.41,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":137.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":205.18},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":171.25},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":171.25},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":171.25},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":264.41,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":102.75,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":239.75},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":137.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":139.74,"additional_payer_notes":"APC"}]}]},{"description":"Onc nonsm cll lng ca 37 gen","code_information":[{"code":"0388U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2625.0,"maximum":6755.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3500.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5040.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4375.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4375.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4375.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6755.0,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2625.0,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6125.0},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3500.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3570.0,"additional_payer_notes":"APC"}]}]},{"description":"Gi baret esph dna mthyln aly","code_information":[{"code":"0398U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1316.25,"maximum":3387.15,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1755.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2527.2},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2193.75},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2193.75},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2193.75},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3387.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1316.25,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3071.25},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1755.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1790.1,"additional_payer_notes":"APC"}]}]},{"description":"Onc lung flow cytmtry 5 mrk","code_information":[{"code":"0406U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":570.0,"maximum":1466.8,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":760.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1138.18},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":950.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":950.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":950.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1466.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":570.0,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1330.0},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":760.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":775.2,"additional_payer_notes":"APC"}]}]},{"description":"Onc lng aug alg aly whl sld8","code_information":[{"code":"0414U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":529.69,"maximum":1363.06,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":706.25,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1057.68},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":882.81},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":882.81},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":882.81},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1363.06,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":529.69,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1235.94},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":706.25},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":720.38,"additional_payer_notes":"APC"}]}]},{"description":"Psyc genomic alys pnl 26 gen","code_information":[{"code":"0423U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":416.78,"maximum":729.37,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":600.17},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":520.98},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":520.98},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":520.98},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":729.37},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":416.78}]}]},{"description":"Klhl11 antb sr/csf asy qual","code_information":[{"code":"0432U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":27.43,"maximum":70.58,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":36.57,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":52.66},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":45.71},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":45.71},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":45.71},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":70.58,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27.43,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":64.0},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36.57},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":37.3,"additional_payer_notes":"APC"}]}]},{"description":"Car scr sev inh cond 5 genes","code_information":[{"code":"0449U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1824.88,"maximum":3193.54,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2627.83},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2281.1},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2281.1},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2281.1},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3193.54},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1824.88}]}]},{"description":"Onc brst ca s100 a8&a9 elisa","code_information":[{"code":"0458U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":195.38,"maximum":502.76,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":260.5,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":375.12},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":325.63},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":325.63},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":325.63},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":502.76,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":195.38,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":455.88},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":260.5},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":265.71,"additional_payer_notes":"APC"}]}]},{"description":"Hered pan ca gsap 88gene ngs","code_information":[{"code":"0474U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":977.96,"maximum":2516.62,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1303.95,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1877.69},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1629.94},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1629.94},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1629.94},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2516.62,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":977.96,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2281.91},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1303.95},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1330.03,"additional_payer_notes":"APC"}]}]},{"description":"Ob pe biochem asy sfit1&pigf","code_information":[{"code":"0482U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":96.62,"maximum":248.62,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":128.82,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":185.5},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":161.03},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":161.03},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":161.03},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":248.62,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":96.62,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":225.44},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":128.82},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":131.4,"additional_payer_notes":"APC"}]}]},{"description":"Onc cutan/uveal mlnma cd146","code_information":[{"code":"0490U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1826.25,"maximum":4699.55,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2435.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3506.4},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3043.75},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3043.75},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3043.75},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4699.55,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1826.25,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":4261.25},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2435.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2483.7,"additional_payer_notes":"APC"}]}]},{"description":"Gi barretts esophgl cell 89","code_information":[{"code":"0506U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1453.51,"maximum":3740.36,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1938.01,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2790.73},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2422.51},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2422.51},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2422.51},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3740.36,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1453.51,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3391.52},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1938.01},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1976.77,"additional_payer_notes":"APC"}]}]},{"description":"Gi ibd ia quan deter adl lvl","code_information":[{"code":"0514U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":28.93,"maximum":74.44,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":38.57,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":55.54},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":48.21},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":48.21},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":48.21},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":74.44,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":28.93,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":67.5},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38.57},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":39.34,"additional_payer_notes":"APC"}]}]},{"description":"Renal function panel","code_information":[{"code":"80069","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6.51,"maximum":17.57,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8.68,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":17.57},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10.85},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10.85},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10.85},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":16.75,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6.51,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15.19},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8.68},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8.85,"additional_payer_notes":"APC"}]}]},{"description":"Drug assay caffeine","code_information":[{"code":"80155","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":28.62,"maximum":74.44,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":38.57,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":28.62},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":48.21},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":48.21},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":48.21},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":74.44,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":28.93,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":67.5},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38.57},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":39.34,"additional_payer_notes":"APC"}]}]},{"description":"Assay dipropylacetic acd tot","code_information":[{"code":"80164","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":10.16,"maximum":27.43,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.54,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":27.43},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16.93},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16.93},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16.93},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":26.13,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10.16,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23.7},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13.54},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.81,"additional_payer_notes":"APC"}]}]},{"description":"Drug screen quan lamotrigine","code_information":[{"code":"80175","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":9.94,"maximum":26.82,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.25,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":26.82},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16.56},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16.56},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16.56},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":25.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9.94,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23.19},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13.25},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.52,"additional_payer_notes":"APC"}]}]},{"description":"Assay of phenobarbital","code_information":[{"code":"80184","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":11.48,"maximum":29.53,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15.3,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":23.16},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19.13},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19.13},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19.13},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":29.53,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11.48,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26.78},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15.3},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15.61,"additional_payer_notes":"APC"}]}]},{"description":"Drug assay leflunomide","code_information":[{"code":"80193","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":28.93,"maximum":74.44,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":38.57,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":57.3},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":48.21},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":48.21},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":48.21},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":74.44,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":28.93,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":67.5},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38.57},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":39.34,"additional_payer_notes":"APC"}]}]},{"description":"Assay of vancomycin","code_information":[{"code":"80202","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":10.16,"maximum":27.43,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.54,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":27.43},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16.93},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16.93},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16.93},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":26.13,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10.16,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23.7},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13.54},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.81,"additional_payer_notes":"APC"}]}]},{"description":"Drug assay voriconazole","code_information":[{"code":"80285","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":20.33,"maximum":52.32,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27.11,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":40.27},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":33.89},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":33.89},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":33.89},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":52.32,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20.33,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":47.44},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27.11},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27.65,"additional_payer_notes":"APC"}]}]},{"description":"Aldosterone suppression eval","code_information":[{"code":"80408","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":94.12,"maximum":253.94,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":125.5,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":253.94},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":156.88},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":156.88},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":156.88},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":242.22,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":94.12,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":219.63},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":125.5},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":128.01,"additional_payer_notes":"APC"}]}]},{"description":"Dexamethasone panel","code_information":[{"code":"80420","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":121.41,"maximum":312.43,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":161.88,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":145.79},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":202.35},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":202.35},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":202.35},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":312.43,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":121.41,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":283.29},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":161.88},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":165.12,"additional_payer_notes":"APC"}]}]},{"description":"Insulin tolerance panel","code_information":[{"code":"80435","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":77.25,"maximum":208.44,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":103.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":208.44},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":128.75},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":128.75},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":128.75},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":198.79,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":77.25,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":180.25},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":103.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":105.06,"additional_payer_notes":"APC"}]}]},{"description":"Excision lesion mouth roof","code_information":[{"code":"42107","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":11300.84,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Reconstruct cleft palate","code_information":[{"code":"42205","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2459.51,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3279.35,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6329.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2459.51,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3344.94,"additional_payer_notes":"APC"}]}]},{"description":"Repair nose to lip fistula","code_information":[{"code":"42260","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":11300.84,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Removal of salivary stone","code_information":[{"code":"42330","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2459.51,"maximum":6329.15,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3279.35,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6329.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2459.51,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3344.94,"additional_payer_notes":"APC"}]}]},{"description":"Excise parotid gland/lesion","code_information":[{"code":"42415","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Parotid duct diversion","code_information":[{"code":"42507","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Salivary surgery procedure","code_information":[{"code":"42699","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":175.7,"maximum":13249.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":234.27,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":13249.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":10779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":13249.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":452.14,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":175.7,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":238.96,"additional_payer_notes":"APC"}]}]},{"description":"Remove pharynx foreign body","code_information":[{"code":"42809","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":331.39,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":441.86,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":852.79,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":331.39,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":450.7,"additional_payer_notes":"APC"}]}]},{"description":"Removal of adenoids","code_information":[{"code":"42831","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2459.51,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3279.35,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6329.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2459.51,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3344.94,"additional_payer_notes":"APC"}]}]},{"description":"Surgical opening of stomach","code_information":[{"code":"43510","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":672.83,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":897.11,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1731.42,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":672.83,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":915.05,"additional_payer_notes":"APC"}]}]},{"description":"Drain cerebro spinal fluid","code_information":[{"code":"62272","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":523.65,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":698.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1347.51,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":523.65,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":712.16,"additional_payer_notes":"APC"}]}]},{"description":"Inject for spine disk x-ray","code_information":[{"code":"62291","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Colonoscopy w/band ligation","code_information":[{"code":"45398","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":887.71,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1183.61,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2284.37,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":887.71,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1207.28,"additional_payer_notes":"APC"}]}]},{"description":"Exc abd tum 5 cm or less","code_information":[{"code":"49203","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7529.0,"maximum":7791.0,"payers_information":[{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0}]}]},{"description":"Exchange drainage catheter","code_information":[{"code":"49423","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1423.51,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1898.01,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3663.16,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1423.51,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1935.97,"additional_payer_notes":"APC"}]}]},{"description":"Embedded IP Cath Exit-Site","code_information":[{"code":"49436","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1423.51,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1898.01,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3663.16,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1423.51,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1935.97,"additional_payer_notes":"APC"}]}]},{"description":"Fix g/colon tube w/device","code_information":[{"code":"49460","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":672.83,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":897.11,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1731.42,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":672.83,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":915.05,"additional_payer_notes":"APC"}]}]},{"description":"Prp i/hern init reduc >5 yr","code_information":[{"code":"49505","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2656.06,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3541.41,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6834.92,"additional_payer_notes":"APC"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5415.0},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2656.06,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3612.24,"additional_payer_notes":"APC"}]}]},{"description":"Rerepair fem hernia reduce","code_information":[{"code":"49555","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2656.06,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3541.41,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6834.92,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2656.06,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3612.24,"additional_payer_notes":"APC"}]}]},{"description":"Renal abscess open drain","code_information":[{"code":"50020","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1550.71,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2067.62,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3990.5,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1550.71,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2108.97,"additional_payer_notes":"APC"}]}]},{"description":"Twn zyg gen seq alys chrms2","code_information":[{"code":"0060U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":569.29,"maximum":1464.97,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":759.05,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":948.81},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":948.81},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":948.81},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1464.97,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":569.29,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1328.34},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":759.05},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":774.23,"additional_payer_notes":"APC"}]}]},{"description":"Candida species pnl amp prb","code_information":[{"code":"0068U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":106.97,"maximum":275.28,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":142.63,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":211.87},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":178.29},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":178.29},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":178.29},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":275.28,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":106.97,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":249.6},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":142.63},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":145.48,"additional_payer_notes":"APC"}]}]},{"description":"Cyp2d6 3' gene dup/mlt","code_information":[{"code":"0076U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":338.18,"maximum":870.26,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":450.91,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":669.83},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":563.64},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":563.64},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":563.64},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":870.26,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":338.18,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":789.09},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":450.91},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":459.93,"additional_payer_notes":"APC"}]}]},{"description":"Crd hrt trnspl mrna 1283 gen","code_information":[{"code":"0087U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2369.56,"maximum":6097.68,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3159.42,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3949.28},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3949.28},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3949.28},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6097.68,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2369.56,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5528.99},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3159.42},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3222.61,"additional_payer_notes":"APC"}]}]},{"description":"Hpv hi risk types male urine","code_information":[{"code":"0096U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":26.32,"maximum":67.72,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":35.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":52.12},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43.86},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43.86},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43.86},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":67.72,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26.32,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":61.41},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35.09},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":35.79,"additional_payer_notes":"APC"}]}]},{"description":"Id aspergillus dna 4 species","code_information":[{"code":"0109U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":106.97,"maximum":275.28,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":142.63,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":211.87},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":178.29},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":178.29},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":178.29},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":275.28,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":106.97,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":249.6},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":142.63},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":145.48,"additional_payer_notes":"APC"}]}]},{"description":"Pain mgmt 11 endogenous anal","code_information":[{"code":"0117U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":630.49,"maximum":1622.45,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":840.65,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1050.81},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1050.81},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1050.81},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1622.45,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":630.49,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1471.14},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":840.65},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":857.46,"additional_payer_notes":"APC"}]}]},{"description":"Hered colon ca do mrna pnl","code_information":[{"code":"0130U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":438.68,"maximum":1128.86,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":584.9,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":868.86},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":731.13},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":731.13},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":731.13},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1128.86,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":438.68,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1023.58},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":584.9},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":596.6,"additional_payer_notes":"APC"}]}]},{"description":"Brca1 brca2 mrna seq alys","code_information":[{"code":"0138U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":351.25,"maximum":903.88,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":468.33,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":585.41},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":585.41},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":585.41},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":903.88,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":351.25,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":819.58},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":468.33},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":477.7,"additional_payer_notes":"APC"}]}]},{"description":"Copy number sequence alys","code_information":[{"code":"0156U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1305.0,"maximum":3358.2,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1740.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2584.7},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2175.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2175.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2175.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3358.2,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1305.0,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3045.0},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1740.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1774.8,"additional_payer_notes":"APC"}]}]},{"description":"Gi ibs ia anti-cdtb&vinculin","code_information":[{"code":"0164U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":84.02,"maximum":216.2,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":112.02,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":166.4},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":140.03},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":140.03},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":140.03},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":216.2,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":84.02,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":196.04},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":112.02},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":114.26,"additional_payer_notes":"APC"}]}]},{"description":"Onc solid tumor 30 prtn trgt","code_information":[{"code":"0174U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":979.03,"maximum":2519.36,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1305.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1939.08},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1631.71},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1631.71},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1631.71},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2519.36,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":979.03,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2284.4},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1305.37},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1331.48,"additional_payer_notes":"APC"}]}]},{"description":"Crom gnotyp cd55 exons 1-10","code_information":[{"code":"0182U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":226.01,"maximum":581.61,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":301.35,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":447.65},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":376.69},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":376.69},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":376.69},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":581.61,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":226.01,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":527.36},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":301.35},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":307.38,"additional_payer_notes":"APC"}]}]},{"description":"Gypb gnotyp ntrns 1 5 seux 3","code_information":[{"code":"0190U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":206.12,"maximum":530.42,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":274.83,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":408.24},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":343.54},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":343.54},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":343.54},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":530.42,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":206.12,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":480.95},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":274.83},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":280.33,"additional_payer_notes":"APC"}]}]},{"description":"Rhd&rhce gntyp rhd1-10&rhce5","code_information":[{"code":"0198U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":212.16,"maximum":545.96,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":282.88,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":420.22},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":353.6},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":353.6},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":353.6},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":545.96,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":212.16,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":495.04},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":282.88},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":288.54,"additional_payer_notes":"APC"}]}]},{"description":"Neuro alzheimer quan imaging","code_information":[{"code":"0207U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":511.2,"maximum":894.6,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":759.38},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":639.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":639.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":639.0},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":894.6},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":511.2}]}]},{"description":"Neuro inh ataxia dna 12 com","code_information":[{"code":"0216U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1152.76,"maximum":2966.45,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1537.02,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2283.2},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1921.28},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1921.28},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1921.28},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2966.45,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1152.76,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2689.79},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1537.02},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1567.76,"additional_payer_notes":"APC"}]}]},{"description":"Antibody sars-cov-2 titer(s)","code_information":[{"code":"0224U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":38.57,"maximum":99.26,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":51.43,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":76.4},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":64.29},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":64.29},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":64.29},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":99.26,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":38.57,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":90.0},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":42.13},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":52.46,"additional_payer_notes":"APC"}]}]},{"description":"Cstb full gene analysis","code_information":[{"code":"0232U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":206.12,"maximum":530.42,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":274.83,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":408.24},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":343.54},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":343.54},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":343.54},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":530.42,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":206.12,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":480.95},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":274.83},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":280.33,"additional_payer_notes":"APC"}]}]},{"description":"Nfct ds vir resp rna 3 trgt","code_information":[{"code":"0240U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":142.6,"maximum":249.6,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":211.87},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":178.29},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":178.29},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":178.29},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":249.6},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":142.6}]}]},{"description":"Onc brn sphrd cll 12 rx pnl","code_information":[{"code":"0248U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2275.4,"maximum":5855.35,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3033.86,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4492.39},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3792.33},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3792.33},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3792.33},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5855.35,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2275.4,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5309.26},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3033.86},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3094.54,"additional_payer_notes":"APC"}]}]},{"description":"Tma/tmao prfl ms/ms ur alg","code_information":[{"code":"0256U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":119.96,"maximum":308.7,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":159.95,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":236.84},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":199.94},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":199.94},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":199.94},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":308.7,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":119.96,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":279.91},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":159.95},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":163.15,"additional_payer_notes":"APC"}]}]},{"description":"Rare ds id opt genome mapg","code_information":[{"code":"0264U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":947.65,"maximum":2438.61,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1263.53,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1870.98},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1579.41},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1579.41},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1579.41},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2438.61,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":947.65,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2211.18},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1263.53},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1288.8,"additional_payer_notes":"APC"}]}]},{"description":"Hem genetic bld do 51 genes","code_information":[{"code":"0272U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":456.13,"maximum":1173.77,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":608.17,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":900.54},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":760.21},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":760.21},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":760.21},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1173.77,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":456.13,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1064.3},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":608.17},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":620.33,"additional_payer_notes":"APC"}]}]},{"description":"Hem vw factor&clgn iv bndg","code_information":[{"code":"0280U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":12.95,"maximum":33.33,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17.27,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":25.66},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21.59},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21.59},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21.59},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":33.33,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.95,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30.22},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17.27},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17.62,"additional_payer_notes":"APC"}]}]},{"description":"Onc lung mrna quan pcr 11&3","code_information":[{"code":"0288U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2904.75,"maximum":7474.89,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3873.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5734.94},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4841.25},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4841.25},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4841.25},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7474.89,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2904.75,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6777.75},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3873.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3950.46,"additional_payer_notes":"APC"}]}]},{"description":"Onc orl&/orop ca 20 mlc feat","code_information":[{"code":"0296U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1462.5,"maximum":3763.5,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1950.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2598.72},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2437.5},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2437.5},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2437.5},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3763.5,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1462.5,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3412.5},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1755.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1989.0,"additional_payer_notes":"APC"}]}]},{"description":"Hem rbc ads whl bld normoxic","code_information":[{"code":"0304U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1556.85,"maximum":4006.29,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2075.8,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3108.72},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2594.75},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2594.75},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2594.75},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4006.29,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1556.85,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3632.65},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2075.8},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2117.32,"additional_payer_notes":"APC"}]}]},{"description":"Ai ds sle alys 8 igg autoant","code_information":[{"code":"0312U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":630.49,"maximum":1622.45,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":840.65,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1244.8},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1050.81},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1050.81},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1050.81},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1622.45,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":630.49,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1471.14},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":840.65},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":857.46,"additional_payer_notes":"APC"}]}]},{"description":"Neph rna psttrnspl perph bld","code_information":[{"code":"0320U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1987.5,"maximum":5114.5,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2650.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3968.64},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3312.5},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3312.5},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3312.5},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5114.5,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1987.5,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":4637.5},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2650.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2703.0,"additional_payer_notes":"APC"}]}]},{"description":"Iadna vag pthgn panel 27 org","code_information":[{"code":"0330U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":312.58,"maximum":804.39,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":416.78,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":617.15},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":520.98},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":520.98},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":520.98},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":804.39,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":312.58,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":729.37},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":416.78},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":425.12,"additional_payer_notes":"APC"}]}]},{"description":"Onc sld tum crcg tum cl slct","code_information":[{"code":"0338U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1826.25,"maximum":4699.55,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2435.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3646.66},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3043.75},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3043.75},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3043.75},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4699.55,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1826.25,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":4261.25},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2435.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2483.7,"additional_payer_notes":"APC"}]}]},{"description":"Rx metab/pcx dna 16 gen alys","code_information":[{"code":"0347U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1002.07,"maximum":2578.65,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1336.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1978.42},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1670.11},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1670.11},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1670.11},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2578.65,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1002.07,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2338.16},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1336.09},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1362.81,"additional_payer_notes":"APC"}]}]},{"description":"Onc prst8 ca alys all psa","code_information":[{"code":"0359U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":570.0,"maximum":1466.8,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":760.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1138.18},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":950.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":950.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":950.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1466.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":570.0,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1330.0},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":760.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":775.2,"additional_payer_notes":"APC"}]}]},{"description":"Onc bldr 10 flwg trurl rescj","code_information":[{"code":"0367U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":676.64,"maximum":1741.21,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":902.18,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1351.1},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1127.73},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1127.73},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1127.73},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1741.21,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":676.64,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1578.82},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":902.18},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":920.22,"additional_payer_notes":"APC"}]}]},{"description":"Serpina1 gene","code_information":[{"code":"81332","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":32.74,"maximum":88.33,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":43.65,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":88.33},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":54.56},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":54.56},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":54.56},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":84.24,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":32.74,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":76.39},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":43.65},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":44.52,"additional_payer_notes":"APC"}]}]},{"description":"Trb@ gene rearrange amplify","code_information":[{"code":"81340","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":156.69,"maximum":422.75,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":208.92,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":422.75},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":261.15},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":261.15},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":261.15},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":403.22,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":156.69,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":365.61},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":208.92},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":213.1,"additional_payer_notes":"APC"}]}]},{"description":"Srsf2 gene common variants","code_information":[{"code":"81348","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":131.55,"maximum":338.52,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":175.4,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":260.56},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":219.25},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":219.25},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":219.25},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":338.52,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":131.55,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":306.95},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":175.4},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":178.91,"additional_payer_notes":"APC"}]}]},{"description":"Zrsr2 gene common variants","code_information":[{"code":"81360","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":144.94,"maximum":372.97,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":193.25,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":287.06},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":241.56},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":241.56},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":241.56},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":372.97,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":144.94,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":338.19},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":193.25},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":197.12,"additional_payer_notes":"APC"}]}]},{"description":"Hla i typing 1 locus lr","code_information":[{"code":"81373","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":95.57,"maximum":245.94,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":127.43,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":225.35},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":159.29},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":159.29},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":159.29},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":245.94,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":95.57,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":223.0},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":127.43},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":129.98,"additional_payer_notes":"APC"}]}]},{"description":"Hla i typing 1 allele hr","code_information":[{"code":"81381","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":127.42,"maximum":327.91,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":169.9,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":191.38},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":212.38},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":212.38},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":212.38},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":327.91,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":127.42,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":297.33},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":169.9},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":173.3,"additional_payer_notes":"APC"}]}]},{"description":"Mopath procedure level 6","code_information":[{"code":"81405","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":226.01,"maximum":581.61,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":301.35,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":447.65},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":376.69},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":376.69},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":376.69},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":581.61,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":226.01,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":527.36},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":301.35},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":307.38,"additional_payer_notes":"APC"}]}]},{"description":"Car ion chnnlpath inc 2 gns","code_information":[{"code":"81414","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":438.68,"maximum":1191.84,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":584.9,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1191.84},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":731.13},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":731.13},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":731.13},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1128.86,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":438.68,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1023.58},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":584.9},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":596.6,"additional_payer_notes":"APC"}]}]},{"description":"Genome sequence analysis","code_information":[{"code":"81425","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3773.4,"maximum":9710.22,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5031.2,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7473.7},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":6289.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":6289.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":6289.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":9710.22,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3773.4,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8804.6},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5031.2},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5131.82,"additional_payer_notes":"APC"}]}]},{"description":"Hereditary colon ca dsordrs","code_information":[{"code":"81435","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":584.9,"maximum":2516.62,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1303.95,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1183.55},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1629.94},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1629.94},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1629.94},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2516.62,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":977.96,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2281.91},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":584.9},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1330.03,"additional_payer_notes":"APC"}]}]},{"description":"Genetic tstg severe inh cond","code_information":[{"code":"81443","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1836.42,"maximum":4725.72,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2448.56,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3637.26},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3060.7},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3060.7},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3060.7},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4725.72,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1836.42,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":4284.98},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2448.56},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2497.53,"additional_payer_notes":"APC"}]}]},{"description":"So neo gsap dna mcrstl ins","code_information":[{"code":"81457","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":672.65,"maximum":1730.96,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":896.87,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1291.49},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1121.09},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1121.09},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1121.09},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1730.96,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":672.65,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1569.52},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":896.87},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":914.81,"additional_payer_notes":"APC"}]}]},{"description":"X-linked intellectual dblt","code_information":[{"code":"81470","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":685.5,"maximum":1764.02,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":914.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1357.73},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1142.5},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1142.5},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1142.5},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1764.02,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":685.5,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1599.5},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":914.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":932.28,"additional_payer_notes":"APC"}]}]},{"description":"Fetal aneuploidy trisom risk","code_information":[{"code":"81507","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":596.25,"maximum":1534.35,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":795.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1180.94},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":993.75},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":993.75},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":993.75},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1534.35,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":596.25,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1391.25},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":795.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":810.9,"additional_payer_notes":"APC"}]}]},{"description":"Nfct ds bv&vaginitis dna alg","code_information":[{"code":"81515","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":197.24,"maximum":507.57,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":262.99,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":378.71},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":328.74},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":328.74},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":328.74},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":507.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":197.24,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":460.23},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":262.99},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":268.25,"additional_payer_notes":"APC"}]}]},{"description":"Oncology colon mrna","code_information":[{"code":"81525","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2337.0,"maximum":6013.88,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3116.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4643.18},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3895.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3895.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3895.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6013.88,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2337.0,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5453.0},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3116.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3178.32,"additional_payer_notes":"APC"}]}]},{"description":"Onc prostate mrna 46 genes","code_information":[{"code":"81541","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2904.75,"maximum":7474.89,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3873.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5753.22},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4841.25},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4841.25},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4841.25},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7474.89,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2904.75,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6777.75},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3873.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3950.46,"additional_payer_notes":"APC"}]}]},{"description":"Cardiology hrt trnspl mrna","code_information":[{"code":"81595","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2430.0,"maximum":6253.2,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3240.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4219.84},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4050.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4050.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4050.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6253.2,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2430.0,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5670.0},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3240.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3304.8,"additional_payer_notes":"APC"}]}]},{"description":"Assay of adp & amp","code_information":[{"code":"82030","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":19.35,"maximum":52.2,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25.8,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":52.2},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":32.25},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":32.25},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":32.25},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":49.79,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19.35,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":45.15},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25.8},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26.32,"additional_payer_notes":"APC"}]}]},{"description":"Antiepileptics nos 1-3","code_information":[{"code":"80339","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":35.06,"maximum":35.06,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":35.06}]}]},{"description":"Gabapentin non-blood","code_information":[{"code":"80355","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":35.06,"maximum":35.06,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":35.06}]}]},{"description":"Drug screening oxycodone","code_information":[{"code":"80365","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":35.06,"maximum":35.06,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":35.06}]}]},{"description":"Stereoisomer analysis","code_information":[{"code":"80374","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":35.06,"maximum":35.06,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":35.06}]}]},{"description":"Urinalysis auto w/scope","code_information":[{"code":"81001","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2.38,"maximum":6.41,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3.17,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6.41},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3.96},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3.96},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3.96},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6.12,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2.38,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5.55},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3.17},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3.23,"additional_payer_notes":"APC"}]}]},{"description":"Urinalysis volume measure","code_information":[{"code":"81050","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2.73,"maximum":7.03,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3.64,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6.06},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4.55},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4.55},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4.55},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7.03,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2.73,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6.37},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3.64},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3.71,"additional_payer_notes":"APC"}]}]},{"description":"Hpa-15 genotyping","code_information":[{"code":"81112","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":91.66,"maximum":235.88,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":122.22,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":224.14},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":152.78},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":152.78},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":152.78},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":235.88,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":91.66,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":213.89},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":122.22},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":124.66,"additional_payer_notes":"APC"}]}]},{"description":"Brca1 gene full dup/del alys","code_information":[{"code":"81166","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":226.01,"maximum":581.61,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":301.35,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":447.65},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":376.69},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":376.69},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":376.69},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":581.61,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":226.01,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":527.36},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":301.35},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":307.38,"additional_payer_notes":"APC"}]}]},{"description":"Asxl1 full gene sequence","code_information":[{"code":"81175","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":507.38,"maximum":1305.64,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":676.5,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1050.25},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":845.63},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":845.63},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":845.63},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1305.64,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":507.38,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1183.88},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":676.5},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":690.03,"additional_payer_notes":"APC"}]}]},{"description":"Atxn10 gene detc abnor allel","code_information":[{"code":"81183","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":102.75,"maximum":264.41,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":137.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":203.51},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":171.25},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":171.25},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":171.25},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":264.41,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":102.75,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":239.75},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":137.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":139.74,"additional_payer_notes":"APC"}]}]},{"description":"Ntrk1 translocation analysis","code_information":[{"code":"81191","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":155.48,"maximum":400.11,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":207.31,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":307.94},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":259.14},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":259.14},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":259.14},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":400.11,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":155.48,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":362.79},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":207.31},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":211.46,"additional_payer_notes":"APC"}]}]},{"description":"Apc gene dup/delet variants","code_information":[{"code":"81203","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":150.0,"maximum":386.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":200.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":297.1},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":250.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":250.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":250.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":386.0,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":150.0,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":350.0},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":200.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":204.0,"additional_payer_notes":"APC"}]}]},{"description":"Brca1&2 185&5385&6174 var","code_information":[{"code":"81212","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":262.1,"maximum":849.2,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":440.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":262.1},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":550.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":550.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":550.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":849.2,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":330.0,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":770.0},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":440.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":448.8,"additional_payer_notes":"APC"}]}]},{"description":"Cftr gene dup/delet variants","code_information":[{"code":"81222","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":326.3,"maximum":839.69,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":435.07,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":646.27},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":543.84},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":543.84},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":543.84},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":839.69,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":326.3,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":761.37},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":435.07},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":443.77,"additional_payer_notes":"APC"}]}]},{"description":"Cyp3a4 gene common variants","code_information":[{"code":"81230","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":131.11,"maximum":337.38,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":174.81,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":259.67},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":218.51},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":218.51},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":218.51},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":337.38,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":131.11,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":305.92},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":174.81},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":178.31,"additional_payer_notes":"APC"}]}]},{"description":"F9 full gene sequence","code_information":[{"code":"81238","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":450.0,"maximum":1158.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":600.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":891.29},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":750.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":750.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":750.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1158.0,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":450.0,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1050.0},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":600.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":612.0,"additional_payer_notes":"APC"}]}]},{"description":"Flt3 gene analysis","code_information":[{"code":"81246","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":62.25,"maximum":160.19,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":83.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":123.35},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":103.75},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":103.75},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":103.75},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":160.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":62.25,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":145.25},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":83.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":84.66,"additional_payer_notes":"APC"}]}]},{"description":"Gjb6 gene com variants","code_information":[{"code":"81254","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":26.25,"maximum":67.55,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":35.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":52.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43.75},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43.75},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43.75},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":67.55,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26.25,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":61.25},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":35.7,"additional_payer_notes":"APC"}]}]},{"description":"Igh gene rearrang dir probe","code_information":[{"code":"81262","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":51.41,"maximum":132.3,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":68.55,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":88.33},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":85.69},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":85.69},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":85.69},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":132.3,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":51.41,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":119.96},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":68.55},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":69.92,"additional_payer_notes":"APC"}]}]},{"description":"Jak2 gene","code_information":[{"code":"81270","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":68.74,"maximum":185.5,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":91.66,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":185.5},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":114.58},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":114.58},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":114.58},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":176.9,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":68.74,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":160.41},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":91.66},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":93.49,"additional_payer_notes":"APC"}]}]},{"description":"Igh@/bcl2 translocation alys","code_information":[{"code":"81278","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":155.48,"maximum":400.11,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":207.31,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":307.94},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":259.14},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":259.14},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":259.14},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":400.11,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":155.48,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":362.79},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":207.31},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":211.46,"additional_payer_notes":"APC"}]}]},{"description":"Fxn gene known famil variant","code_information":[{"code":"81289","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":138.9,"maximum":357.44,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":185.2,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":275.11},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":231.5},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":231.5},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":231.5},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":357.44,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":138.9,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":324.1},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":185.2},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":188.9,"additional_payer_notes":"APC"}]}]},{"description":"Msh2 gene dup/delete variant","code_information":[{"code":"81297","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":159.98,"maximum":411.67,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":213.3,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":225.02},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":266.63},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":266.63},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":266.63},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":411.67,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":159.98,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":373.28},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":213.3},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":217.57,"additional_payer_notes":"APC"}]}]},{"description":"Myd88 gene p.leu265pro vrnt","code_information":[{"code":"81305","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":131.55,"maximum":338.52,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":175.4,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":260.56},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":219.25},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":219.25},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":219.25},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":338.52,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":131.55,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":306.95},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":175.4},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":178.91,"additional_payer_notes":"APC"}]}]},{"description":"Pca3/klk3 antigen","code_information":[{"code":"81313","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":191.29,"maximum":492.25,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":255.05,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":386.6},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":318.81},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":318.81},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":318.81},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":492.25,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":191.29,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":446.34},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":255.05},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":260.15,"additional_payer_notes":"APC"}]}]},{"description":"Pten gene full sequence","code_information":[{"code":"81321","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":450.0,"maximum":1158.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":600.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":890.99},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":750.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":750.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":750.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1158.0,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":450.0,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1050.0},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":600.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":612.0,"additional_payer_notes":"APC"}]}]},{"description":"Liver surgery procedure","code_information":[{"code":"47399","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":525.32,"maximum":13249.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":700.42,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":13249.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":10779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":13249.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1351.81,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":525.32,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":714.43,"additional_payer_notes":"APC"}]}]},{"description":"Plmt ureteral stent prq","code_information":[{"code":"50695","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2614.94,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3486.59,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6729.12,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2614.94,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3556.32,"additional_payer_notes":"APC"}]}]},{"description":"Repair of eye wound","code_information":[{"code":"65275","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2916.44,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3888.58,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7504.96,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2916.44,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3966.35,"additional_payer_notes":"APC"}]}]},{"description":"Removal of eye lesion","code_information":[{"code":"65426","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1763.69,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2351.59,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4538.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1763.69,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2398.62,"additional_payer_notes":"APC"}]}]},{"description":"Corneal transplant","code_information":[{"code":"65750","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3947.51,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5263.35,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":10158.27,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3947.51,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5368.62,"additional_payer_notes":"APC"}]}]},{"description":"Radial keratotomy","code_information":[{"code":"65771","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0}]}]},{"description":"Impltj ntrstrml crnl rng seg","code_information":[{"code":"65785","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3066.31,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4088.41,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7890.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3066.31,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4170.17,"additional_payer_notes":"APC"}]}]},{"description":"Incise inner eye adhesions","code_information":[{"code":"65865","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1712.02,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2282.69,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4405.59,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1712.02,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2328.34,"additional_payer_notes":"APC"}]}]},{"description":"Injection treatment of eye","code_information":[{"code":"66030","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1712.02,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2282.69,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4405.59,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1712.02,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2328.34,"additional_payer_notes":"APC"}]}]},{"description":"Trnslum dil eye canal w/stnt","code_information":[{"code":"66175","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3947.51,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5263.35,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":10158.27,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3947.51,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5368.62,"additional_payer_notes":"APC"}]}]},{"description":"Incision of iris","code_information":[{"code":"66500","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1712.02,"maximum":4405.59,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2282.69,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4405.59,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1712.02,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2328.34,"additional_payer_notes":"APC"}]}]},{"description":"Repair iris & ciliary body","code_information":[{"code":"66682","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1712.02,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2282.69,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4405.59,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1712.02,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2328.34,"additional_payer_notes":"APC"}]}]},{"description":"Removal of inner eye lesion","code_information":[{"code":"66770","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":408.01,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":544.01,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1049.93,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":408.01,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":554.89,"additional_payer_notes":"APC"}]}]},{"description":"Extraction of lens","code_information":[{"code":"66920","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1712.02,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2282.69,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4405.59,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1712.02,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2328.34,"additional_payer_notes":"APC"}]}]},{"description":"Incise & treat bladder","code_information":[{"code":"51030","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7529.0,"maximum":7791.0,"payers_information":[{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0}]}]},{"description":"Dilate urethra stricture","code_information":[{"code":"53600","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":185.35,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":247.13,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":476.96,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":185.35,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":252.07,"additional_payer_notes":"APC"}]}]},{"description":"Prostatic microwave thermotx","code_information":[{"code":"53850","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2614.94,"maximum":6729.12,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3486.59,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6729.12,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2614.94,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3556.32,"additional_payer_notes":"APC"}]}]},{"description":"Onc ovrn bchm asy 7 prtn alg","code_information":[{"code":"0375U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":672.75,"maximum":1731.21,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":897.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1343.35},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1121.25},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1121.25},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1121.25},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1731.21,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":672.75,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1569.75},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":897.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":914.94,"additional_payer_notes":"APC"}]}]},{"description":"Neph ckd rsk hi stg kdn ds","code_information":[{"code":"0384U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":562.5,"maximum":1447.5,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":750.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1123.2},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":937.5},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":937.5},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":937.5},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1447.5,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":562.5,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1312.5},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":750.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":765.0,"additional_payer_notes":"APC"}]}]},{"description":"Neu prksn msfl ?-syncln prtn","code_information":[{"code":"0393U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":405.74,"maximum":1044.11,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":540.99,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":810.19},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":676.24},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":676.24},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":676.24},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1044.11,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":405.74,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":946.73},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":540.99},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":551.81,"additional_payer_notes":"APC"}]}]},{"description":"Onc prst8 mrna 18 gen dre ur","code_information":[{"code":"0403U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":570.0,"maximum":1466.8,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":760.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1138.18},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":950.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":950.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":950.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1466.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":570.0,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1330.0},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":760.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":775.2,"additional_payer_notes":"APC"}]}]},{"description":"Psyc genom alys pnl 15 gen","code_information":[{"code":"0411U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1002.07,"maximum":2578.65,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1336.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2000.93},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1670.11},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1670.11},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1670.11},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2578.65,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1002.07,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2338.16},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1336.09},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1362.81,"additional_payer_notes":"APC"}]}]},{"description":"Hpv orop swab 14 hi-risk typ","code_information":[{"code":"0429U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":26.32,"maximum":67.72,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":35.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":50.53},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43.86},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43.86},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43.86},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":67.72,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26.32,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":61.41},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35.09},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":35.79,"additional_payer_notes":"APC"}]}]},{"description":"Psyc anxiety do mrna 15 bmrk","code_information":[{"code":"0437U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":570.0,"maximum":1466.8,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":760.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1094.4},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":950.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":950.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":950.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1466.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":570.0,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1330.0},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":760.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":775.2,"additional_payer_notes":"APC"}]}]},{"description":"Abeta42 & ptau181 eclia csf","code_information":[{"code":"0445U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":195.38,"maximum":502.76,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":260.5,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":375.12},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":325.63},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":325.63},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":325.63},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":502.76,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":195.38,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":455.88},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":260.5},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":265.71,"additional_payer_notes":"APC"}]}]},{"description":"U rare ds id opt genome mapg","code_information":[{"code":"0454U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":947.65,"maximum":2438.61,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1263.53,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1819.49},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1579.41},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1579.41},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1579.41},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2438.61,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":947.65,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2211.18},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1263.53},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1288.8,"additional_payer_notes":"APC"}]}]},{"description":"Onc clrc ca 35 vrn kras&nras","code_information":[{"code":"0471U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":570.0,"maximum":1466.8,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":760.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1094.4},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":950.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":950.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":950.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1466.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":570.0,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1330.0},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":760.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":775.2,"additional_payer_notes":"APC"}]}]},{"description":"Tau phosphorylated ptau217","code_information":[{"code":"0479U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":12.95,"maximum":33.33,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17.27,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":24.86},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21.59},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21.59},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21.59},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":33.33,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.95,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30.22},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17.27},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17.62,"additional_payer_notes":"APC"}]}]},{"description":"Onc sol tum cfcdna tgsap 84","code_information":[{"code":"0487U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2189.7,"maximum":5634.83,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2919.6,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4204.22},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3649.5},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3649.5},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3649.5},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5634.83,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2189.7,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5109.3},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2919.6},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2977.99,"additional_payer_notes":"APC"}]}]},{"description":"Onc prst8 alys crcg plsm prt","code_information":[{"code":"0495U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":570.0,"maximum":1466.8,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":760.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1094.4},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":950.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":950.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":950.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1466.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":570.0,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1330.0},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":760.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":775.2,"additional_payer_notes":"APC"}]}]},{"description":"Neuro alz ds ?amyl&tau prtn","code_information":[{"code":"0503U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":562.5,"maximum":1447.5,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":750.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1080.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":937.5},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":937.5},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":937.5},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1447.5,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":562.5,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1312.5},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":750.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":765.0,"additional_payer_notes":"APC"}]}]},{"description":"Onc sol tum 3dmicroenvir 36+","code_information":[{"code":"0511U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2275.4,"maximum":5855.35,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3033.86,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4368.76},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3792.33},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3792.33},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3792.33},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5855.35,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2275.4,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5309.26},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3033.86},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3094.54,"additional_payer_notes":"APC"}]}]},{"description":"Ther rx mntr meds p/d/a 110+","code_information":[{"code":"0519U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":185.19,"maximum":476.56,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":246.92,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":355.56},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":308.65},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":308.65},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":308.65},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":476.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":185.19,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":432.11},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":246.92},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":251.86,"additional_payer_notes":"APC"}]}]},{"description":"Acth stimulation panel","code_information":[{"code":"80400","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":24.46,"maximum":66.01,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":32.62,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":66.01},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":40.78},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":40.78},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":40.78},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":62.96,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":24.46,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":57.09},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32.62},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":33.27,"additional_payer_notes":"APC"}]}]},{"description":"Renin stimulation panel","code_information":[{"code":"80416","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":156.99,"maximum":403.99,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":209.32,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":267.04},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":261.65},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":261.65},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":261.65},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":403.99,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":156.99,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":366.31},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":209.32},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":213.51,"additional_payer_notes":"APC"}]}]},{"description":"Growth hormone panel","code_information":[{"code":"80430","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":97.0,"maximum":249.61,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":129.33,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":158.82},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":161.66},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":161.66},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":161.66},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":249.61,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":97.0,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":226.33},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":129.33},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":131.92,"additional_payer_notes":"APC"}]}]},{"description":"Assay of aldolase","code_information":[{"code":"82085","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7.28,"maximum":19.64,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9.71,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":19.64},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12.14},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12.14},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12.14},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":18.74,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7.28,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16.99},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9.71},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9.9,"additional_payer_notes":"APC"}]}]},{"description":"Amines vaginal fluid qual","code_information":[{"code":"82120","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4.49,"maximum":11.56,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5.99,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7.62},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7.49},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7.49},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7.49},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4.49,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10.48},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5.99},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6.11,"additional_payer_notes":"APC"}]}]},{"description":"Amniotic fluid scan","code_information":[{"code":"82143","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7.01,"maximum":18.05,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9.35,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":13.87},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11.69},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11.69},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11.69},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":18.05,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7.01,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16.36},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9.35},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9.54,"additional_payer_notes":"APC"}]}]},{"description":"Assay of apolipoprotein","code_information":[{"code":"82172","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":15.82,"maximum":40.7,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":31.37},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26.36},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26.36},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26.36},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":40.7,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15.82,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36.91},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21.09},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21.51,"additional_payer_notes":"APC"}]}]},{"description":"Bile acids cholylglycine","code_information":[{"code":"82240","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":19.94,"maximum":53.78,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26.58,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":53.78},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":33.23},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":33.23},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":33.23},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":51.3,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19.94,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":46.52},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26.58},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27.11,"additional_payer_notes":"APC"}]}]},{"description":"Assay test for blood fecal","code_information":[{"code":"82274","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":11.94,"maximum":32.2,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15.92,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":32.2},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19.9},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19.9},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19.9},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":30.73,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11.94,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27.86},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15.92},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16.24,"additional_payer_notes":"APC"}]}]},{"description":"Assay of calcium in urine","code_information":[{"code":"82340","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4.52,"maximum":12.2,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6.03,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":12.2},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7.54},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7.54},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7.54},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11.64,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4.52,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10.55},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6.03},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6.15,"additional_payer_notes":"APC"}]}]},{"description":"Assay carboxyhb qual","code_information":[{"code":"82376","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":10.55,"maximum":27.16,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14.07,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":12.12},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17.59},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17.59},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17.59},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":27.16,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10.55,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24.62},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14.07},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14.35,"additional_payer_notes":"APC"}]}]},{"description":"Assay of ceruloplasmin","code_information":[{"code":"82390","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8.06,"maximum":21.74,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10.74,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":21.74},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13.43},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13.43},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13.43},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":20.73,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8.06,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18.8},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10.74},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10.95,"additional_payer_notes":"APC"}]}]},{"description":"Assay serum cholinesterase","code_information":[{"code":"82480","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5.9,"maximum":15.94,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7.87,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":15.94},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":9.84},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":9.84},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":9.84},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":15.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5.9,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13.77},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7.87},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8.03,"additional_payer_notes":"APC"}]}]},{"description":"Cortisol free","code_information":[{"code":"82530","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":12.53,"maximum":33.8,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16.71,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":33.8},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20.89},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20.89},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20.89},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":32.25,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.53,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29.24},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16.71},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17.04,"additional_payer_notes":"APC"}]}]},{"description":"Assay of creatinine","code_information":[{"code":"82565","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3.84,"maximum":10.37,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5.12,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":10.37},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":6.4},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":6.4},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":6.4},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":9.88,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3.84,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8.96},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5.12},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5.22,"additional_payer_notes":"APC"}]}]},{"description":"Cystatin c","code_information":[{"code":"82610","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":13.89,"maximum":35.74,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18.52,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":27.5},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23.15},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23.15},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23.15},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":35.74,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.89,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32.41},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18.52},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18.89,"additional_payer_notes":"APC"}]}]},{"description":"Vit d 1 25-dihydroxy","code_information":[{"code":"82652","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":28.88,"maximum":77.9,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":38.5,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":77.9},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":48.13},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":48.13},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":48.13},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":74.3,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":28.88,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":67.38},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38.5},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":39.27,"additional_payer_notes":"APC"}]}]},{"description":"Assay of estrogens","code_information":[{"code":"82671","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":24.22,"maximum":65.35,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":32.3,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":65.35},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":40.38},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":40.38},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":40.38},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":62.34,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":24.22,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":56.53},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32.3},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":32.95,"additional_payer_notes":"APC"}]}]},{"description":"Fats/lipids feces quant","code_information":[{"code":"82710","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":12.6,"maximum":34.01,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16.8,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":34.01},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":32.42,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.6,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29.4},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16.8},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17.14,"additional_payer_notes":"APC"}]}]},{"description":"Assay of folic acid rbc","code_information":[{"code":"82747","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":13.24,"maximum":34.06,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17.65,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":23.54},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22.06},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22.06},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22.06},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":34.06,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.24,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30.89},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17.65},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18.0,"additional_payer_notes":"APC"}]}]},{"description":"Assay of ige","code_information":[{"code":"82785","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":12.34,"maximum":33.32,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16.46,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":33.32},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20.58},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20.58},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20.58},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":31.77,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.34,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28.81},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16.46},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16.79,"additional_payer_notes":"APC"}]}]},{"description":"Gastrin test","code_information":[{"code":"82938","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":13.27,"maximum":35.81,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17.69,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":35.81},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22.11},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22.11},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22.11},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":34.14,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.27,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30.96},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17.69},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18.04,"additional_payer_notes":"APC"}]}]},{"description":"Glucose tolerance test (GTT)","code_information":[{"code":"82951","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":9.65,"maximum":26.03,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.87,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":26.03},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16.09},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16.09},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16.09},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":24.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9.65,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22.52},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12.87},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.13,"additional_payer_notes":"APC"}]}]},{"description":"Assay of glutathione","code_information":[{"code":"82978","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":11.59,"maximum":29.82,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15.45,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":28.85},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19.31},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19.31},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19.31},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":29.82,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11.59,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27.04},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15.45},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15.76,"additional_payer_notes":"APC"}]}]},{"description":"Assay of haptoglobin quant","code_information":[{"code":"83010","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":9.44,"maximum":25.45,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.58,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":25.45},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15.73},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15.73},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15.73},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":24.28,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9.44,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22.02},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12.58},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.83,"additional_payer_notes":"APC"}]}]},{"description":"Hemoglobin copper sulfate","code_information":[{"code":"83026","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3.01,"maximum":7.74,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4.01,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4.78},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5.01},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5.01},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5.01},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7.74,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3.01,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7.02},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":4.01},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4.09,"additional_payer_notes":"APC"}]}]},{"description":"Blood sulfhemoglobin assay","code_information":[{"code":"83060","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6.6,"maximum":16.98,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8.8,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":16.73},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":16.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6.6,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15.4},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8.8},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8.98,"additional_payer_notes":"APC"}]}]},{"description":"Assay of homovanillic acid","code_information":[{"code":"83150","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":16.81,"maximum":43.25,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22.41,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":28.25},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28.01},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28.01},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28.01},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":43.25,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16.81,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":39.22},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22.41},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22.86,"additional_payer_notes":"APC"}]}]},{"description":"Ria nonantibody","code_information":[{"code":"83519","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":13.8,"maximum":35.51,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18.4,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":27.34},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":35.51,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.8,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32.2},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18.4},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18.77,"additional_payer_notes":"APC"}]}]},{"description":"Iron binding test","code_information":[{"code":"83550","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6.56,"maximum":17.71,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8.74,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":17.71},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10.93},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10.93},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10.93},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":16.87,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6.56,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15.3},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8.74},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8.91,"additional_payer_notes":"APC"}]}]},{"description":"Lactoferrin fecal (qual)","code_information":[{"code":"83630","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":14.78,"maximum":39.72,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19.7,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":39.72},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24.63},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24.63},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24.63},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":38.02,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14.78,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34.48},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19.7},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20.09,"additional_payer_notes":"APC"}]}]},{"description":"Lamellar bdy fetal lung","code_information":[{"code":"83664","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":14.49,"maximum":38.27,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19.32,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":38.27},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24.15},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24.15},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24.15},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":37.29,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14.49,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33.81},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19.32},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19.71,"additional_payer_notes":"APC"}]}]},{"description":"Assay of lipoprotein","code_information":[{"code":"83718","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6.14,"maximum":16.57,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":16.57},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10.24},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10.24},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10.24},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":15.81,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6.14,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14.33},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8.19},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8.35,"additional_payer_notes":"APC"}]}]},{"description":"Mass spectrometry qual/quan","code_information":[{"code":"83789","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":18.08,"maximum":46.53,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":24.11,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":36.53},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":30.14},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":30.14},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":30.14},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":46.53,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18.08,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":42.19},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24.11},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":24.59,"additional_payer_notes":"APC"}]}]},{"description":"Assay of myoglobin","code_information":[{"code":"83874","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":9.69,"maximum":26.14,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.92,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":26.14},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16.15},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16.15},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16.15},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":24.94,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9.69,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22.61},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12.92},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.18,"additional_payer_notes":"APC"}]}]},{"description":"Organic acids total quant","code_information":[{"code":"83918","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":17.7,"maximum":45.55,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23.6,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":33.3},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":29.5},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":29.5},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":29.5},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":45.55,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17.7,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":41.3},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23.6},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":24.07,"additional_payer_notes":"APC"}]}]},{"description":"Oncoprotein dcp","code_information":[{"code":"83951","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":48.31,"maximum":130.33,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":64.41,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":130.33},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":80.51},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":80.51},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":80.51},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":124.31,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":48.31,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":112.72},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":64.41},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":65.7,"additional_payer_notes":"APC"}]}]},{"description":"Assay prostate phosphatase","code_information":[{"code":"84066","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7.24,"maximum":19.56,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9.66,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":19.56},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12.08},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12.08},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12.08},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":18.64,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7.24,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16.91},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9.66},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9.85,"additional_payer_notes":"APC"}]}]},{"description":"Removal of ureter stone","code_information":[{"code":"51060","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1550.71,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2067.62,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3990.5,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1550.71,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2108.97,"additional_payer_notes":"APC"}]}]},{"description":"Removal of bladder lesion","code_information":[{"code":"51525","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0}]}]},{"description":"Cystoscopy & ureter catheter","code_information":[{"code":"52005","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1550.71,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2067.62,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3990.5,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1550.71,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2108.97,"additional_payer_notes":"APC"}]}]},{"description":"Cystoscopy and treatment","code_information":[{"code":"52240","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3977.55,"maximum":10235.57,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5303.4,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":10235.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3977.55,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5409.47,"additional_payer_notes":"APC"}]}]},{"description":"Cystoscopy and treatment","code_information":[{"code":"52281","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1550.71,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2067.62,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3990.5,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1550.71,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2108.97,"additional_payer_notes":"APC"}]}]},{"description":"Cystoscopy and treatment","code_information":[{"code":"52305","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3977.55,"maximum":10235.57,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5303.4,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":10235.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3977.55,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5409.47,"additional_payer_notes":"APC"}]}]},{"description":"Cystoscopy and treatment","code_information":[{"code":"52330","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2614.94,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3486.59,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6729.12,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2614.94,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3556.32,"additional_payer_notes":"APC"}]}]},{"description":"Cystouretero W/Renal Strict","code_information":[{"code":"52346","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3977.55,"maximum":10235.57,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5303.4,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":10235.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3977.55,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5409.47,"additional_payer_notes":"APC"}]}]},{"description":"Cystourethro cut ejacul duct","code_information":[{"code":"52402","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2614.94,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3486.59,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6729.12,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2614.94,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3556.32,"additional_payer_notes":"APC"}]}]},{"description":"Laser surgery of prostate","code_information":[{"code":"52647","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0}]}]},{"description":"Drainage of urethra abscess","code_information":[{"code":"53040","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2614.94,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3486.59,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6729.12,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2614.94,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3556.32,"additional_payer_notes":"APC"}]}]},{"description":"Removal of urethra lesion","code_information":[{"code":"53230","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3977.55,"maximum":10235.57,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5303.4,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":10235.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3977.55,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5409.47,"additional_payer_notes":"APC"}]}]},{"description":"Revise urethra stage 1","code_information":[{"code":"53400","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3977.55,"maximum":10235.57,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5303.4,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":10235.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3977.55,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5409.47,"additional_payer_notes":"APC"}]}]},{"description":"Male sling procedure","code_information":[{"code":"53440","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":27583.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13049.77,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":25186.06,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9787.33,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":27583.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13310.77,"additional_payer_notes":"APC"}]}]},{"description":"Revision of urethra","code_information":[{"code":"53450","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2614.94,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3486.59,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6729.12,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2614.94,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3556.32,"additional_payer_notes":"APC"}]}]},{"description":"Assay of urine phosphorus","code_information":[{"code":"84105","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4.34,"maximum":11.16,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5.78,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":10.48},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7.23},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7.23},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7.23},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11.16,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4.34,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10.12},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5.78},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5.9,"additional_payer_notes":"APC"}]}]},{"description":"Assay of urine potassium","code_information":[{"code":"84133","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3.55,"maximum":9.13,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4.73,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":8.7},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5.91},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5.91},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5.91},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":9.13,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3.55,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8.28},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":4.73},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4.82,"additional_payer_notes":"APC"}]}]},{"description":"Assay of prolactin","code_information":[{"code":"84146","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":14.54,"maximum":39.23,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19.38,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":39.23},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24.23},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24.23},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24.23},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":37.4,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14.54,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33.92},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19.38},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19.77,"additional_payer_notes":"APC"}]}]},{"description":"Assay of protein any source","code_information":[{"code":"84160","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4.21,"maximum":10.83,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5.61,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":8.11},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7.01},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7.01},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7.01},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":10.83,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4.21,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9.82},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5.61},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5.72,"additional_payer_notes":"APC"}]}]},{"description":"Assay of proinsulin","code_information":[{"code":"84206","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":20.02,"maximum":51.51,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26.69,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":36.05},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":33.36},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":33.36},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":33.36},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":51.51,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20.02,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":46.71},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26.69},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27.22,"additional_payer_notes":"APC"}]}]},{"description":"Assay nonendocrine receptor","code_information":[{"code":"84238","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":27.43,"maximum":73.99,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":36.57,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":73.99},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":45.71},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":45.71},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":45.71},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":70.58,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27.43,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":64.0},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36.57},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":37.3,"additional_payer_notes":"APC"}]}]},{"description":"Assay of serum sodium","code_information":[{"code":"84295","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3.61,"maximum":9.73,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4.81,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":9.73},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":6.01},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":6.01},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":6.01},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":9.28,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3.61,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8.42},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":4.81},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4.91,"additional_payer_notes":"APC"}]}]},{"description":"Sugars single qual","code_information":[{"code":"84376","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4.12,"maximum":11.12,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5.5,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":11.12},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":6.88},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":6.88},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":6.88},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":10.62,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4.12,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9.63},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5.5},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5.61,"additional_payer_notes":"APC"}]}]},{"description":"Assay of total testosterone","code_information":[{"code":"84403","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":19.36,"maximum":50.99,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25.81,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":50.99},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":32.26},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":32.26},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":32.26},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":49.81,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19.36,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":45.17},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25.81},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26.33,"additional_payer_notes":"APC"}]}]},{"description":"Assay of neonatal thyroxine","code_information":[{"code":"84437","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4.85,"maximum":13.08,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6.47,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":13.08},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8.09},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8.09},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8.09},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":12.49,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4.85,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11.32},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6.47},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6.6,"additional_payer_notes":"APC"}]}]},{"description":"Alanine amino (ALT) (SGPT)","code_information":[{"code":"84460","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3.98,"maximum":10.73,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5.3,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":10.73},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":6.63},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":6.63},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":6.63},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":10.23,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3.98,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9.28},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5.3},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5.41,"additional_payer_notes":"APC"}]}]},{"description":"Assay duodenal fluid trypsin","code_information":[{"code":"84485","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5.4,"maximum":15.2,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7.2,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":15.2},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":9.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":9.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":9.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13.9,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5.4,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12.6},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7.2},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7.34,"additional_payer_notes":"APC"}]}]},{"description":"Urea-N clearance test","code_information":[{"code":"84545","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5.4,"maximum":13.9,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7.2,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":13.37},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":9.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":9.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":9.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13.9,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5.4,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12.6},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7.2},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7.34,"additional_payer_notes":"APC"}]}]},{"description":"Assay of vip","code_information":[{"code":"84586","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":25.8,"maximum":68.19,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":35.33,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":25.8},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":44.16},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":44.16},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":44.16},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":68.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26.5,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":61.83},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35.33},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":36.04,"additional_payer_notes":"APC"}]}]},{"description":"Assay of c-peptide","code_information":[{"code":"84681","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":10.56,"maximum":40.16,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20.81,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":10.56},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26.01},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26.01},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26.01},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":40.16,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15.61,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36.42},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20.81},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21.23,"additional_payer_notes":"APC"}]}]},{"description":"Bl smear w/o diff wbc count","code_information":[{"code":"85008","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2.57,"maximum":6.96,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3.43,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6.96},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4.29},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4.29},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4.29},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6.62,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2.57,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6.0},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3.43},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3.5,"additional_payer_notes":"APC"}]}]},{"description":"Automated rbc count","code_information":[{"code":"85041","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2.26,"maximum":6.1,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3.02,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6.1},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3.78},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3.78},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3.78},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5.83,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2.26,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5.29},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3.02},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3.08,"additional_payer_notes":"APC"}]}]},{"description":"Blood clot retraction","code_information":[{"code":"85170","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7.32,"maximum":31.46,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16.3,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7.32},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20.38},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20.38},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20.38},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":31.46,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.22,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28.53},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16.3},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16.63,"additional_payer_notes":"APC"}]}]},{"description":"Clot factor viii vw antigen","code_information":[{"code":"85246","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":17.2,"maximum":46.43,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22.94,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":46.43},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28.68},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28.68},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28.68},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":44.27,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17.2,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":40.15},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22.94},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23.4,"additional_payer_notes":"APC"}]}]},{"description":"Clot factor fletcher fact","code_information":[{"code":"85292","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":14.2,"maximum":38.32,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18.93,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":38.32},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23.66},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23.66},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23.66},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":36.53,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14.2,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33.13},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18.93},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19.31,"additional_payer_notes":"APC"}]}]},{"description":"Assay Activated Protein C","code_information":[{"code":"85307","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":11.49,"maximum":29.57,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15.32,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":28.91},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19.15},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19.15},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19.15},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":29.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11.49,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26.81},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15.32},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15.63,"additional_payer_notes":"APC"}]}]},{"description":"Fibrinogen test","code_information":[{"code":"85366","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":17.45,"maximum":155.29,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":80.46,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":17.45},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":100.58},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":100.58},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":100.58},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":155.29,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":60.34,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":140.81},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":80.46},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":82.07,"additional_payer_notes":"APC"}]}]},{"description":"Clotting funct activity","code_information":[{"code":"85397","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":23.14,"maximum":59.56,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":30.86,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":46.43},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":38.58},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":38.58},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":38.58},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":59.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23.14,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":54.01},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30.86},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":31.48,"additional_payer_notes":"APC"}]}]},{"description":"Hemoglobin fetal","code_information":[{"code":"85460","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5.8,"maximum":15.66,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7.73,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":15.66},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":9.66},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":9.66},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":9.66},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":14.92,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5.8,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13.53},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7.73},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7.88,"additional_payer_notes":"APC"}]}]},{"description":"RBC mechanical fragility","code_information":[{"code":"85547","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6.45,"maximum":17.41,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8.6,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":17.41},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10.75},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10.75},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10.75},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":16.6,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6.45,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15.05},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8.6},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8.77,"additional_payer_notes":"APC"}]}]},{"description":"Prothrombin test","code_information":[{"code":"85611","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2.96,"maximum":7.97,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3.94,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7.97},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4.93},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4.93},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4.93},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7.6,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2.96,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6.9},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3.94},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4.02,"additional_payer_notes":"APC"}]}]},{"description":"Thrombin time titer","code_information":[{"code":"85675","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5.14,"maximum":13.84,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6.85,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":13.84},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8.56},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8.56},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8.56},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13.22,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5.14,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11.99},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6.85},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6.99,"additional_payer_notes":"APC"}]}]},{"description":"Allergen specific IgE","code_information":[{"code":"86005","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5.98,"maximum":16.14,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7.97,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":16.14},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":9.96},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":9.96},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":9.96},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":15.38,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5.98,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13.95},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7.97},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8.13,"additional_payer_notes":"APC"}]}]},{"description":"Antinuclear antibodies","code_information":[{"code":"86038","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":9.07,"maximum":23.33,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":21.08},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15.11},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15.11},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15.11},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":23.33,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9.07,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21.16},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12.09},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.33,"additional_payer_notes":"APC"}]}]},{"description":"Antistreptolysin o titer","code_information":[{"code":"86060","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5.48,"maximum":14.77,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7.3,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":14.77},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":9.13},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":9.13},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":9.13},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":14.09,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5.48,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12.78},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7.3},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7.45,"additional_payer_notes":"APC"}]}]},{"description":"Chemotaxis assay","code_information":[{"code":"86155","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":11.99,"maximum":32.35,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15.99,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":32.35},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19.99},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19.99},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19.99},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":30.86,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11.99,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27.98},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15.99},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16.31,"additional_payer_notes":"APC"}]}]},{"description":"Deoxyribonuclease antibody","code_information":[{"code":"86215","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":9.94,"maximum":25.57,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.25,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":25.42},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16.56},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16.56},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16.56},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":25.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9.94,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23.19},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13.25},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.52,"additional_payer_notes":"APC"}]}]},{"description":"Growth hormone antibody","code_information":[{"code":"86277","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":11.8,"maximum":31.86,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15.74,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":31.86},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19.68},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19.68},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19.68},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":30.38,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11.8,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27.55},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15.74},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16.05,"additional_payer_notes":"APC"}]}]},{"description":"Heterophile antibody titer","code_information":[{"code":"86309","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4.85,"maximum":13.08,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6.47,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":13.08},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8.09},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8.09},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8.09},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":12.49,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4.85,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11.32},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6.47},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6.6,"additional_payer_notes":"APC"}]}]},{"description":"Ia nfct ab sarscov2 covid19","code_information":[{"code":"86328","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":33.96,"maximum":87.39,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":45.28,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":67.27},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":56.6},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":56.6},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":56.6},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":87.39,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":33.96,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":79.24},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":45.28},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":46.19,"additional_payer_notes":"APC"}]}]},{"description":"Endocervical curettage","code_information":[{"code":"57505","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":683.26,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":911.02,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1758.27,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":683.26,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":929.24,"additional_payer_notes":"APC"}]}]},{"description":"Vag hyst w/enterocele compl","code_information":[{"code":"58294","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3710.98,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4947.97,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":9549.58,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3710.98,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5046.93,"additional_payer_notes":"APC"}]}]},{"description":"Insert heyman uteri capsule","code_information":[{"code":"58346","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3388.0,"maximum":9549.58,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4947.97,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":9549.58,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3710.98,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5046.93,"additional_payer_notes":"APC"}]}]},{"description":"Transfer of embryo","code_information":[{"code":"58976","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":226.06,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":301.41,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":581.72,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":226.06,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":307.44,"additional_payer_notes":"APC"}]}]},{"description":"Fetal scalp blood sample","code_information":[{"code":"59030","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":226.06,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":301.41,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":581.72,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":226.06,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":307.44,"additional_payer_notes":"APC"}]}]},{"description":"Antepartum manipulation","code_information":[{"code":"59412","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2401.4,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3201.87,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6179.61,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2401.4,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3265.91,"additional_payer_notes":"APC"}]}]},{"description":"Biopsy of vulva/perineum","code_information":[{"code":"56605","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":683.26,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":911.02,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1758.27,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":683.26,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":929.24,"additional_payer_notes":"APC"}]}]},{"description":"Extensive vulva surgery","code_information":[{"code":"56634","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":27583.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":27583.0}]}]},{"description":"Insert cervical dilator","code_information":[{"code":"59200","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":226.06,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":301.41,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":581.72,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":226.06,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":307.44,"additional_payer_notes":"APC"}]}]},{"description":"Care of miscarriage","code_information":[{"code":"59820","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2401.4,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3201.87,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6179.61,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2401.4,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3265.91,"additional_payer_notes":"APC"}]}]},{"description":"Nps surg dilat eust tube bi","code_information":[{"code":"69706","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Gastric motility studies","code_information":[{"code":"91020","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":276.82,"maximum":2334.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":369.09,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":712.35,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":276.82,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":376.48,"additional_payer_notes":"APC"}]}]},{"description":"Breath hydrogen/methane test","code_information":[{"code":"91065","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":160.18,"maximum":2334.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":213.57,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":412.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":160.18,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":217.84,"additional_payer_notes":"APC"}]}]},{"description":"Electrogastrography W/Test","code_information":[{"code":"91133","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":98.7,"maximum":2334.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":131.6,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":253.99,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":98.7,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":134.23,"additional_payer_notes":"APC"}]}]},{"description":"Prq card angio/athrect addl","code_information":[{"code":"92925","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":26827.0,"maximum":27583.0,"payers_information":[{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":27583.0}]}]},{"description":"Prq card revasc chronic 1vsl","code_information":[{"code":"92943","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8563.85,"maximum":22037.64,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11418.47,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":22037.64,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8563.85,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11646.84,"additional_payer_notes":"APC"}]}]},{"description":"Dissolve clot heart vessel","code_information":[{"code":"92977","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":2334.0,"payers_information":[{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Inject congenital card cath","code_information":[{"code":"93563","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":2334.0,"payers_information":[{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Heart flow reserve measure","code_information":[{"code":"93572","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":2334.0,"payers_information":[{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Perq transcath cls aortic","code_information":[{"code":"93591","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":13599.0,"maximum":44873.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18131.99,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":44873.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":44873.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":44873.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":34994.75,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13599.0,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":43285.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18494.63,"additional_payer_notes":"APC"}]}]},{"description":"Bundle of His recording","code_information":[{"code":"93600","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3579.0,"maximum":14889.41,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7714.72,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":14889.41,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5786.04,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7869.01,"additional_payer_notes":"APC"}]}]},{"description":"Esophageal recording","code_information":[{"code":"93616","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":903.21,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1204.28,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2324.26,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":903.21,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1228.36,"additional_payer_notes":"APC"}]}]},{"description":"Heart pacing mapping","code_information":[{"code":"93631","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":2334.0,"payers_information":[{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Ablate arrhythmia add on","code_information":[{"code":"93655","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":2334.0,"payers_information":[{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Spin/brain pump refil & main","code_information":[{"code":"95990","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":245.03,"maximum":2334.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":326.71,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":630.55,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":245.03,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":333.24,"additional_payer_notes":"APC"}]}]},{"description":"Implant spinal canal cath","code_information":[{"code":"62351","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Anal sp inf pmp w/reprg&fill","code_information":[{"code":"62369","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":227.84,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":303.79,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":586.32,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":227.84,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":309.87,"additional_payer_notes":"APC"}]}]},{"description":"Bx/exc idrl imed lesn thrlmb","code_information":[{"code":"63287","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6779.0,"maximum":27583.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":27583.0}]}]},{"description":"Pvb thoracic cont infusion","code_information":[{"code":"64463","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":523.65,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":698.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1347.51,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":523.65,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":712.16,"additional_payer_notes":"APC"}]}]},{"description":"Tap block bi by infusion","code_information":[{"code":"64489","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"N block stellate ganglion","code_information":[{"code":"64510","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":656.13,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":874.84,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1688.44,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":656.13,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":892.34,"additional_payer_notes":"APC"}]}]},{"description":"Inc for vagus n elect impl","code_information":[{"code":"64568","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8923.0,"maximum":84083.89,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":43566.78,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":10765.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":8923.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":10765.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":54996.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":54996.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":54996.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":84083.89,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":32675.09,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":51942.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":44438.12,"additional_payer_notes":"APC"}]}]},{"description":"Rmvl devital tis addl 20cm/<","code_information":[{"code":"97598","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":2334.0,"payers_information":[{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Low cost skin substitute app","code_information":[{"code":"C5278","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":2334.0,"payers_information":[{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Revasc lithotr-ather tib/per","code_information":[{"code":"C9774","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":13599.0,"maximum":34994.75,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18131.99,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":34994.75,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13599.0,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":27583.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18494.63,"additional_payer_notes":"APC"}]}]},{"description":"Rabies ig ht&sol human im/sc","code_information":[{"code":"90377","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":182.4,"maximum":682.04,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":243.2,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":265.27},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":450.49},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":450.49},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":450.49},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":469.37,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":182.4,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":463.46},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":682.04},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":248.06,"additional_payer_notes":"APC"}]}]},{"description":"Cciiv3 vac no prsv 0.5 ml im","code_information":[{"code":"90661","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":40.54,"maximum":100.32,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":40.54},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":70.01},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":70.01},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":70.01},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":68.17},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":100.32}]}]},{"description":"Td vacc no presv 7 yrs+ im","code_information":[{"code":"90714","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":37.36,"maximum":91.15,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":37.36},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":69.09},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":69.09},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":69.09},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":61.94},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":91.15}]}]},{"description":"Hepb vacc 4 dose immunsup im","code_information":[{"code":"90747","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":154.83,"maximum":383.2,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":154.83},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":267.43},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":267.43},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":267.43},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":260.39},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":383.2}]}]},{"description":"Inj, gadopiclenol, 1 ml","code_information":[{"code":"A9573","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3.82,"maximum":9.75,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3.82},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":6.47},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":6.47},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":6.47},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6.62},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9.75}]}]},{"description":"Insti hexaminolevulinate hcl","code_information":[{"code":"A9589","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1516.25,"maximum":3753.54,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1516.25},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2706.23},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2706.23},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2706.23},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2550.61},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3753.54}]}]},{"description":"Inj acetaminophen -fresenius","code_information":[{"code":"J0134","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":0.05,"maximum":0.12,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":0.06},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.11},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.11},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.11},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.05},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.07},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.12}]}]},{"description":"Epinephrine (intl med sys)","code_information":[{"code":"J0168","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4.13,"maximum":4.13,"payers_information":[{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4.13},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4.13},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4.13}]}]},{"description":"Agalsidase beta injection","code_information":[{"code":"J0180","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":174.54,"maximum":608.54,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":232.72,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":245.12},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":437.5},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":437.5},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":437.5},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":449.15,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":242.0},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":174.54,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":413.51},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":608.54},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":237.37,"additional_payer_notes":"APC"}]}]},{"description":"Inj., patisiran, 0.1 mg","code_information":[{"code":"J0222","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":75.77,"maximum":269.07,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":101.03,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":108.94},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":189.66},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":189.66},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":189.66},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":194.98,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":107.01},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":75.77,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":182.84},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":269.07},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":103.05,"additional_payer_notes":"APC"}]}]},{"description":"Aminophyllin 250 MG inj","code_information":[{"code":"J0280","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5.6,"maximum":15.77,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":12.16},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15.77},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15.77},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15.77},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5.6},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9.56},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14.07}]}]},{"description":"Inj., plazomicin, 5 mg","code_information":[{"code":"J0291","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2.64,"maximum":9.72,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3.52,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3.93},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":6.79},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":6.79},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":6.79},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6.79,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3.87},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2.64,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6.6},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9.72},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3.59,"additional_payer_notes":"APC"}]}]},{"description":"Injection, aztreonam, 100 mg","code_information":[{"code":"J0457","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2.24,"maximum":5.64,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2.73},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5.06},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5.06},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5.06},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2.24},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3.83},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5.64}]}]},{"description":"Dicyclomine injection","code_information":[{"code":"J0500","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":14.15,"maximum":40.57,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":14.15},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22.18},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22.18},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22.18},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16.14},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27.57},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":40.57}]}]},{"description":"Bivalirudin","code_information":[{"code":"J0583","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":0.17,"maximum":0.43,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":0.17},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.32},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.32},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.32},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.18},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.3},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.43}]}]},{"description":"Inj., lanadelumab-flyo, 1 mg","code_information":[{"code":"J0593","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":66.16,"maximum":280.01,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":88.22,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":93.28},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":165.19},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":165.19},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":165.19},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":170.26,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":66.16,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":280.01},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":89.98,"additional_payer_notes":"APC"}]}]},{"description":"Calcium glucon (wg critical)","code_information":[{"code":"J0613","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":0.09,"maximum":0.3,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":0.09},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.15},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.15},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.15},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.11},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.2},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.3}]}]},{"description":"Inj, levothyroxine, freskabi","code_information":[{"code":"J0651","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4.13,"maximum":13.48,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6.84,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7.04},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13.48},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13.48},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13.48},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13.19,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":4.13},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5.13,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7.07},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10.4},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6.97,"additional_payer_notes":"APC"}]}]},{"description":"Cefazolin sodium injection","code_information":[{"code":"J0690","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":0.89,"maximum":2.21,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":0.91},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1.59},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1.59},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1.59},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.89},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1.5},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2.21}]}]},{"description":"Betamethasone acet&sod phosp","code_information":[{"code":"J0702","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7.54,"maximum":20.44,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7.54},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13.09},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13.09},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13.09},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8.13},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13.89},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20.44}]}]},{"description":"Inj, clindamycin phosp 300mg","code_information":[{"code":"J0736","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1.77,"maximum":5.79,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1.77},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3.17},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3.17},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3.17},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2.31},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3.94},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5.79}]}]},{"description":"Hiv prep, ftc/tdf 200/300mg","code_information":[{"code":"J0750","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":0.34,"maximum":4.95,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":0.45,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1.41},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3.3},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3.3},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3.3},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":0.87,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1.97},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":0.34,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3.37},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":4.95},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":0.46,"additional_payer_notes":"APC"}]}]},{"description":"Cosyntropin cortrosyn inj","code_information":[{"code":"J0834","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":36.2,"maximum":91.01,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":36.74},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":53.24},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":53.24},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":53.24},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36.2},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":61.85},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":91.01}]}]},{"description":"Injection, dalbavancin","code_information":[{"code":"J0875","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8.47,"maximum":42.47,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11.29,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":17.13},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":29.55},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":29.55},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":29.55},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":21.8,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16.89},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8.47,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28.86},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":42.47},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11.52,"additional_payer_notes":"APC"}]}]},{"description":"Epoetin beta esrd use","code_information":[{"code":"J0887","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1.33,"maximum":3.32,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1.39},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2.69},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2.69},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2.69},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1.33},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2.26},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3.32}]}]},{"description":"Argatroban dialysis, auromed","code_information":[{"code":"J0899","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1.47,"maximum":14.36,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1.47},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2.76},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2.76},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2.76},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14.36}]}]},{"description":"Acetazolamid sodium injectio","code_information":[{"code":"J1120","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":20.97,"maximum":58.86,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":20.97},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":32.73},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":32.73},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":32.73},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23.41},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":40.0},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":58.86}]}]},{"description":"Inj. cetirizine hcl 0.5mg","code_information":[{"code":"J1201","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":12.87,"maximum":42.82,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17.16,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":17.18},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":31.15},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":31.15},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":31.15},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":33.11,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17.03},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.87,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29.1},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":42.82},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17.5,"additional_payer_notes":"APC"}]}]},{"description":"Dopamine injection","code_information":[{"code":"J1265","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":0.78,"maximum":2.1,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":0.78},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1.25},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1.25},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1.25},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.84},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1.42},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2.1}]}]},{"description":"Inj tofersen intrathec 1 mg","code_information":[{"code":"J1304","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":123.61,"maximum":422.91,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":164.82,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":170.87},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":295.15},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":295.15},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":295.15},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":318.09,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":168.19},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":123.61,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":287.38},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":422.91},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":168.11,"additional_payer_notes":"APC"}]}]},{"description":"Ertapenem injection","code_information":[{"code":"J1335","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":10.1,"maximum":29.98,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":10.1},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17.14},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17.14},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17.14},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11.93},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20.37},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29.98}]}]},{"description":"Fecal?microbiota jslm 1 ml","code_information":[{"code":"J1440","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":49.2,"maximum":173.15,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":65.6,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":70.32},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":121.66},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":121.66},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":121.66},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":126.62,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":68.86},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":49.2,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":117.66},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":173.15},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":66.92,"additional_payer_notes":"APC"}]}]},{"description":"Foscarnet sodium injection","code_information":[{"code":"J1455","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":23.79,"maximum":104.21,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":23.79},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":29.61},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":29.61},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":29.61},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":41.44},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":70.82},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":104.21}]}]},{"description":"Inj cuvitru, 100 mg","code_information":[{"code":"J1555","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":13.61,"maximum":45.23,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18.15,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":18.35},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":33.42},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":33.42},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":33.42},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":35.02,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17.98},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.61,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30.73},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":45.23},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18.51,"additional_payer_notes":"APC"}]}]},{"description":"Octagam injection","code_information":[{"code":"J1568","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":35.29,"maximum":134.23,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":47.06,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":52.87},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":91.91},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":91.91},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":91.91},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":90.82,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":53.38},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":35.29,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":91.21},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":134.23},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":48.0,"additional_payer_notes":"APC"}]}]},{"description":"Inj, glycopyrrolate, 0.1 mg","code_information":[{"code":"J1596","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":0.56,"maximum":1.58,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":0.56},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.82},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.82},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.82},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.62},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1.07},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1.58}]}]},{"description":"Haloperidol injection","code_information":[{"code":"J1630","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":0.86,"maximum":3.3,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":0.86},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1.59},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1.59},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1.59},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1.31},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2.24},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3.3}]}]},{"description":"Fondaparinux sodium","code_information":[{"code":"J1652","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":0.72,"maximum":1.83,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":0.95},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1.37},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1.37},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1.37},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.72},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1.24},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1.83}]}]},{"description":"Inj, spesolimab-sbzo, 1 mg","code_information":[{"code":"J1747","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":49.3,"maximum":167.24,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":65.73,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":67.57},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":124.88},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":124.88},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":124.88},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":126.86,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":66.51},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":49.3,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":113.65},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":167.24},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":67.04,"additional_payer_notes":"APC"}]}]},{"description":"Inj, folic acid, 0.1 mg","code_information":[{"code":"J1808","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":0.07,"maximum":0.11,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":0.07},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.11},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.11},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.11}]}]},{"description":"Inj labetalol hcl hikma, 5mg","code_information":[{"code":"J1921","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1.5,"maximum":3.76,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1.52},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2.63},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2.63},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2.63},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1.5},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2.55},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3.76}]}]},{"description":"Leuprolide acetate /3.75 mg","code_information":[{"code":"J1950","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1380.95,"maximum":4537.81,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1841.26,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1837.33},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3300.48},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3300.48},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3300.48},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3553.63,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1804.66},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1380.95,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3083.54},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":4537.81},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1878.09,"additional_payer_notes":"APC"}]}]},{"description":"Inj, lidocaine in d5w, 1 mg","code_information":[{"code":"J2002","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":0.01,"maximum":0.03,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":0.01},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.01},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.01},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.01},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.02},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.03}]}]},{"description":"Inj meropenem (wg crit care)","code_information":[{"code":"J2183","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1.76,"maximum":4.49,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1.76},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3.09},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3.09},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3.09},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1.79},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3.05},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":4.49}]}]},{"description":"Inj midazolam (wg crit care)","code_information":[{"code":"J2251","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":0.18,"maximum":0.46,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":0.19},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.32},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.32},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.32},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.18},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.31},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.46}]}]},{"description":"Inj, moxifloxacin 100 mg","code_information":[{"code":"J2280","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":9.37,"maximum":23.55,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":9.43},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16.55},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16.55},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16.55},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9.37},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16.0},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23.55}]}]},{"description":"Natalizumab injection","code_information":[{"code":"J2323","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":18.3,"maximum":65.01,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":24.41,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":26.81},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":45.84},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":45.84},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":45.84},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":47.1,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25.85},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18.3,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":44.18},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":65.01},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":24.89,"additional_payer_notes":"APC"}]}]},{"description":"Omalizumab injection","code_information":[{"code":"J2357","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":34.94,"maximum":102.8,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":46.59,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":44.13},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":77.07},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":77.07},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":77.07},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":89.91,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":40.88},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":34.94,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":69.86},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":102.8},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":47.52,"additional_payer_notes":"APC"}]}]},{"description":"Chloroprocaine opht gel, 1mg","code_information":[{"code":"J2403","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":0.66,"maximum":1.67,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":0.66},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1.14},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1.14},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1.14},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.66},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1.13},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1.67}]}]},{"description":"Pamidronate disodium /30 mg","code_information":[{"code":"J2430","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":13.62,"maximum":34.25,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":15.27},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21.2},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21.2},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21.2},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13.62},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23.27},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34.25}]}]},{"description":"Penicillin g potassium inj","code_information":[{"code":"J2540","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":0.81,"maximum":2.05,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":0.86},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1.67},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1.67},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1.67},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.81},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1.39},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2.05}]}]},{"description":"Inj vasopressin (am reg) 1 u","code_information":[{"code":"J2599","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":0.9,"maximum":3.27,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1.46},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.9},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.9},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.9},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1.3},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2.22},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3.27}]}]},{"description":"Inj protamine sulfate/10 MG","code_information":[{"code":"J2720","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1.23,"maximum":3.11,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1.54},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3.11},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3.11},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3.11},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1.23},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2.11},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3.1}]}]},{"description":"Inj avacincaptad pegol 0.1mg","code_information":[{"code":"J2782","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":77.4,"maximum":295.94,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":103.2,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":118.18},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":201.2},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":201.2},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":201.2},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":199.18,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":117.7},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":77.4,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":201.1},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":295.94},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":105.27,"additional_payer_notes":"APC"}]}]},{"description":"Risperidone, long acting","code_information":[{"code":"J2794","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8.33,"maximum":29.91,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11.1,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":11.55},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20.79},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20.79},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20.79},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":21.43,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11.9},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8.33,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20.33},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29.91},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11.33,"additional_payer_notes":"APC"}]}]},{"description":"Sargramostim injection","code_information":[{"code":"J2820","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":46.86,"maximum":163.4,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":62.47,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":65.87},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":106.57},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":106.57},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":106.57},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":120.57,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":64.98},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":46.86,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":111.04},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":163.4},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":63.72,"additional_payer_notes":"APC"}]}]},{"description":"Inj. eptinezumab-jjmr 1 mg","code_information":[{"code":"J3032","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":15.83,"maximum":52.6,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21.1,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":21.25},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":37.71},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":37.71},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":37.71},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":40.72,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20.92},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15.83,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35.74},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":52.6},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21.52,"additional_payer_notes":"APC"}]}]},{"description":"Inj testostero enanthate 1mg","code_information":[{"code":"J3121","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":0.06,"maximum":0.13,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":0.06},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.1},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.1},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.1},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.06},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.09},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.13}]}]},{"description":"Inj secukinumab intrav 1mg","code_information":[{"code":"J3247","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":13.67,"maximum":48.25,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18.23,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":19.5},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":33.9},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":33.9},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":33.9},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":35.19,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19.19},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.67,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32.78},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":48.25},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18.6,"additional_payer_notes":"APC"}]}]},{"description":"Triamcinolone acet inj nos","code_information":[{"code":"J3301","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":0.96,"maximum":2.46,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":0.96},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1.64},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1.64},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1.64},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.97},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1.67},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2.46}]}]},{"description":"Inj vancomycin (xellia) 10mg","code_information":[{"code":"J3375","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":0.25,"maximum":0.25,"payers_information":[{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.25},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.25},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.25}]}]},{"description":"Remove ear lesion","code_information":[{"code":"69550","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Explore inner ear","code_information":[{"code":"69805","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Acid perfusion of esophagus","code_information":[{"code":"91030","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":276.82,"maximum":2334.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":369.09,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":712.35,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":276.82,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":376.48,"additional_payer_notes":"APC"}]}]},{"description":"Esophageal Capsule Endoscopy","code_information":[{"code":"91111","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":672.83,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":897.11,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1731.42,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":672.83,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":915.05,"additional_payer_notes":"APC"}]}]},{"description":"New eye exam & treatment","code_information":[{"code":"92018","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1763.69,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2351.59,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4538.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1763.69,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2398.62,"additional_payer_notes":"APC"}]}]},{"description":"Prq card stent w/angio addl","code_information":[{"code":"92929","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":17314.0,"maximum":18364.0,"payers_information":[{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0}]}]},{"description":"Heart/lung resuscitation cpr","code_information":[{"code":"92950","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":160.18,"maximum":2334.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":213.57,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":412.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":160.18,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":217.84,"additional_payer_notes":"APC"}]}]},{"description":"Endoluminl ivus oct c ea","code_information":[{"code":"92979","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":2334.0,"payers_information":[{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Inject l ventr/atrial angio","code_information":[{"code":"93565","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":2334.0,"payers_information":[{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Njx cath slct pulm vn angrph","code_information":[{"code":"93574","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":2334.0,"payers_information":[{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Right ventricular recording","code_information":[{"code":"93603","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":903.21,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1204.28,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2324.26,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":903.21,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1228.36,"additional_payer_notes":"APC"}]}]},{"description":"Electrophysiology evaluation","code_information":[{"code":"93619","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5786.04,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7714.72,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":14889.41,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5786.04,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7869.01,"additional_payer_notes":"APC"}]}]},{"description":"Electrophysiology evaluation","code_information":[{"code":"93641","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":2334.0,"payers_information":[{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Tx l/r atrial fib addl","code_information":[{"code":"93657","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":2334.0,"payers_information":[{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Photodynamic tx skin","code_information":[{"code":"96567","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":148.84,"maximum":2334.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":198.45,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":383.01,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":148.84,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":202.42,"additional_payer_notes":"APC"}]}]},{"description":"Low cost skin substitute app","code_information":[{"code":"C5272","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":2334.0,"payers_information":[{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Colpopexy, min/inv, ex-perit","code_information":[{"code":"C9778","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3710.98,"maximum":9549.58,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4947.97,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":9549.58,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3710.98,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5046.93,"additional_payer_notes":"APC"}]}]},{"description":"Cont intraop neuro monitor","code_information":[{"code":"G0453","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":2334.0,"payers_information":[{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Hepa vaccine adult im","code_information":[{"code":"90632","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":79.38,"maximum":194.96,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":79.38},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":138.1},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":138.1},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":138.1},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":132.48},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":194.96}]}]},{"description":"Pcv13 vaccine im","code_information":[{"code":"90670","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":283.79,"maximum":702.37,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":283.79},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":490.18},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":490.18},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":490.18},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":477.28},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":702.37}]}]},{"description":"Ppsv23 vacc 2 yrs+ subq/im","code_information":[{"code":"90732","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":146.82,"maximum":363.38,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":146.82},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":253.6},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":253.6},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":253.6},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":246.92},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":363.38}]}]},{"description":"Inj prohance multipack","code_information":[{"code":"A9576","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1.57,"maximum":3.98,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1.57},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2.69},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2.69},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2.69},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2.7},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3.98}]}]},{"description":"Inj., omadacycline, 1 mg","code_information":[{"code":"J0121","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3.14,"maximum":10.68,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4.26},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7.62},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7.62},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7.62},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":8.08,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":4.24},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3.14,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7.25},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10.68},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4.27,"additional_payer_notes":"APC"}]}]},{"description":"Inj, acetaminophen (hikma)","code_information":[{"code":"J0137","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":0.03,"maximum":0.13,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":0.03},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.1},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.1},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.1},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.06},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.09},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.13}]}]},{"description":"Inj, aducanumab-avwa, 2 mg","code_information":[{"code":"J0172","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6.47,"maximum":16.29,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6.58},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11.36},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11.36},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11.36},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6.47},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11.06},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16.29}]}]},{"description":"Injection, alemtuzumab","code_information":[{"code":"J0202","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1908.7,"maximum":6570.37,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2544.94,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2685.64},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4637.33},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4637.33},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4637.33},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4911.73,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2613.0},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1908.7,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":4464.72},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6570.37},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2595.84,"additional_payer_notes":"APC"}]}]},{"description":"Inj. lumasiran, 0.5 mg","code_information":[{"code":"J0224","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":252.73,"maximum":865.79,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":336.97,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":350.74},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":625.3},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":625.3},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":625.3},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":650.36,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":344.32},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":252.73,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":588.32},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":865.79},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":343.71,"additional_payer_notes":"APC"}]}]},{"description":"Amiodarone HCl","code_information":[{"code":"J0282","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":0.36,"maximum":1.06,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":0.36},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.96},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.96},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.96},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.42},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.72},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1.06}]}]},{"description":"Anidulafungin injection","code_information":[{"code":"J0348","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":0.52,"maximum":1.39,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":0.52},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.92},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.92},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.92},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.55},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.94},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1.39}]}]},{"description":"Baclofen 10 mg injection","code_information":[{"code":"J0475","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":139.58,"maximum":473.29,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":186.11,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":192.28},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":334.06},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":334.06},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":334.06},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":359.18,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":188.22},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":139.58,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":321.6},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":473.29},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":189.83,"additional_payer_notes":"APC"}]}]},{"description":"Inj., benralizumab, 1 mg","code_information":[{"code":"J0517","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":124.17,"maximum":451.64,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":165.56,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":179.63},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":319.45},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":319.45},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":319.45},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":319.54,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":179.62},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":124.17,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":306.9},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":451.64},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":168.87,"additional_payer_notes":"APC"}]}]},{"description":"Injection,onabotulinumtoxina","code_information":[{"code":"J0585","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4.88,"maximum":17.62,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6.51,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7.13},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12.35},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12.35},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12.35},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":12.56,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7.0},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4.88,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11.97},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17.62},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6.64,"additional_payer_notes":"APC"}]}]},{"description":"Butorphanol tartrate 1 mg","code_information":[{"code":"J0595","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5.16,"maximum":15.46,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5.16},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":9.6},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":9.6},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":9.6},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6.15},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10.51},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15.46}]}]},{"description":"Caspofungin acetate","code_information":[{"code":"J0637","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3.67,"maximum":13.78,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3.67},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4.31},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4.31},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4.31},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5.47},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9.36},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13.78}]}]},{"description":"Inj, bupivacaine, nos, 0.5mg","code_information":[{"code":"J0665","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":0.01,"maximum":0.03,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":0.01},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.02},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.02},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.02},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.01},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.02},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.03}]}]},{"description":"Cefoxitin sodium injection","code_information":[{"code":"J0694","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4.82,"maximum":12.11,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5.51},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":9.75},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":9.75},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":9.75},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":4.82},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8.23},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12.11}]}]},{"description":"Ceftaroline fosamil inj","code_information":[{"code":"J0712","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3.29,"maximum":10.76,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4.39,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4.39},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8.06},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8.06},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8.06},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":8.47,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":4.27},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3.29,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7.31},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10.76},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4.48,"additional_payer_notes":"APC"}]}]},{"description":"Injection, cabotegravir 1 mg","code_information":[{"code":"J0739","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5.47,"maximum":18.76,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7.29,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7.58},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13.36},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13.36},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13.36},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":14.08,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7.47},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5.47,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12.75},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18.76},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7.44,"additional_payer_notes":"APC"}]}]},{"description":"Colistimethate sodium inj","code_information":[{"code":"J0770","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":13.13,"maximum":33.1,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":13.13},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21.64},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21.64},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21.64},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13.17},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22.5},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33.1}]}]},{"description":"Inj crotalidae im f(ab')2 eq","code_information":[{"code":"J0841","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1112.14,"maximum":2796.47,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1147.91},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1983.86},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1983.86},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1983.86},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1112.14},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1900.26},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2796.47}]}]},{"description":"Daptomycin injection","code_information":[{"code":"J0878","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":0.03,"maximum":0.12,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":0.03},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.06},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.06},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.06},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.04},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.07},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.12}]}]},{"description":"Inj, decitabine (sun pharma)","code_information":[{"code":"J0893","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":0.86,"maximum":100.52,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":0.86},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1.48},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1.48},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1.48},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":100.52}]}]},{"description":"Inj, methylpred acetate 1 mg","code_information":[{"code":"J1010","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":0.12,"maximum":0.33,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":0.12},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.23},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.23},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.23},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.12},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.22},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.33}]}]},{"description":"Vitamin b12 injection","code_information":[{"code":"J3420","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":0.74,"maximum":3.47,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":0.74},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1.8},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1.8},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1.8},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1.37},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2.35},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3.47}]}]},{"description":"Inj potassium chloride","code_information":[{"code":"J3480","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":0.11,"maximum":0.32,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":0.23},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.32},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.32},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.32},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.11},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.19},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.28}]}]},{"description":"5% dextrose/water","code_information":[{"code":"J7060","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1.95,"maximum":4.9,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3.85},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3.85},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3.85},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1.95},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3.33},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":4.9}]}]},{"description":"Human fibrinogen conc inj","code_information":[{"code":"J7178","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1.12,"maximum":4.03,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1.49,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1.63},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2.89},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2.89},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2.89},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2.87,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1.61},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1.12,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2.74},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":4.03},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1.52,"additional_payer_notes":"APC"}]}]},{"description":"Humate-P, inj","code_information":[{"code":"J7187","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1.15,"maximum":3.94,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1.54,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1.6},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2.83},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2.83},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2.83},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2.96,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1.56},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1.15,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2.68},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3.94},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1.57,"additional_payer_notes":"APC"}]}]},{"description":"Antithrombin iii injection","code_information":[{"code":"J7197","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3.13,"maximum":10.77,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4.17,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4.33},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7.76},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7.76},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7.76},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":8.06,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":4.29},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3.13,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7.33},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10.77},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4.26,"additional_payer_notes":"APC"}]}]},{"description":"Factor viii pegylated recomb","code_information":[{"code":"J7207","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1.59,"maximum":5.73,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2.12,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2.31},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4.09},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4.09},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4.09},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4.09,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2.27},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1.59,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3.89},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5.73},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2.16,"additional_payer_notes":"APC"}]}]},{"description":"Aminolevulinic acid hcl top","code_information":[{"code":"J7308","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":291.96,"maximum":1076.1,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":389.28,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":433.85},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":748.36},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":748.36},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":748.36},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":751.31,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":427.96},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":291.96,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":731.23},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1076.1},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":397.07,"additional_payer_notes":"APC"}]}]},{"description":"Hymovis injection 1 mg","code_information":[{"code":"J7322","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":13.6,"maximum":47.42,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18.13,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":19.25},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":33.14},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":33.14},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":33.14},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":34.99,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18.86},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.6,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32.23},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":47.42},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18.49,"additional_payer_notes":"APC"}]}]},{"description":"Synojoynt, inj., 1 mg","code_information":[{"code":"J7331","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":9.27,"maximum":24.24,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":9.27},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10.66},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10.66},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10.66},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9.64},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16.47},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24.24}]}]},{"description":"Mometasone sinus sinuva","code_information":[{"code":"J7402","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8.51,"maximum":30.9,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11.34,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":12.49},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21.56},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21.56},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21.56},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":21.9,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12.29},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8.51,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21.0},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30.9},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11.57,"additional_payer_notes":"APC"}]}]},{"description":"Prednisolone oral per 5 mg","code_information":[{"code":"J7510","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":0.52,"maximum":1.55,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":0.53},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.52},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.52},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.52},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.62},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1.05},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1.55}]}]},{"description":"Sirolimus, oral","code_information":[{"code":"J7520","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1.15,"maximum":2.89,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1.25},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1.82},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1.82},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1.82},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1.15},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1.96},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2.89}]}]},{"description":"Albuterol non-comp con","code_information":[{"code":"J7611","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":0.17,"maximum":0.43,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":0.2},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.31},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.31},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.31},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.17},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.3},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.43}]}]},{"description":"Ipratropium bromide non-comp","code_information":[{"code":"J7644","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":0.4,"maximum":1.01,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":0.4},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.75},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.75},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.75},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.4},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.68},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1.01}]}]},{"description":"Oral dexamethasone","code_information":[{"code":"J8540","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":0.03,"maximum":0.17,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":0.07},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.03},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.03},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.03},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.07},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.11},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.17}]}]},{"description":"Topotecan oral","code_information":[{"code":"J8705","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":94.0,"maximum":340.11,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":125.33,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":137.39},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":237.31},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":237.31},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":237.31},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":241.89,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":135.27},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":94.0,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":231.12},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":340.11},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":127.84,"additional_payer_notes":"APC"}]}]},{"description":"Inj, tarlatamab-dlle, 1 mg","code_information":[{"code":"J9026","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1209.32,"maximum":4289.08,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1612.42,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1727.85},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2978.24},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2978.24},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2978.24},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3111.97,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1209.32,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":4289.08},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1644.67,"additional_payer_notes":"APC"}]}]},{"description":"Bevacizumab injection","code_information":[{"code":"J9035","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":56.12,"maximum":199.25,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":74.82,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":80.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":138.79},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":138.79},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":138.79},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":144.41,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":79.25},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":56.12,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":135.4},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":199.25},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":76.32,"additional_payer_notes":"APC"}]}]},{"description":"Injection, carfilzomib, 1 mg","code_information":[{"code":"J9047","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":45.22,"maximum":141.49,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":60.29,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":57.04},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":104.67},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":104.67},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":104.67},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":116.36,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":56.26},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":45.22,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":96.14},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":141.49},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":61.5,"additional_payer_notes":"APC"}]}]},{"description":"Inj cladribine per 1 mg","code_information":[{"code":"J9065","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6.14,"maximum":30.69,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":11.22},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18.48},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18.48},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18.48},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":15.8,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12.2},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6.14,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20.85},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30.69},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8.35,"additional_payer_notes":"APC"}]}]},{"description":"Inj. calaspargase pegol-mknl","code_information":[{"code":"J9118","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":64.34,"maximum":208.35,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":85.79,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":84.18},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":155.62},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":155.62},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":155.62},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":165.57,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":82.85},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":64.34,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":141.58},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":208.35},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":87.5,"additional_payer_notes":"APC"}]}]},{"description":"Degarelix injection","code_information":[{"code":"J9155","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3.36,"maximum":11.65,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4.48,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4.8},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8.28},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8.28},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8.28},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":8.65,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":4.63},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3.36,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7.92},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11.65},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4.57,"additional_payer_notes":"APC"}]}]},{"description":"Etoposide injection","code_information":[{"code":"J9181","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1.05,"maximum":2.67,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1.18},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2.48},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2.48},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2.48},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1.05},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1.81},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2.67}]}]},{"description":"Inj mogamulizumab-kpkc, 1 mg","code_information":[{"code":"J9204","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":193.9,"maximum":662.44,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":258.54,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":267.99},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":472.14},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":472.14},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":472.14},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":498.97,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":263.44},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":193.9,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":450.14},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":662.44},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":263.71,"additional_payer_notes":"APC"}]}]},{"description":"Leuprolide acetate suspnsion","code_information":[{"code":"J9217","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":120.26,"maximum":492.2,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":160.34,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":189.52},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":295.3},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":295.3},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":295.3},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":309.46,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":195.75},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":120.26,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":334.46},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":492.2},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":163.55,"additional_payer_notes":"APC"}]}]},{"description":"Inj melphalan (hepzato) 1 mg","code_information":[{"code":"J9248","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":601.11,"maximum":2106.67,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":801.48,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":851.18},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1496.8},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1496.8},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1496.8},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1546.85,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":837.81},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":601.11,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1431.53},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2106.67},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":817.51,"additional_payer_notes":"APC"}]}]},{"description":"Inj. tagraxofusp-erzs 10 mcg","code_information":[{"code":"J9269","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":268.14,"maximum":922.63,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":357.52,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":372.38},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":662.37},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":662.37},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":662.37},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":690.02,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":366.92},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":268.14,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":626.95},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":922.63},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":364.67,"additional_payer_notes":"APC"}]}]},{"description":"Inj glofitamab gxbm, 2.5 mg","code_information":[{"code":"J9286","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2148.51,"maximum":7543.8,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2864.68,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3050.08},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5264.08},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5264.08},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5264.08},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5528.83,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3000.14},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2148.51,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5126.18},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7543.8},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2921.97,"additional_payer_notes":"APC"}]}]},{"description":"Injection, nivolumab","code_information":[{"code":"J9299","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":25.67,"maximum":87.95,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":34.22,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":35.59},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":62.7},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":62.7},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":62.7},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":66.05,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34.97},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25.67,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":59.76},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":87.95},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":34.91,"additional_payer_notes":"APC"}]}]},{"description":"Inj, polatuzumab vedotin 1mg","code_information":[{"code":"J9309","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":107.71,"maximum":361.88,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":143.61,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":146.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":258.84},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":258.84},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":258.84},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":277.17,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":143.91},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":107.71,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":245.9},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":361.88},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":146.48,"additional_payer_notes":"APC"}]}]},{"description":"Inj epcoritamab-bysp 0.16 mg","code_information":[{"code":"J9321","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":43.49,"maximum":150.25,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":57.99,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":60.35},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":105.75},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":105.75},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":105.75},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":111.92,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":59.75},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":43.49,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":102.1},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":150.25},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":59.15,"additional_payer_notes":"APC"}]}]},{"description":"Inj efgartigimod 2mg","code_information":[{"code":"J9332","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":24.41,"maximum":88.34,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":32.55,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":35.62},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":61.55},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":61.55},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":61.55},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":62.83,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35.14},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":24.41,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":60.03},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":88.34},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":33.2,"additional_payer_notes":"APC"}]}]},{"description":"Inj mosunetuzumab-axgb, 1 mg","code_information":[{"code":"J9350","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":505.87,"maximum":1745.32,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":674.5,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":705.06},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1240.22},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1240.22},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1240.22},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1301.78,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":694.1},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":505.87,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1185.98},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1745.32},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":687.98,"additional_payer_notes":"APC"}]}]},{"description":"Inj fam-trastu deru-nxki 1mg","code_information":[{"code":"J9358","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":24.66,"maximum":78.44,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":32.87,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":31.79},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":57.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":57.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":57.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":63.45,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31.19},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":24.66,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":53.3},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":78.44},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":33.53,"additional_payer_notes":"APC"}]}]},{"description":"Esophagus motility study","code_information":[{"code":"91010","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":276.82,"maximum":2334.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":369.09,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":712.35,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":276.82,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":376.48,"additional_payer_notes":"APC"}]}]},{"description":"Esoph imped funct test > 1hr","code_information":[{"code":"91038","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":276.82,"maximum":2334.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":369.09,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":712.35,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":276.82,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":376.48,"additional_payer_notes":"APC"}]}]},{"description":"Anal pressure record","code_information":[{"code":"91122","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":2334.0,"payers_information":[{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Prq cardiac angio addl art","code_information":[{"code":"92921","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":17314.0,"maximum":18364.0,"payers_information":[{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0}]}]},{"description":"Prq revasc byp graft addl","code_information":[{"code":"92938","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":17314.0,"maximum":18364.0,"payers_information":[{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0}]}]},{"description":"Prq coronary mech thrombect","code_information":[{"code":"92973","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":2334.0,"payers_information":[{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Pul art balloon repr percut","code_information":[{"code":"92997","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8563.85,"maximum":22037.64,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11418.47,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":22037.64,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8563.85,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11646.84,"additional_payer_notes":"APC"}]}]},{"description":"Njx cth slct p-art angrp uni","code_information":[{"code":"93569","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":2334.0,"payers_information":[{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Perq transcath closure pda","code_information":[{"code":"93582","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":13599.0,"maximum":43643.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18131.99,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43643.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43643.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43643.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":34994.75,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13599.0,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":41120.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18494.63,"additional_payer_notes":"APC"}]}]},{"description":"Electrophys map 3d add-on","code_information":[{"code":"93613","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":2334.0,"payers_information":[{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Stimulation pacing heart","code_information":[{"code":"93623","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":2334.0,"payers_information":[{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Ep & ablate supravent arrhyt","code_information":[{"code":"93653","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":19389.9,"maximum":49896.68,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25853.2,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43643.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43643.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43643.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":49896.68,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19389.9,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":41120.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26370.26,"additional_payer_notes":"APC"}]}]},{"description":"Interrogation vad in person","code_information":[{"code":"93750","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":70.53,"maximum":2334.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":94.04,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":181.49,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":70.53,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":95.92,"additional_payer_notes":"APC"}]}]},{"description":"Digoxin immune fab (ovine)","code_information":[{"code":"J1162","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4037.49,"maximum":13803.03,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5383.32,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5465.44},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":9440.3},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":9440.3},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":9440.3},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":10389.81,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5489.4},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4037.49,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9379.46},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13803.03},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5490.99,"additional_payer_notes":"APC"}]}]},{"description":"Chlorothiazide sodium inj","code_information":[{"code":"J1205","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":35.73,"maximum":164.6,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":35.73},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":76.73},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":76.73},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":76.73},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":65.46},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":111.85},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":164.6}]}]},{"description":"Inj doxycycline hyclate 1 mg","code_information":[{"code":"J1271","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":0.13,"maximum":0.22,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":0.13},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.22},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.22},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.22}]}]},{"description":"Injection, inclisiran, 1 mg","code_information":[{"code":"J1306","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":9.68,"maximum":33.43,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.9,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":13.5},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23.47},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23.47},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23.47},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":24.91,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13.29},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9.68,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22.72},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33.43},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.16,"additional_payer_notes":"APC"}]}]},{"description":"Estradiol valerate 10 MG inj","code_information":[{"code":"J1380","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8.03,"maximum":21.62,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":8.03},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14.65},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14.65},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14.65},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8.6},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14.69},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21.62}]}]},{"description":"Inj tbo filgrastim 1 microg","code_information":[{"code":"J1447","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":0.18,"maximum":1.09,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":0.24,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":0.41},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.56},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.56},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.56},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":0.46,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.43},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":0.18,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.74},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1.09},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":0.24,"additional_payer_notes":"APC"}]}]},{"description":"Galsulfase injection","code_information":[{"code":"J1458","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":394.48,"maximum":1320.2,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":525.97,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":533.37},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":960.46},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":960.46},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":960.46},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1015.12,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":525.04},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":394.48,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":897.1},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1320.2},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":536.49,"additional_payer_notes":"APC"}]}]},{"description":"Gammaplex injection","code_information":[{"code":"J1557","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":49.7,"maximum":154.56,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":66.27,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":63.23},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":118.69},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":118.69},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":118.69},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":127.9,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":61.46},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":49.7,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":105.02},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":154.56},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":67.6,"additional_payer_notes":"APC"}]}]},{"description":"Ganciclovir sodium injection","code_information":[{"code":"J1570","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":31.12,"maximum":78.24,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":35.3},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":75.28},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":75.28},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":75.28},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31.12},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":53.17},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":78.24}]}]},{"description":"Golimumab for iv use 1mg","code_information":[{"code":"J1602","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8.28,"maximum":28.69,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11.04,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":11.85},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20.96},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20.96},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20.96},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":21.3,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11.41},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8.28,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19.5},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28.69},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11.26,"additional_payer_notes":"APC"}]}]},{"description":"Hemin, 1 mg","code_information":[{"code":"J1640","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":26.87,"maximum":90.17,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":35.82,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":36.38},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":64.91},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":64.91},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":64.91},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":69.13,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35.86},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26.87,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":61.27},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":90.17},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":36.54,"additional_payer_notes":"APC"}]}]},{"description":"Hydrocortisone sodium succ i","code_information":[{"code":"J1720","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":22.64,"maximum":57.01,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":22.64},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":40.28},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":40.28},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":40.28},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22.67},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38.74},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":57.01}]}]},{"description":"Inj iron dextran","code_information":[{"code":"J1750","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":14.24,"maximum":47.37,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18.99,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":18.95},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":34.25},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":34.25},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":34.25},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":36.66,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18.84},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14.24,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32.19},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":47.37},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19.37,"additional_payer_notes":"APC"}]}]},{"description":"Lyumjev for insulin pump use","code_information":[{"code":"J1813","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":16.76,"maximum":42.14,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":16.86},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":29.02},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":29.02},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":29.02},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16.76},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28.64},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":42.14}]}]},{"description":"Laronidase injection","code_information":[{"code":"J1931","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":31.12,"maximum":105.14,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":41.49,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":42.47},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":75.77},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":75.77},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":75.77},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":80.07,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":41.81},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":31.12,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":71.45},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":105.14},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":42.32,"additional_payer_notes":"APC"}]}]},{"description":"Leuprolide inj, camcevi, 1mg","code_information":[{"code":"J1952","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":31.54,"maximum":152.21,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":42.06,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":57.62},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":97.67},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":97.67},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":97.67},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":81.17,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":60.53},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":31.54,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":103.43},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":152.21},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":42.9,"additional_payer_notes":"APC"}]}]},{"description":"Linezolid injection","code_information":[{"code":"J2020","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3.23,"maximum":8.12,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3.82},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":6.59},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":6.59},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":6.59},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3.23},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5.51},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8.12}]}]},{"description":"Meropenem","code_information":[{"code":"J2185","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":0.42,"maximum":1.06,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":0.47},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.83},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.83},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.83},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.42},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.72},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1.06}]}]},{"description":"Inj, mirikizumab-mrkz, 1 mg","code_information":[{"code":"J2267","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":24.49,"maximum":123.57,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":32.66,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":52.33},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":91.72},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":91.72},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":91.72},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":63.03,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":49.15},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":24.49,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":83.97},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":123.57},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":33.31,"additional_payer_notes":"APC"}]}]},{"description":"Inj, nafcillin sodium, 20 mg","code_information":[{"code":"J2290","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":0.11,"maximum":0.76,"payers_information":[{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.11},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.11},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.11},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.76}]}]},{"description":"Inj ublituximab-xiiy, 1 mg","code_information":[{"code":"J2329","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":54.18,"maximum":187.94,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":72.24,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":75.53},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":136.62},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":136.62},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":136.62},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":139.42,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":74.74},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":54.18,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":127.71},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":187.94},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":73.68,"additional_payer_notes":"APC"}]}]},{"description":"Inj. olanzapine, 0.5mg","code_information":[{"code":"J2359","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":0.81,"maximum":2.05,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1.02},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1.73},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1.73},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1.73},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.81},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1.39},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2.05}]}]},{"description":"Ondansetron hcl injection","code_information":[{"code":"J2405","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":0.09,"maximum":0.25,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":0.1},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.17},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.17},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.17},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.09},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.17},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.25}]}]},{"description":"Palonosetron hcl","code_information":[{"code":"J2469","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":0.55,"maximum":1.6,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":0.55},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.85},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.85},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.85},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.64},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1.09},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1.6}]}]},{"description":"Pentamidine non-comp unit","code_information":[{"code":"J2545","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":85.95,"maximum":216.13,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":87.45},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":156.5},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":156.5},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":156.5},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":85.95},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":146.87},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":216.13}]}]},{"description":"Inj progesterone per 50 MG","code_information":[{"code":"J2675","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":0.73,"maximum":2.43,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":0.73},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1.19},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1.19},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1.19},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.97},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1.65},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2.43}]}]},{"description":"Phentolaine mesylate inj","code_information":[{"code":"J2760","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":216.47,"maximum":1074.38,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":288.62,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":494.23},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":829.36},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":829.36},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":829.36},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":557.05,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":427.27},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":216.47,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":730.07},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1074.38},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":294.4,"additional_payer_notes":"APC"}]}]},{"description":"Regadenoson injection","code_information":[{"code":"J2785","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4.12,"maximum":10.38,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4.85},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5.49},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5.49},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5.49},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":4.12},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7.05},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10.38}]}]},{"description":"Inj., perseris, 0.5 mg","code_information":[{"code":"J2798","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":9.15,"maximum":33.18,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.2,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":13.37},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23.06},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23.06},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23.06},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":23.55,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13.2},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9.15,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22.55},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33.18},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.45,"additional_payer_notes":"APC"}]}]},{"description":"Inj sulfameth/trim 5 mg/1 mg","code_information":[{"code":"J2865","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":0.07,"maximum":0.1,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":0.07},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.1},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.1},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.1}]}]},{"description":"Inj, taliglucerace alfa 10 u","code_information":[{"code":"J3060","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":32.01,"maximum":113.31,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":42.68,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":44.7},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":78.02},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":78.02},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":78.02},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":82.36,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":45.06},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":32.01,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":77.0},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":113.31},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":43.53,"additional_payer_notes":"APC"}]}]},{"description":"Chlorpromazine hcl injection","code_information":[{"code":"J3230","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":31.94,"maximum":82.98,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":31.94},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":51.43},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":51.43},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":51.43},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33.0},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":56.39},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":82.98}]}]},{"description":"Tobramycin sulfate injection","code_information":[{"code":"J3260","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1.76,"maximum":5.36,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1.76},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4.67},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4.67},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4.67},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2.13},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3.64},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5.36}]}]},{"description":"Triptorelin pamoate","code_information":[{"code":"J3315","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":349.77,"maximum":1310.31,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":466.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":518.79},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":934.61},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":934.61},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":934.61},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":900.08,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":521.11},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":349.77,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":890.39},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1310.31},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":475.69,"additional_payer_notes":"APC"}]}]},{"description":"Velaglucerase alfa","code_information":[{"code":"J3385","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":294.63,"maximum":1018.26,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":392.84,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":411.8},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":722.35},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":722.35},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":722.35},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":758.19,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":404.96},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":294.63,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":691.94},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1018.26},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":400.7,"additional_payer_notes":"APC"}]}]},{"description":"Injection, Fulvestrant","code_information":[{"code":"J9395","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7.2,"maximum":18.13,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7.59},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13.26},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13.26},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13.26},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7.2},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12.32},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18.13}]}]},{"description":"Ondansetron oral","code_information":[{"code":"Q0162","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":0.01,"maximum":0.03,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":0.01},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.03},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.03},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.03},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.02},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.03}]}]},{"description":"Brexucabtagene car pos t","code_information":[{"code":"Q2053","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":382577.94,"maximum":1328720.23,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":510103.92,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":538339.08},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":930468.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":930468.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":930468.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":984500.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":382577.94,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":902895.29},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1328720.23},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":520306.0,"additional_payer_notes":"APC"}]}]},{"description":"Oasis wound matrix","code_information":[{"code":"Q4102","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":13.21,"maximum":237.56,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":123.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":13.21},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22.24},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22.24},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22.24},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":237.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":92.32,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22.33},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32.87},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":125.55,"additional_payer_notes":"APC"}]}]},{"description":"Alloskin","code_information":[{"code":"Q4115","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":13.62,"maximum":237.56,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":123.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":13.62},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27.5},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27.5},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27.5},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":237.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":92.32,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28.03},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":41.25},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":125.55,"additional_payer_notes":"APC"}]}]},{"description":"Grafix core","code_information":[{"code":"Q4132","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":41.25,"maximum":372.57,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":123.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":41.25},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":169.45},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":169.45},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":169.45},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":237.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":92.32,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":253.17},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":372.57},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":125.55,"additional_payer_notes":"APC"}]}]},{"description":"Neox 1k, 1cm","code_information":[{"code":"Q4148","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":92.32,"maximum":347.14,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":123.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":141.27},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":239.52},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":239.52},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":239.52},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":237.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":92.32,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":235.89},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":347.14},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":125.55,"additional_payer_notes":"APC"}]}]},{"description":"Marigen 1 square cm","code_information":[{"code":"Q4158","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":69.98,"maximum":237.56,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":123.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":69.98},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":126.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":126.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":126.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":237.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":92.32,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":139.6},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":205.44},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":125.55,"additional_payer_notes":"APC"}]}]},{"description":"Cygnus, per sq cm","code_information":[{"code":"Q4170","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":78.95,"maximum":2093.95,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":123.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":489.21},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":78.95},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":78.95},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":78.95},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":237.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":92.32,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2093.95},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":125.55,"additional_payer_notes":"APC"}]}]},{"description":"Epicord 1 sq cm","code_information":[{"code":"Q4187","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":92.32,"maximum":660.83,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":123.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":271.72},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":459.55},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":459.55},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":459.55},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":237.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":92.32,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":449.05},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":660.83},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":125.55,"additional_payer_notes":"APC"}]}]},{"description":"Puraply xt 1 sq cm","code_information":[{"code":"Q4197","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":80.89,"maximum":237.56,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":123.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":80.89},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":134.97},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":134.97},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":134.97},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":237.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":92.32,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":134.38},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":197.77},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":125.55,"additional_payer_notes":"APC"}]}]},{"description":"Progenamatrix, per sq cm","code_information":[{"code":"Q4222","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":92.32,"maximum":318.42,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":123.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":149.52},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":242.34},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":242.34},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":242.34},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":237.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":92.32,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":216.38},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":318.42},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":125.55,"additional_payer_notes":"APC"}]}]},{"description":"Derm-maxx, per sq cm","code_information":[{"code":"Q4238","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":92.32,"maximum":4241.62,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":123.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1809.49},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3277.58},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3277.58},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3277.58},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":237.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":92.32,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2882.28},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":4241.62},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":125.55,"additional_payer_notes":"APC"}]}]},{"description":"Relese, per sq cm","code_information":[{"code":"Q4257","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":92.32,"maximum":1327.82,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":123.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":544.43},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1240.06},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1240.06},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1240.06},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":237.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":92.32,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":902.28},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1327.82},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":125.55,"additional_payer_notes":"APC"}]}]},{"description":"Neostim dl per sq cm","code_information":[{"code":"Q4267","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":92.32,"maximum":1010.89,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":123.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":302.07},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":551.03},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":551.03},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":551.03},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":237.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":92.32,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":686.92},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1010.89},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":125.55,"additional_payer_notes":"APC"}]}]},{"description":"Xcell amnio matrix per sq cm","code_information":[{"code":"Q4280","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":92.32,"maximum":5609.44,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":123.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3570.66},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5496.42},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5496.42},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5496.42},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":237.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":92.32,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3811.74},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5609.44},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":125.55,"additional_payer_notes":"APC"}]}]},{"description":"Amnio tri-core, per sq cm","code_information":[{"code":"Q4295","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":92.32,"maximum":7188.98,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":123.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2565.2},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4873.88},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4873.88},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4873.88},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":237.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":92.32,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7188.98},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":125.55,"additional_payer_notes":"APC"}]}]},{"description":"Complete aa, per sq cm","code_information":[{"code":"Q4303","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":92.32,"maximum":9291.32,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":123.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3737.14},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":6399.2},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":6399.2},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":6399.2},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":237.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":92.32,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6313.66},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9291.32},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":125.55,"additional_payer_notes":"APC"}]}]},{"description":"Acapatch, per sq cm","code_information":[{"code":"Q4325","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":92.32,"maximum":7706.47,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":123.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2273.7},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3887.13},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3887.13},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3887.13},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":237.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":92.32,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7706.47},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":125.55,"additional_payer_notes":"APC"}]}]},{"description":"Dermacyte ac matrx per sq cm","code_information":[{"code":"Q4343","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":92.32,"maximum":7585.73,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":123.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3247.31},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5608.99},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5608.99},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5608.99},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":237.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":92.32,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7585.73},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":125.55,"additional_payer_notes":"APC"}]}]},{"description":"Inj Retacrit esrd on dialysi","code_information":[{"code":"Q5105","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":0.78,"maximum":2.05,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":0.78},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1.44},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1.44},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1.44},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1.39},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2.05}]}]},{"description":"Inj  ogivri 10 mg","code_information":[{"code":"Q5114","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":23.96,"maximum":141.14,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":31.94,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":51.5},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":84.72},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":84.72},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":84.72},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":61.65,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23.96,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":95.9},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":141.14},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":32.58,"additional_payer_notes":"APC"}]}]},{"description":"Inj, nyvepria","code_information":[{"code":"Q5122","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":102.68,"maximum":318.57,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":136.91,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":147.68},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":250.87},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":250.87},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":250.87},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":264.24,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":102.68,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":216.47},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":318.57},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":139.65,"additional_payer_notes":"APC"}]}]},{"description":"Inj, fylnetra, 0.5 mg","code_information":[{"code":"Q5130","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":78.83,"maximum":499.64,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":105.11,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":180.57},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":283.5},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":283.5},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":283.5},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":202.86,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":78.83,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":339.51},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":499.64},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":107.21,"additional_payer_notes":"APC"}]}]},{"description":"HOCM <=149 mg/ml iodine, 1ml","code_information":[{"code":"Q9958","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":0.09,"maximum":0.2,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":0.09},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.14},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.14},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.14},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.13},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.2}]}]},{"description":"Dbrdmt prmlg les w/pdt","code_information":[{"code":"96574","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":148.84,"maximum":2334.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":198.45,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":383.01,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":148.84,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":202.42,"additional_payer_notes":"APC"}]}]},{"description":"Low cost skin substitute app","code_information":[{"code":"C5276","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":2334.0,"payers_information":[{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Perc d-e cor revasc t cabg b","code_information":[{"code":"C9605","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Cystoscopy prostatic imp 1-3","code_information":[{"code":"C9739","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3977.55,"maximum":10235.57,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5303.4,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":10235.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3977.55,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5409.47,"additional_payer_notes":"APC"}]}]},{"description":"Cysto, litho, vacuum kidney","code_information":[{"code":"C9761","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7022.52,"maximum":18071.3,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9363.37,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":18071.3,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7022.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9550.63,"additional_payer_notes":"APC"}]}]},{"description":"Revasc lithotrip tibi/perone","code_information":[{"code":"C9772","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8563.85,"maximum":27583.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11418.47,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":22037.64,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8563.85,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":27583.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11646.84,"additional_payer_notes":"APC"}]}]},{"description":"Open tx iliac spine uni/bil","code_information":[{"code":"G0412","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Hep b ig im","code_information":[{"code":"90371","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":102.71,"maximum":398.33,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":136.95,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":157.54},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":248.26},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":248.26},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":248.26},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":264.32,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":102.71,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":270.67},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":398.33},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":139.69,"additional_payer_notes":"APC"}]}]},{"description":"Iiv3 vaccine splt 0.5 ml im","code_information":[{"code":"90658","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":24.05,"maximum":59.52,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":24.05},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":41.53},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":41.53},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":41.53},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":40.44},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":59.52}]}]},{"description":"Pcv20 vaccine im","code_information":[{"code":"90677","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":344.19,"maximum":811.42,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":344.19},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":594.51},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":594.51},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":594.51},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":551.37},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":811.42}]}]},{"description":"Hepb vacc 3 dose ped/adol im","code_information":[{"code":"90744","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":34.84,"maximum":83.77,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":34.84},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":60.17},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":60.17},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":60.17},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":56.92},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":83.77}]}]},{"description":"Sarscov2 vac 25 mcg/.25ml im","code_information":[{"code":"91321","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":161.77,"maximum":400.37,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":161.77},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":279.41},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":279.41},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":279.41},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":272.06},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":400.37}]}]},{"description":"Gadoxetate disodium inj","code_information":[{"code":"A9581","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":16.18,"maximum":40.03,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":16.18},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27.94},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27.94},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27.94},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27.2},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":40.03}]}]},{"description":"Acetylcysteine injection","code_information":[{"code":"J0132","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":0.5,"maximum":1.5,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":0.5},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.7},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.7},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.7},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.59},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1.02},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1.5}]}]},{"description":"Inj epinephrine (bpi)","code_information":[{"code":"J0166","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4.34,"maximum":4.34,"payers_information":[{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4.34},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4.34},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4.34}]}]},{"description":"Aflibercept injection","code_information":[{"code":"J0178","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":557.7,"maximum":2180.92,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":743.6,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":875.45},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1501.07},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1501.07},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1501.07},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1435.16,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":867.33},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":557.7,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1481.98},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2180.92},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":758.48,"additional_payer_notes":"APC"}]}]},{"description":"Inj aval alfa-nqpt 4mg","code_information":[{"code":"J0219","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":62.96,"maximum":211.98,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":83.94,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":85.6},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":153.43},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":153.43},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":153.43},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":162.01,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":84.3},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":62.96,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":144.04},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":211.98},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":85.62,"additional_payer_notes":"APC"}]}]},{"description":"Glassia injection","code_information":[{"code":"J0257","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4.19,"maximum":15.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5.58,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10.85},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10.85},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10.85},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":10.78,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5.97},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4.19,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10.19},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5.69,"additional_payer_notes":"APC"}]}]},{"description":"Amphotericin b liposome inj","code_information":[{"code":"J0289","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":14.88,"maximum":65.29,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19.84,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":25.64},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":42.97},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":42.97},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":42.97},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":38.3,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25.96},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14.88,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":44.36},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":65.29},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20.24,"additional_payer_notes":"APC"}]}]},{"description":"Inj, abilify asimtufii, 1 mg","code_information":[{"code":"J0402","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4.64,"maximum":16.12,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6.18,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6.46},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11.46},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11.46},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11.46},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11.94,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6.4},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4.64,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10.95},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16.12},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6.31,"additional_payer_notes":"APC"}]}]},{"description":"Belimumab injection","code_information":[{"code":"J0490","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":43.72,"maximum":149.49,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":58.3,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":60.47},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":106.41},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":106.41},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":106.41},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":112.51,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":59.45},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":43.72,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":101.58},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":149.49},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":59.46,"additional_payer_notes":"APC"}]}]},{"description":"Inj, brixadi, 7 days or less","code_information":[{"code":"J0577","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":322.93,"maximum":1167.03,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":430.58,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":467.94},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":803.37},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":803.37},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":803.37},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":831.01,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":464.11},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":322.93,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":793.02},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1167.03},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":439.19,"additional_payer_notes":"APC"}]}]},{"description":"Inj daxibotulinumtoxina-lanm","code_information":[{"code":"J0589","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2.3,"maximum":8.51,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3.07,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3.29},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5.91},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5.91},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5.91},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5.92,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2.3,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8.51},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3.13,"additional_payer_notes":"APC"}]}]},{"description":"Edetate calcium disodium inj","code_information":[{"code":"J0600","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4642.12,"maximum":16563.97,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6189.49,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7106.03},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12263.68},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12263.68},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12263.68},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11945.71,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6587.41},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4642.12,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11255.59},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16563.97},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6313.28,"additional_payer_notes":"APC"}]}]},{"description":"Injection, khapzory, 0.5 mg","code_information":[{"code":"J0642","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1.3,"maximum":3.68,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1.3},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2.13},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2.13},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2.13},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1.46},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2.5},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3.68}]}]},{"description":"Inj cefazolin sodium, hikma","code_information":[{"code":"J0688","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1.08,"maximum":2.72,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1.08},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1.74},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1.74},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1.74},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1.08},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1.85},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2.72}]}]},{"description":"Inj, cefiderocol, 10 mg","code_information":[{"code":"J0699","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1.91,"maximum":6.2,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2.55,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2.51},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4.56},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4.56},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4.56},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4.92,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2.47},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1.91,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":4.22},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6.2},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2.6,"additional_payer_notes":"APC"}]}]},{"description":"Chorionic gonadotropin/1000u","code_information":[{"code":"J0725","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":20.08,"maximum":53.56,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":20.08},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":33.27},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":33.27},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":33.27},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21.3},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36.39},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":53.56}]}]},{"description":"Cilastatin sodium injection","code_information":[{"code":"J0743","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7.8,"maximum":19.6,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":8.07},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13.25},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13.25},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13.25},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7.8},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13.32},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19.6}]}]},{"description":"Inj. acthar gel to 40 units","code_information":[{"code":"J0801","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3100.09,"maximum":10421.27,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4133.45,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4282.77},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7956.11},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7956.11},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7956.11},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7977.56,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":4144.48},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3100.09,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7081.49},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10421.27},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4216.12,"additional_payer_notes":"APC"}]}]},{"description":"Inj, daptomycin (xellia)","code_information":[{"code":"J0873","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":0.03,"maximum":0.12,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":0.03},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.08},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.08},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.08},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.04},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.07},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.12}]}]},{"description":"Argatroban esrd dialysis 1mg","code_information":[{"code":"J0884","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":0.87,"maximum":2.18,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1.05},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1.4},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1.4},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1.4},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.87},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1.48},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2.18}]}]},{"description":"Denosumab injection","code_information":[{"code":"J0897","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":22.58,"maximum":75.31,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":30.1,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":30.59},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":55.55},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":55.55},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":55.55},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":58.09,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29.94},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22.58,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":51.17},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":75.31},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":30.7,"additional_payer_notes":"APC"}]}]},{"description":"Vitamin k phytonadione inj","code_information":[{"code":"J3430","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2.39,"maximum":6.02,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2.7},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5.4},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5.4},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5.4},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2.39},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":4.09},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6.02}]}]},{"description":"Ziprasidone mesylate","code_information":[{"code":"J3486","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5.7,"maximum":19.57,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5.7},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5.96},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5.96},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5.96},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7.79},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13.3},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19.57}]}]},{"description":"Ringers lactate infusion","code_information":[{"code":"J7120","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2.53,"maximum":6.57,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2.53},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4.68},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4.68},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4.68},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2.61},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":4.46},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6.57}]}]},{"description":"Factor XIII anti-hem factor","code_information":[{"code":"J7180","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8.43,"maximum":28.51,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11.24,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":11.53},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20.48},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20.48},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20.48},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":21.68,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11.34},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8.43,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19.37},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28.51},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11.46,"additional_payer_notes":"APC"}]}]},{"description":"Factor viia","code_information":[{"code":"J7189","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2.08,"maximum":6.95,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2.77,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2.78},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5.03},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5.03},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5.03},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5.35,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2.76},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2.08,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":4.72},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6.95},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2.83,"additional_payer_notes":"APC"}]}]},{"description":"Factor ix recombinan rixubis","code_information":[{"code":"J7200","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1.29,"maximum":4.49,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1.72,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1.79},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2.98},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2.98},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2.98},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3.31,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1.79},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1.29,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3.05},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":4.49},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1.75,"additional_payer_notes":"APC"}]}]},{"description":"Factor viii nuwiq recomb 1iu","code_information":[{"code":"J7209","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":0.92,"maximum":3.38,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1.22,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1.31},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2.23},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2.23},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2.23},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2.36,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1.34},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":0.92,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2.29},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3.38},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1.25,"additional_payer_notes":"APC"}]}]},{"description":"Dexamethasone intra implant","code_information":[{"code":"J7312","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":152.74,"maximum":559.63,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":203.66,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":225.76},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":390.02},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":390.02},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":390.02},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":393.06,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":222.56},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":152.74,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":380.29},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":559.63},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":207.73,"additional_payer_notes":"APC"}]}]},{"description":"Orthovisc inj per dose","code_information":[{"code":"J7324","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":75.25,"maximum":250.85,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":100.33,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":137.83},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":185.63},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":185.63},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":185.63},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":193.64,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":99.76},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":75.25,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":170.46},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":250.85},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":102.34,"additional_payer_notes":"APC"}]}]},{"description":"Capsaicin 8% patch","code_information":[{"code":"J7336","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2.63,"maximum":9.06,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3.51,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3.72},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":6.42},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":6.42},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":6.42},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6.77,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3.61},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2.63,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6.16},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9.06},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3.58,"additional_payer_notes":"APC"}]}]},{"description":"Cyclosporine oral 100 mg","code_information":[{"code":"J7502","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2.22,"maximum":5.99,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2.22},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3.93},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3.93},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3.93},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2.38},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":4.07},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5.99}]}]},{"description":"Prednisone ir or dr oral 1mg","code_information":[{"code":"J7512","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":0.01,"maximum":0.03,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":0.01},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.01},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.01},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.01},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.01},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.02},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.03}]}]},{"description":"Tacrolimus injection","code_information":[{"code":"J7525","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":201.13,"maximum":693.35,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":268.18,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":280.57},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":498.24},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":498.24},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":498.24},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":517.58,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":275.74},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":201.13,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":471.14},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":693.35},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":273.54,"additional_payer_notes":"APC"}]}]},{"description":"Albuterol non-comp unit","code_information":[{"code":"J7613","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":0.08,"maximum":0.2,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":0.09},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.14},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.14},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.14},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.08},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.13},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.2}]}]},{"description":"Revefenacin inh non-com 1mcg","code_information":[{"code":"J7677","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":0.22,"maximum":0.54,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":0.22},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.36},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.36},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.36},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.22},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.37},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.54}]}]},{"description":"Methotrexate oral 2.5 MG","code_information":[{"code":"J8610","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":0.19,"maximum":0.5,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":0.22},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.38},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.38},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.38},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.19},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.33},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.5}]}]},{"description":"Arsenic trioxide injection","code_information":[{"code":"J9017","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5.07,"maximum":12.74,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5.27},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11.13},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11.13},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11.13},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5.07},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8.66},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12.74}]}]},{"description":"Inj, nogapendekin pmln, 1mcg","code_information":[{"code":"J9028","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":70.73,"maximum":258.29,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":94.31,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":104.04},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":178.82},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":178.82},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":178.82},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":182.01,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":102.72},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":70.73,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":175.51},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":258.29},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":96.19,"additional_payer_notes":"APC"}]}]},{"description":"Injection, blinatumomab","code_information":[{"code":"J9039","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":129.68,"maximum":415.21,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":172.9,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":167.51},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":310.09},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":310.09},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":310.09},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":333.7,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":165.12},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":129.68,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":282.14},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":415.21},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":176.36,"additional_payer_notes":"APC"}]}]},{"description":"Carmustine injection","code_information":[{"code":"J9050","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":160.16,"maximum":695.11,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":240.01,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":160.16},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":329.92},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":329.92},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":329.92},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":463.22,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":276.44},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":180.01,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":472.34},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":695.11},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":244.81,"additional_payer_notes":"APC"}]}]},{"description":"Inj cyclophos dr.reddy's 5mg","code_information":[{"code":"J9072","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6.69,"maximum":28.59,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8.92,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":9.96},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17.11},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17.11},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17.11},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":17.22,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6.69,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28.59},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9.1,"additional_payer_notes":"APC"}]}]},{"description":"Dactinomycin injection","code_information":[{"code":"J9120","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":230.56,"maximum":884.27,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":307.41,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":317.68},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":575.55},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":575.55},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":575.55},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":593.3,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":351.67},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":230.56,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":600.88},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":884.27},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":313.56,"additional_payer_notes":"APC"}]}]},{"description":"Docetaxel (ingenus), 1 mg","code_information":[{"code":"J9172","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":34.72,"maximum":142.15,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":46.29,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":56.78},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":93.25},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":93.25},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":93.25},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":89.33,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":56.53},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":34.72,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":96.59},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":142.15},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":47.21,"additional_payer_notes":"APC"}]}]},{"description":"Fluorouracil injection","code_information":[{"code":"J9190","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2.41,"maximum":6.07,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2.43},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3.26},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3.26},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3.26},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2.41},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":4.13},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6.07}]}]},{"description":"Irinotecan injection","code_information":[{"code":"J9206","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1.8,"maximum":5.36,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1.8},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2.65},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2.65},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2.65},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2.14},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3.64},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5.36}]}]},{"description":"Supprelin LA implant","code_information":[{"code":"J9226","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":28118.98,"maximum":123225.25,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":37491.97,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":49733.24},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":86564.74},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":86564.74},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":86564.74},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":72359.51,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":49006.08},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":28118.98,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":83734.33},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":123225.25},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":38241.81,"additional_payer_notes":"APC"}]}]},{"description":"Nelarabine injection","code_information":[{"code":"J9261","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":49.06,"maximum":203.53,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":65.41,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":69.5},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":120.42},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":120.42},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":120.42},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":126.24,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":80.94},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":49.06,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":138.31},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":203.53},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":66.72,"additional_payer_notes":"APC"}]}]},{"description":"Inj, dostarlimab-gxly, 10 mg","code_information":[{"code":"J9272","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":188.47,"maximum":653.57,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":251.3,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":264.15},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":463.26},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":463.26},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":463.26},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":485.01,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":259.92},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":188.47,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":444.11},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":653.57},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":256.32,"additional_payer_notes":"APC"}]}]},{"description":"Mitoxantrone hydrochl / 5 MG","code_information":[{"code":"J9293","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":22.28,"maximum":165.58,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":29.7,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":30.46},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":56.24},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":56.24},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":56.24},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":57.32,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":65.85},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22.28,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":112.52},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":165.58},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":30.3,"additional_payer_notes":"APC"}]}]},{"description":"Panitumumab injection","code_information":[{"code":"J9303","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":136.64,"maximum":451.14,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":182.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":181.41},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":327.84},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":327.84},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":327.84},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":351.62,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":179.42},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":136.64,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":306.56},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":451.14},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":185.83,"additional_payer_notes":"APC"}]}]},{"description":"Inj., rituximab, 10 mg","code_information":[{"code":"J9312","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":54.96,"maximum":208.89,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":73.28,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":84.07},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":144.27},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":144.27},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":144.27},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":141.43,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":83.08},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":54.96,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":141.95},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":208.89},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":74.74,"additional_payer_notes":"APC"}]}]},{"description":"Inj, pemrydi rtu, 10 mg","code_information":[{"code":"J9324","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":50.95,"maximum":223.62,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":67.94,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":89.17},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":152.19},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":152.19},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":152.19},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":131.11,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":88.93},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":50.95,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":151.96},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":223.62},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":69.29,"additional_payer_notes":"APC"}]}]},{"description":"Inj efgart-alfa 2mg hya-qvfc","code_information":[{"code":"J9334","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":25.69,"maximum":90.12,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":34.26,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":36.71},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":64.1},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":64.1},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":64.1},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":66.12,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35.84},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25.69,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":61.24},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":90.12},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":34.94,"additional_payer_notes":"APC"}]}]},{"description":"Injection trabectedin 0.1mg","code_information":[{"code":"J9352","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":307.86,"maximum":987.59,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":410.48,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":400.21},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":727.83},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":727.83},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":727.83},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":792.22,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":392.76},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":307.86,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":671.09},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":987.59},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":418.69,"additional_payer_notes":"APC"}]}]},{"description":"Vinblastine sulfate inj","code_information":[{"code":"J9360","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5.23,"maximum":13.15,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5.65},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10.05},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10.05},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10.05},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5.23},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8.94},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13.15}]}]},{"description":"Albumin (human),5%, 50ml","code_information":[{"code":"P9041","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7.96,"maximum":28.91,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10.62,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":11.68},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20.17},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20.17},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20.17},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":20.49,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7.96,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19.65},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28.91},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10.83,"additional_payer_notes":"APC"}]}]},{"description":"Inj, pemivibart, 4500 mg","code_information":[{"code":"Q0224","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7241.85,"maximum":17923.59,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7241.85},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13754.1},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13754.1},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13754.1},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12179.48},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17923.59}]}]},{"description":"Idecabtagene vicleucel car","code_information":[{"code":"Q2055","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":425983.34,"maximum":1438330.59,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":567977.78,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":580384.71},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1028394.85},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1028394.85},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1028394.85},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1096197.12,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":425983.34,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":977378.0},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1438330.59},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":579337.34,"additional_payer_notes":"APC"}]}]},{"description":"Integra bmwd","code_information":[{"code":"Q4104","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":54.77,"maximum":237.56,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":123.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":54.77},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":102.14},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":102.14},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":102.14},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":237.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":92.32,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":96.94},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":142.66},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":125.55,"additional_payer_notes":"APC"}]}]},{"description":"Theraskin","code_information":[{"code":"Q4121","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":56.97,"maximum":237.56,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":123.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":56.97},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":92.82},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":92.82},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":92.82},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":237.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":92.32,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":89.63},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":131.9},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":125.55,"additional_payer_notes":"APC"}]}]},{"description":"Amnioexcel or biodexcel, 1cm","code_information":[{"code":"Q4137","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":92.32,"maximum":317.66,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":123.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":112.4},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":191.36},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":191.36},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":191.36},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":237.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":92.32,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":215.86},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":317.66},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":125.55,"additional_payer_notes":"APC"}]}]},{"description":"Amnioband, guardian 1 sq cm","code_information":[{"code":"Q4151","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":92.32,"maximum":390.46,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":123.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":150.13},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":260.66},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":260.66},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":260.66},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":237.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":92.32,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":265.33},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":390.46},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":125.55,"additional_payer_notes":"APC"}]}]},{"description":"Nushield 1 square cm","code_information":[{"code":"Q4160","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":92.32,"maximum":1007.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":123.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":101.92},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1007.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1007.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1007.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":237.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":92.32,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":173.77},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":255.72},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":125.55,"additional_payer_notes":"APC"}]}]},{"description":"Palingen or palingen xplus","code_information":[{"code":"Q4173","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":92.32,"maximum":3102.4,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":123.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":396.56},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":677.45},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":677.45},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":677.45},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":237.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":92.32,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3102.4},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":125.55,"additional_payer_notes":"APC"}]}]},{"description":"Artacent ac 1 sq cm","code_information":[{"code":"Q4190","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":92.32,"maximum":641.67,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":123.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":195.24},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":245.89},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":245.89},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":245.89},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":237.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":92.32,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":436.03},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":641.67},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":125.55,"additional_payer_notes":"APC"}]}]},{"description":"Matrion 1 sq cm","code_information":[{"code":"Q4201","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":92.32,"maximum":237.56,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":123.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":94.99},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":150.53},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":150.53},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":150.53},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":237.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":92.32,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":157.31},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":231.5},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":125.55,"additional_payer_notes":"APC"}]}]},{"description":"Amniocore per sq cm","code_information":[{"code":"Q4227","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":92.32,"maximum":3423.32,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":123.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1311.75},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2214.24},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2214.24},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2214.24},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":237.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":92.32,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3423.32},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":125.55,"additional_payer_notes":"APC"}]}]},{"description":"Dermacyte Amn mem allo sq cm","code_information":[{"code":"Q4248","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":92.32,"maximum":7343.56,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":123.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3076.82},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5366.54},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5366.54},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5366.54},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":237.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":92.32,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7343.56},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":125.55,"additional_payer_notes":"APC"}]}]},{"description":"Celera per sq cm","code_information":[{"code":"Q4259","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":92.32,"maximum":3486.81,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":123.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1072.79},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1788.77},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1788.77},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1788.77},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":237.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":92.32,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2369.37},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3486.81},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":125.55,"additional_payer_notes":"APC"}]}]},{"description":"Complete ft per sq cm","code_information":[{"code":"Q4271","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":92.32,"maximum":4197.04,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":123.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1539.03},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2299.92},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2299.92},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2299.92},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":237.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":92.32,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2851.98},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":4197.04},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":125.55,"additional_payer_notes":"APC"}]}]},{"description":"Cygnus dual per sq cm","code_information":[{"code":"Q4282","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":92.32,"maximum":1325.26,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":123.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":536.04},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":639.85},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":639.85},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":639.85},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":237.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":92.32,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":900.54},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1325.26},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":125.55,"additional_payer_notes":"APC"}]}]},{"description":"Emerge matrix, per sq cm","code_information":[{"code":"Q4297","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":92.32,"maximum":4868.26,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":123.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1923.04},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3224.97},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3224.97},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3224.97},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":237.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":92.32,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3308.1},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":4868.26},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":125.55,"additional_payer_notes":"APC"}]}]},{"description":"Via matrix, per sq cm","code_information":[{"code":"Q4309","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":92.32,"maximum":5720.1,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":123.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1456.37},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2486.25},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2486.25},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2486.25},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":237.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":92.32,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5720.1},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":125.55,"additional_payer_notes":"APC"}]}]},{"description":"Most, per sq cm","code_information":[{"code":"Q4328","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":92.32,"maximum":9512.75,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":123.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4081.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":6979.29},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":6979.29},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":6979.29},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":237.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":92.32,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9512.75},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":125.55,"additional_payer_notes":"APC"}]}]},{"description":"Xwrap plus, per sq cm","code_information":[{"code":"Q4357","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":92.32,"maximum":9063.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":123.09,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":9063.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":9063.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":9063.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":237.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":92.32,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":125.55,"additional_payer_notes":"APC"}]}]},{"description":"Inj mvasi 10 mg","code_information":[{"code":"Q5107","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":18.4,"maximum":78.21,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":24.53,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":32.8},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":54.81},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":54.81},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":54.81},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":47.35,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18.4,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":53.15},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":78.21},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25.02,"additional_payer_notes":"APC"}]}]},{"description":"Inj., trazimera, 10 mg","code_information":[{"code":"Q5116","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":9.77,"maximum":54.37,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.03,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":27.42},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":54.37},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":54.37},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":54.37},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":25.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9.77,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35.09},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":51.65},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.29,"additional_payer_notes":"APC"}]}]},{"description":"Inj. byooviz, 0.1 mg","code_information":[{"code":"Q5124","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":94.13,"maximum":465.08,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":240.97,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":94.13},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":118.09},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":118.09},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":118.09},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":465.08,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":180.73,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":313.02},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":460.65},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":245.79,"additional_payer_notes":"APC"}]}]},{"description":"Inj, tyenne, 1 mg","code_information":[{"code":"Q5135","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3.04,"maximum":11.19,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4.06,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4.48},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8.91},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8.91},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8.91},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7.83,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3.04,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7.6},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11.19},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4.14,"additional_payer_notes":"APC"}]}]},{"description":"HOCM 350-399mg/ml iodine,1ml","code_information":[{"code":"Q9963","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":0.24,"maximum":0.59,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":0.24},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.41},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.41},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.41},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.41},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.59}]}]},{"description":"Dexamethasone sodium phos","code_information":[{"code":"J1100","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":0.1,"maximum":0.3,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":0.1},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.23},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.23},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.23},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.11},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.2},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.3}]}]},{"description":"Dexrazoxane hcl injection","code_information":[{"code":"J1190","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":31.08,"maximum":220.19,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":41.44,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":89.06},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":60.96},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":60.96},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":60.96},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":79.98,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":87.57},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":31.08,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":149.63},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":220.19},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":42.27,"additional_payer_notes":"APC"}]}]},{"description":"Dipyridamole injection","code_information":[{"code":"J1245","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4.19,"maximum":10.54,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4.22},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7.34},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7.34},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7.34},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":4.19},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7.16},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10.54}]}]},{"description":"Inj, sutimlimab-jome, 10 mg","code_information":[{"code":"J1302","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":14.73,"maximum":49.35,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19.64,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":19.94},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":34.41},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":34.41},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":34.41},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":37.91,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19.63},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14.73,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33.54},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":49.35},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20.03,"additional_payer_notes":"APC"}]}]},{"description":"Epoprostenol injection","code_information":[{"code":"J1325","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":17.69,"maximum":44.76,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":17.69},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":30.78},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":30.78},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":30.78},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17.79},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30.41},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":44.76}]}]},{"description":"Inj. fe derisomaltose 10 mg","code_information":[{"code":"J1437","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":15.81,"maximum":56.55,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21.08,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":22.91},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":36.01},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":36.01},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":36.01},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":40.68,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22.49},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15.81,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38.42},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":56.55},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21.5,"additional_payer_notes":"APC"}]}]},{"description":"Fosaprepitant injection","code_information":[{"code":"J1453","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":0.13,"maximum":0.33,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":0.13},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.22},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.22},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.22},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.13},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.22},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.33}]}]},{"description":"Inj, alyglo, 500 mg","code_information":[{"code":"J1552","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":91.16,"maximum":399.91,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":121.54,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":151.92},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":249.13},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":249.13},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":249.13},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":234.58,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":159.04},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":91.16,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":271.75},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":399.91},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":123.97,"additional_payer_notes":"APC"}]}]},{"description":"Gamunex-c/gammaked","code_information":[{"code":"J1561","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":36.76,"maximum":133.44,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":49.01,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":53.19},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":91.26},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":91.26},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":91.26},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":94.6,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":53.06},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":36.76,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":90.67},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":133.44},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":49.99,"additional_payer_notes":"APC"}]}]},{"description":"Inj, panzyga, 500 mg","code_information":[{"code":"J1576","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":53.51,"maximum":188.13,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":71.35,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":77.47},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":141.47},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":141.47},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":141.47},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":137.7,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":74.81},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":53.51,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":127.84},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":188.13},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":72.77,"additional_payer_notes":"APC"}]}]},{"description":"Inj, granisetron, xr, 0.1 mg","code_information":[{"code":"J1627","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2.41,"maximum":15.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3.22,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5.82},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":9.42},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":9.42},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":9.42},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6.21,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5.97},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2.41,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10.19},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3.28,"additional_payer_notes":"APC"}]}]},{"description":"Dalteparin sodium","code_information":[{"code":"J1645","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":15.01,"maximum":37.74,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":17.64},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":34.28},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":34.28},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":34.28},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15.01},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25.64},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37.74}]}]},{"description":"Infliximab not biosimil 10mg","code_information":[{"code":"J1745","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":23.61,"maximum":83.11,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":31.48,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":33.57},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":59.24},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":59.24},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":59.24},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":60.75,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33.05},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23.61,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":56.48},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":83.11},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":32.11,"additional_payer_notes":"APC"}]}]},{"description":"Inj, esmolol hcl, 10mg","code_information":[{"code":"J1805","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":0.23,"maximum":0.58,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":0.31},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.54},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.54},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.54},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.23},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.39},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.58}]}]},{"description":"Ketorolac tromethamine inj","code_information":[{"code":"J1885","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":0.21,"maximum":2.05,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":0.29,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":0.55},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.66},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.66},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.66},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":0.55,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.81},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":0.21,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1.39},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2.05},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":0.29,"additional_payer_notes":"APC"}]}]},{"description":"Inj., aristada initio, 1 mg","code_information":[{"code":"J1943","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2.6,"maximum":8.51,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3.46,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3.45},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":6.18},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":6.18},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":6.18},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6.68,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3.39},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2.6,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5.79},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8.51},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3.53,"additional_payer_notes":"APC"}]}]},{"description":"Levofloxacin injection","code_information":[{"code":"J1956","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1.13,"maximum":5.15,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1.13},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3.72},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3.72},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3.72},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2.04},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3.5},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5.15}]}]},{"description":"Meperidine hydrochl /100 MG","code_information":[{"code":"J2175","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7.54,"maximum":29.82,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":11.15},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":29.82},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":29.82},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":29.82},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7.54},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12.88},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18.94}]}]},{"description":"Micafungin sodium injection","code_information":[{"code":"J2248","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":0.3,"maximum":0.76,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":0.31},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.59},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.59},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.59},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.3},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.52},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.76}]}]},{"description":"Inj, motixafortide, 0.25 mg","code_information":[{"code":"J2277","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":19.86,"maximum":68.66,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26.48,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":27.74},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":47.91},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":47.91},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":47.91},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":51.1,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27.3},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19.86,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":46.66},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":68.66},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27.01,"additional_payer_notes":"APC"}]}]},{"description":"Inj, naloxone (zimhi) 0.01mg","code_information":[{"code":"J2313","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":0.03,"maximum":0.03,"payers_information":[{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.03},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.03},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.03}]}]},{"description":"Octreotide inj, non-depot","code_information":[{"code":"J2354","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":0.65,"maximum":2.21,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":0.65},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1.15},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1.15},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1.15},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.88},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1.5},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2.21}]}]},{"description":"Inj, immphentiv, 20 mcg","code_information":[{"code":"J2373","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":0.15,"maximum":0.38,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":0.15},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.25},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.25},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.25},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.15},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.26},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.38}]}]},{"description":"Paliperidone palmitate inj","code_information":[{"code":"J2426","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":11.57,"maximum":40.1,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15.43,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":16.21},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28.66},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28.66},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28.66},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":29.78,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15.95},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11.57,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27.25},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":40.1},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15.74,"additional_payer_notes":"APC"}]}]},{"description":"Pegloticase injection","code_information":[{"code":"J2507","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2947.0,"maximum":9665.01,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3929.34,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3921.85},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":6913.84},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":6913.84},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":6913.84},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7583.62,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3843.73},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2947.0,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6567.59},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9665.01},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4007.92,"additional_payer_notes":"APC"}]}]},{"description":"Inj desmopressin acetate","code_information":[{"code":"J2597","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4.94,"maximum":13.48,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4.94},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7.4},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7.4},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7.4},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5.36},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9.16},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13.48}]}]},{"description":"Oxacillin sodium injeciton","code_information":[{"code":"J2700","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":0.7,"maximum":2.92,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":0.7},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1.56},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1.56},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1.56},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1.15},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1.98},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2.92}]}]},{"description":"Inj, susvimo 0.1 mg","code_information":[{"code":"J2779","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":56.1,"maximum":219.05,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":74.8,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":87.71},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":149.02},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":149.02},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":149.02},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":144.35,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":87.12},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":56.1,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":148.85},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":219.05},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":76.29,"additional_payer_notes":"APC"}]}]},{"description":"Rhophylac injection","code_information":[{"code":"J2791","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5.3,"maximum":13.32,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5.37},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":9.44},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":9.44},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":9.44},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5.3},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9.05},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13.32}]}]},{"description":"Inj, rifampin, 1 mg","code_information":[{"code":"J2804","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":0.15,"maximum":0.3,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":0.15},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.3},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.3},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.3}]}]},{"description":"Streptomycin injection","code_information":[{"code":"J3000","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":28.15,"maximum":76.94,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":28.15},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":59.57},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":59.57},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":59.57},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30.6},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":52.28},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":76.94}]}]},{"description":"Terbutaline sulfate inj","code_information":[{"code":"J3105","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1.55,"maximum":5.82,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1.55},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5.21},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5.21},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5.21},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2.32},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3.96},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5.82}]}]},{"description":"Inj., tildrakizumab, 1 mg","code_information":[{"code":"J3245","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":93.2,"maximum":362.59,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":124.27,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":144.61},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":239.85},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":239.85},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":239.85},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":239.85,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":144.19},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":93.2,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":246.38},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":362.59},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":126.76,"additional_payer_notes":"APC"}]}]},{"description":"Inj xipere 1 mg","code_information":[{"code":"J3299","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":35.83,"maximum":131.82,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":47.77,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":53.05},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":91.2},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":91.2},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":91.2},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":92.2,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":52.43},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":35.83,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":89.58},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":131.82},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":48.73,"additional_payer_notes":"APC"}]}]},{"description":"Inj, vancomycin hcl, 10 mg","code_information":[{"code":"J3373","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":0.06,"maximum":0.06,"payers_information":[{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.06},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.06},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.06}]}]},{"description":"Intrinsic factor antibody","code_information":[{"code":"86340","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":11.31,"maximum":29.1,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15.08,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":20.53},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18.85},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18.85},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18.85},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":29.1,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11.31,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26.39},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15.08},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15.38,"additional_payer_notes":"APC"}]}]},{"description":"Nk cells total count","code_information":[{"code":"86357","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":28.3,"maximum":76.34,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":37.73,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":76.34},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":47.16},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":47.16},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":47.16},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":72.82,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":28.3,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":66.03},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37.73},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":38.48,"additional_payer_notes":"APC"}]}]},{"description":"Stem cells total count","code_information":[{"code":"86367","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":58.34,"maximum":150.12,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":77.78,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":76.34},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":97.23},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":97.23},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":97.23},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":150.12,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":58.34,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":136.12},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":77.78},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":79.34,"additional_payer_notes":"APC"}]}]},{"description":"Neutrlzg antb sarscov2 scr","code_information":[{"code":"86408","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":31.6,"maximum":81.31,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":42.13,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":62.59},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":52.66},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":52.66},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":52.66},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":81.31,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":31.6,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":73.73},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":42.13},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":42.97,"additional_payer_notes":"APC"}]}]},{"description":"Streptokinase antibody","code_information":[{"code":"86590","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":9.5,"maximum":24.43,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.66,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":22.34},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15.83},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15.83},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15.83},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":24.43,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9.5,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22.16},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12.66},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.91,"additional_payer_notes":"APC"}]}]},{"description":"Bartonella Antibody","code_information":[{"code":"86611","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7.64,"maximum":19.65,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10.18,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":11.77},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12.73},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12.73},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12.73},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":19.65,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7.64,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17.82},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10.18},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10.38,"additional_payer_notes":"APC"}]}]},{"description":"Candida antibody","code_information":[{"code":"86628","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":9.01,"maximum":23.18,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.01,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":11.77},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15.01},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15.01},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15.01},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":23.18,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9.01,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21.02},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12.01},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.25,"additional_payer_notes":"APC"}]}]},{"description":"Diphtheria antibody","code_information":[{"code":"86648","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":11.41,"maximum":29.36,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15.21,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":11.77},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19.01},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19.01},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19.01},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":29.36,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11.41,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26.62},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15.21},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15.51,"additional_payer_notes":"APC"}]}]},{"description":"Epstein-barr capsid vca","code_information":[{"code":"86665","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":13.6,"maximum":36.72,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18.14,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":36.72},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22.68},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22.68},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22.68},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":35.01,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.6,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31.75},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18.14},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18.5,"additional_payer_notes":"APC"}]}]},{"description":"Htlv-i antibody","code_information":[{"code":"86687","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6.82,"maximum":17.54,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":16.98},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11.36},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11.36},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11.36},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":17.54,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6.82,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15.91},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9.09},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9.27,"additional_payer_notes":"APC"}]}]},{"description":"Hiv-1antibody","code_information":[{"code":"86701","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6.67,"maximum":17.99,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8.89,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":17.99},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11.11},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11.11},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11.11},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":17.16,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6.67,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15.56},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8.89},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9.07,"additional_payer_notes":"APC"}]}]},{"description":"Hepatitis a igm antibody","code_information":[{"code":"86709","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8.44,"maximum":22.76,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11.26,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":22.76},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14.08},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14.08},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14.08},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":21.73,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8.44,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19.71},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11.26},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11.49,"additional_payer_notes":"APC"}]}]},{"description":"Mucormycosis antibody","code_information":[{"code":"86732","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":11.25,"maximum":28.95,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":26.7},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18.75},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18.75},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18.75},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":28.95,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11.25,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26.25},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15.3,"additional_payer_notes":"APC"}]}]},{"description":"Respiratory virus antibody","code_information":[{"code":"86756","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":11.77,"maximum":30.67,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15.89,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":11.77},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19.86},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19.86},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19.86},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":30.67,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11.92,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27.81},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15.89},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16.21,"additional_payer_notes":"APC"}]}]},{"description":"Tetanus antibody","code_information":[{"code":"86774","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":11.1,"maximum":29.95,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14.8,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":29.95},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18.5},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18.5},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18.5},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":28.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11.1,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25.9},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14.8},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15.1,"additional_payer_notes":"APC"}]}]},{"description":"Virus antibody nos","code_information":[{"code":"86790","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":9.66,"maximum":24.86,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.88,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":11.77},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16.1},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16.1},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16.1},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":24.86,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9.66,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22.54},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12.88},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.14,"additional_payer_notes":"APC"}]}]},{"description":"Cytotoxic antibody screening","code_information":[{"code":"86807","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":58.99,"maximum":151.79,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":78.65,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":80.1},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":98.31},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":98.31},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":98.31},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":151.79,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":58.99,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":137.64},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":78.65},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":80.22,"additional_payer_notes":"APC"}]}]},{"description":"Hla x-match noncytotoxc addl","code_information":[{"code":"86826","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":27.4,"maximum":70.5,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":36.53,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":54.18},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":45.66},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":45.66},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":45.66},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":70.5,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27.4,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":63.93},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36.53},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":37.26,"additional_payer_notes":"APC"}]}]},{"description":"Hla class ii semiquant panel","code_information":[{"code":"86835","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":242.22,"maximum":653.52,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":322.96,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":653.52},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":403.7},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":403.7},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":403.7},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":623.31,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":242.22,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":565.18},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":322.96},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":329.42,"additional_payer_notes":"APC"}]}]},{"description":"Blood typing patient serum","code_information":[{"code":"86904","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":16.34,"maximum":112.62,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":58.35,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":19.25},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20.43},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20.43},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20.43},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":112.62,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":43.76,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28.6},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16.34},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":59.52,"additional_payer_notes":"APC"}]}]},{"description":"Feces culture aerobic bact","code_information":[{"code":"87045","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7.08,"maximum":19.09,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9.44,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":19.09},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11.8},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11.8},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11.8},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":18.22,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7.08,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16.52},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9.44},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9.63,"additional_payer_notes":"APC"}]}]},{"description":"Culture screen only","code_information":[{"code":"87081","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4.97,"maximum":13.42,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6.63,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":13.42},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8.29},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8.29},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8.29},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":12.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4.97,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11.6},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6.63},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6.76,"additional_payer_notes":"APC"}]}]},{"description":"Fungi identification mold","code_information":[{"code":"87107","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7.74,"maximum":20.9,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10.32,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":20.9},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12.9},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12.9},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12.9},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":19.92,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7.74,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18.06},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10.32},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10.53,"additional_payer_notes":"APC"}]}]},{"description":"Dna/rna direct probe","code_information":[{"code":"87149","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":15.04,"maximum":40.58,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20.05,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":40.58},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25.06},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25.06},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25.06},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":38.7,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15.04,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35.09},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20.05},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20.45,"additional_payer_notes":"APC"}]}]},{"description":"Macroscopic Exam Arthropod","code_information":[{"code":"87168","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3.2,"maximum":8.64,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4.27,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":8.64},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5.34},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5.34},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5.34},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":8.24,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3.2,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7.47},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":4.27},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4.36,"additional_payer_notes":"APC"}]}]},{"description":"Microbe susceptible mic","code_information":[{"code":"87186","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6.49,"maximum":17.5,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8.65,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":17.5},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10.81},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10.81},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10.81},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":16.69,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6.49,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15.14},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8.65},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8.82,"additional_payer_notes":"APC"}]}]},{"description":"Smear complex stain","code_information":[{"code":"87209","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":13.48,"maximum":36.38,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17.98,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":36.38},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22.48},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22.48},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22.48},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":34.7,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.48,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31.47},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17.98},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18.34,"additional_payer_notes":"APC"}]}]},{"description":"Genet virus isolate hsv","code_information":[{"code":"87255","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":25.4,"maximum":68.54,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":33.86,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":68.54},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":42.33},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":42.33},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":42.33},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":65.35,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25.4,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":59.26},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33.86},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":34.54,"additional_payer_notes":"APC"}]}]},{"description":"Herpes simplex 2 ag if","code_information":[{"code":"87273","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8.98,"maximum":24.26,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11.98,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":24.26},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14.98},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14.98},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14.98},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":23.12,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8.98,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20.97},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11.98},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.22,"additional_payer_notes":"APC"}]}]},{"description":"Rubeola ag if","code_information":[{"code":"87283","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":24.26,"maximum":117.34,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":60.8,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":24.26},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":76.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":76.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":76.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":117.34,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":45.6,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":106.4},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":60.8},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":62.02,"additional_payer_notes":"APC"}]}]},{"description":"Clostridium ag ia","code_information":[{"code":"87324","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8.98,"maximum":24.26,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11.98,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":24.26},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14.98},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14.98},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14.98},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":23.12,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8.98,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20.97},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11.98},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.22,"additional_payer_notes":"APC"}]}]},{"description":"Hpylori stool ia","code_information":[{"code":"87338","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":10.78,"maximum":29.09,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14.38,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":29.09},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17.98},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17.98},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17.98},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":27.75,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10.78,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25.17},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14.38},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14.67,"additional_payer_notes":"APC"}]}]},{"description":"Hiv-1 ag ia","code_information":[{"code":"87390","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":18.04,"maximum":46.44,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":24.06,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":35.69},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":30.08},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":30.08},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":30.08},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":46.44,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18.04,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":42.11},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24.06},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":24.54,"additional_payer_notes":"APC"}]}]},{"description":"Strep a ag ia","code_information":[{"code":"87430","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":12.61,"maximum":32.44,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16.81,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":24.26},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21.01},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21.01},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21.01},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":32.44,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.61,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29.42},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16.81},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17.15,"additional_payer_notes":"APC"}]}]},{"description":"Lyme dis dna dir probe","code_information":[{"code":"87475","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":15.04,"maximum":40.58,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20.05,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":40.58},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25.06},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25.06},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25.06},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":38.7,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15.04,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35.09},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20.05},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20.45,"additional_payer_notes":"APC"}]}]},{"description":"Thiamine hcl 100 mg","code_information":[{"code":"J3411","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1.91,"maximum":4.79,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1.94},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3.4},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3.4},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3.4},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1.91},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3.26},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":4.79}]}]},{"description":"Hyaluronidase recombinant","code_information":[{"code":"J3473","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":0.4,"maximum":1.01,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":0.4},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.69},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.69},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.69},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.4},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.68},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1.01}]}]},{"description":"5% dextrose/normal saline","code_information":[{"code":"J7042","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1.27,"maximum":3.22,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1.38},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2.57},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2.57},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2.57},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1.27},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2.18},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3.22}]}]},{"description":"Inj, factor x, (human), 1iu","code_information":[{"code":"J7175","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7.46,"maximum":25.94,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9.95,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":10.48},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18.83},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18.83},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18.83},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":19.21,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10.32},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7.46,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17.63},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25.94},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10.15,"additional_payer_notes":"APC"}]}]},{"description":"Xyntha inj","code_information":[{"code":"J7185","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1.03,"maximum":4.09,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1.64},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2.93},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2.93},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2.93},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2.65,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1.62},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1.03,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2.78},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":4.09},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1.4,"additional_payer_notes":"APC"}]}]},{"description":"Factor ix complex","code_information":[{"code":"J7194","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1.31,"maximum":4.52,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1.75,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1.83},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3.24},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3.24},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3.24},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3.37,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1.79},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1.31,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3.07},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":4.52},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1.78,"additional_payer_notes":"APC"}]}]},{"description":"Inj recombin esperoct per iu","code_information":[{"code":"J7204","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1.72,"maximum":5.96,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2.3,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2.35},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4.3},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4.3},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4.3},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4.43,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2.36},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1.72,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":4.05},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5.96},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2.34,"additional_payer_notes":"APC"}]}]},{"description":"Inj, ixinity, 1 i.u.","code_information":[{"code":"J7213","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1.45,"maximum":5.99,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1.94,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2.11},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3.63},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3.63},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3.63},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3.74,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2.38},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1.45,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":4.07},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5.99},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1.98,"additional_payer_notes":"APC"}]}]},{"description":"Genvisc 850, inj, 1mg","code_information":[{"code":"J7320","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2.86,"maximum":16.8,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3.81,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6.94},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11.44},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11.44},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11.44},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7.35,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6.68},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2.86,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11.41},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16.8},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3.88,"additional_payer_notes":"APC"}]}]},{"description":"Gel-syn injection 0.1 mg","code_information":[{"code":"J7328","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":0.44,"maximum":1.52,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":0.58,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":0.65},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1.24},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1.24},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1.24},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1.13,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.6},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":0.44,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1.04},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1.52},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":0.6,"additional_payer_notes":"APC"}]}]},{"description":"Cantharidin top, applicator","code_information":[{"code":"J7354","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":521.41,"maximum":1937.74,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":695.21,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":750.49},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1272.23},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1272.23},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1272.23},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1341.75,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":770.64},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":521.41,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1316.74},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1937.74},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":709.11,"additional_payer_notes":"APC"}]}]},{"description":"Tacrol astagraf ex rel oral","code_information":[{"code":"J7508","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":0.61,"maximum":1.55,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":0.63},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1.11},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1.11},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1.11},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.61},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1.05},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1.55}]}]},{"description":"Mycophenolic acid","code_information":[{"code":"J7518","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":0.42,"maximum":1.3,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":0.42},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.7},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.7},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.7},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.52},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.89},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1.3}]}]},{"description":"Formoterol fumarate, inh","code_information":[{"code":"J7606","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1.87,"maximum":5.15,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1.87},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3.74},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3.74},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3.74},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2.04},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3.5},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5.15}]}]},{"description":"Cromolyn sodium noncomp unit","code_information":[{"code":"J7631","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":0.24,"maximum":0.58,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":0.32},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.54},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.54},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.54},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.24},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.39},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.58}]}]},{"description":"Capecitabine, oral, 50 mg","code_information":[{"code":"J8522","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":0.05,"maximum":0.15,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":0.08,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":0.08},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.1},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.1},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.1},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":0.15,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.05},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":0.06,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.07},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.12},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":0.08,"additional_payer_notes":"APC"}]}]},{"description":"Rolapitant, oral, 1mg","code_information":[{"code":"J8670","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1.75,"maximum":4.41,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1.97},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2.96},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2.96},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2.96},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1.75},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3.0},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":4.41}]}]},{"description":"Inj atezolizumb 5mg hya-tqjs","code_information":[{"code":"J9024","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":24.42,"maximum":62.83,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":32.55,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":33.97},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":60.11},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":60.11},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":60.11},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":62.83,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":24.42,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":33.21,"additional_payer_notes":"APC"}]}]},{"description":"Inj., treanda 1 mg","code_information":[{"code":"J9033","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1.36,"maximum":5.71,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2.96,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1.36},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3.52},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3.52},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3.52},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5.71,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1.95},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2.22,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3.33},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":4.9},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3.02,"additional_payer_notes":"APC"}]}]},{"description":"Cabazitaxel injection","code_information":[{"code":"J9043","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":175.3,"maximum":610.09,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":233.73,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":243.88},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":431.49},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":431.49},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":431.49},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":451.1,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":242.62},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":175.3,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":414.57},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":610.09},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":238.4,"additional_payer_notes":"APC"}]}]},{"description":"Inj, amivantamab-vmjw","code_information":[{"code":"J9061","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":17.41,"maximum":58.69,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23.22,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":23.66},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":42.19},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":42.19},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":42.19},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":44.81,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23.34},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17.41,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":39.89},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":58.69},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23.68,"additional_payer_notes":"APC"}]}]},{"description":"Inj, cyclophos (baxter) 5mg","code_information":[{"code":"J9076","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3.29,"maximum":15.82,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4.39,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":9.55},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":9.55},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":9.55},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":8.47,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3.29,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15.82},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4.47,"additional_payer_notes":"APC"}]}]},{"description":"Daunorubicin injection","code_information":[{"code":"J9150","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":25.46,"maximum":64.04,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":29.04},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":37.55},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":37.55},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":37.55},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25.46},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":43.51},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":64.04}]}]},{"description":"Inj, epirubicin hcl, 2 mg","code_information":[{"code":"J9178","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1.76,"maximum":4.44,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1.78},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3.01},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3.01},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3.01},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1.76},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3.02},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":4.44}]}]},{"description":"Goserelin acetate implant","code_information":[{"code":"J9202","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":761.22,"maximum":1914.08,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":775.65},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1394.89},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1394.89},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1394.89},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":761.22},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1300.66},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1914.08}]}]},{"description":"Inj., emapalumab-lzsg, 1 mg","code_information":[{"code":"J9210","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":294.58,"maximum":1025.21,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":392.78,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":419.65},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":725.12},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":725.12},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":725.12},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":758.07,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":407.72},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":294.58,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":696.65},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1025.21},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":400.64,"additional_payer_notes":"APC"}]}]},{"description":"Inj melphalan hydrochl 50 MG","code_information":[{"code":"J9245","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":78.67,"maximum":363.97,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":104.9,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":172.81},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":205.26},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":205.26},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":205.26},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":202.45,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":144.76},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":78.67,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":247.33},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":363.97},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":107.0,"additional_payer_notes":"APC"}]}]},{"description":"Paclitaxel injection","code_information":[{"code":"J9267","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":0.12,"maximum":0.3,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":0.14},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.2},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.2},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.2},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.12},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.2},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.3}]}]},{"description":"Mitomycin injection","code_information":[{"code":"J9280","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":25.58,"maximum":126.19,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":34.11,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":28.16},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":53.72},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":53.72},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":53.72},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":65.83,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":50.18},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25.58,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":85.75},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":126.19},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":34.79,"additional_payer_notes":"APC"}]}]},{"description":"Inj pemetrexed (sandoz) 10mg","code_information":[{"code":"J9297","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1.66,"maximum":4.16,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1.91},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2.3},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2.3},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2.3},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1.66},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2.83},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":4.16}]}]},{"description":"Pralatrexate injection","code_information":[{"code":"J9307","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":289.59,"maximum":1017.59,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":386.12,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":411.15},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":738.77},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":738.77},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":738.77},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":745.22,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":404.68},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":289.59,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":691.47},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1017.59},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":393.84,"additional_payer_notes":"APC"}]}]},{"description":"Inj romidepsin non-lyo 0.1mg","code_information":[{"code":"J9318","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":25.19,"maximum":77.65,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":33.59,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":54.18},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":54.18},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":54.18},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":64.82,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25.19,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":77.65},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":34.26,"additional_payer_notes":"APC"}]}]},{"description":"Temsirolimus injection","code_information":[{"code":"J9330","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":24.51,"maximum":80.37,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":32.68,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":33.35},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":61.34},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":61.34},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":61.34},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":63.07,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31.96},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":24.51,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":54.61},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":80.37},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":33.33,"additional_payer_notes":"APC"}]}]},{"description":"Inj. naxitamab-gqgk, 1 mg","code_information":[{"code":"J9348","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":513.67,"maximum":1748.64,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":684.9,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":706.01},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1303.22},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1303.22},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1303.22},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1321.85,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":695.42},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":513.67,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1188.24},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1748.64},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":698.6,"additional_payer_notes":"APC"}]}]},{"description":"Inj. herceptin hylecta, 10mg","code_information":[{"code":"J9356","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":43.76,"maximum":171.68,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":58.34,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":69.21},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":119.65},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":119.65},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":119.65},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":112.6,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":68.28},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":43.76,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":116.66},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":171.68},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":59.51,"additional_payer_notes":"APC"}]}]},{"description":"Chylmd pneum dna dir probe","code_information":[{"code":"87485","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":15.04,"maximum":40.58,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20.05,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":40.58},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25.06},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25.06},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25.06},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":38.7,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15.04,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35.09},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20.05},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20.45,"additional_payer_notes":"APC"}]}]},{"description":"Cytomeg dna amp probe","code_information":[{"code":"87496","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":26.32,"maximum":71.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":35.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":71.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43.86},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43.86},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43.86},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":67.72,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26.32,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":61.41},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35.09},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":35.79,"additional_payer_notes":"APC"}]}]},{"description":"Iadna-dna/rna probe tq 6-11","code_information":[{"code":"87506","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":197.24,"maximum":507.57,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":262.99,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":431.88},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":328.74},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":328.74},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":328.74},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":507.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":197.24,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":460.23},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":262.99},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":268.25,"additional_payer_notes":"APC"}]}]},{"description":"Hepatitis c rna dir probe","code_information":[{"code":"87520","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":23.42,"maximum":60.25,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":31.22,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":40.58},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":39.03},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":39.03},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":39.03},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":60.25,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23.42,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":54.64},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31.22},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":31.84,"additional_payer_notes":"APC"}]}]},{"description":"Hsv dna amp probe","code_information":[{"code":"87529","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":26.32,"maximum":71.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":35.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":71.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43.86},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43.86},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43.86},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":67.72,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26.32,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":61.41},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35.09},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":35.79,"additional_payer_notes":"APC"}]}]},{"description":"Hiv-2 dna dir probe","code_information":[{"code":"87537","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":16.44,"maximum":42.31,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21.92,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":40.58},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27.4},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27.4},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27.4},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":42.31,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16.44,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38.36},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21.92},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22.36,"additional_payer_notes":"APC"}]}]},{"description":"Mycobacteria dna quant","code_information":[{"code":"87552","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":32.13,"maximum":86.68,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":42.84,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":86.68},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":53.55},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":53.55},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":53.55},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":82.68,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":32.13,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":74.97},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":42.84},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":43.7,"additional_payer_notes":"APC"}]}]},{"description":"Mtb rifampin rst amp prb tq","code_information":[{"code":"87564","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":57.58,"maximum":148.17,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":76.77,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":110.54},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":95.96},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":95.96},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":95.96},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":148.17,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":57.58,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":134.35},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":76.77},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":78.31,"additional_payer_notes":"APC"}]}]},{"description":"Pneumcysts jirovecii amp prb","code_information":[{"code":"87594","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":26.32,"maximum":67.72,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":35.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":50.53},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43.86},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43.86},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43.86},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":67.72,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26.32,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":61.41},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35.09},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":35.79,"additional_payer_notes":"APC"}]}]},{"description":"Rsv dna/rna amp probe","code_information":[{"code":"87634","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":52.65,"maximum":135.49,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":70.2,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":128.74},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":87.75},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":87.75},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":87.75},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":135.49,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":52.65,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":122.85},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":70.2},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":71.6,"additional_payer_notes":"APC"}]}]},{"description":"Strep a dna quant","code_information":[{"code":"87652","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":31.32,"maximum":84.49,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":41.76,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":84.49},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":52.2},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":52.2},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":52.2},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":80.6,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":31.32,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":73.08},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":41.76},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":42.6,"additional_payer_notes":"APC"}]}]},{"description":"Detect agnt mult dna direc","code_information":[{"code":"87800","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":32.75,"maximum":84.28,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":43.67,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":81.17},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":54.59},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":54.59},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":54.59},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":84.28,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":32.75,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":76.42},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":43.67},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":44.54,"additional_payer_notes":"APC"}]}]},{"description":"Adenovirus assay w/optic","code_information":[{"code":"87809","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":16.32,"maximum":42.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21.76,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":24.26},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27.2},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27.2},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27.2},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":42.0,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16.32,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38.08},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21.76},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22.2,"additional_payer_notes":"APC"}]}]},{"description":"Genotype dna/rna hep c","code_information":[{"code":"87902","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":193.09,"maximum":520.94,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":257.45,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":520.94},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":321.81},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":321.81},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":321.81},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":496.88,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":193.09,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":450.54},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":257.45},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":262.6,"additional_payer_notes":"APC"}]}]},{"description":"Sex chromatin identification","code_information":[{"code":"88130","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":13.48,"maximum":34.7,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17.98,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":30.47},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22.48},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22.48},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22.48},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":34.7,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.48,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31.47},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17.98},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18.34,"additional_payer_notes":"APC"}]}]},{"description":"Cytopath c/v redo","code_information":[{"code":"88153","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":18.02,"maximum":46.38,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":24.03,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":21.4},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":30.04},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":30.04},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":30.04},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":46.38,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18.02,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":42.05},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24.03},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":24.51,"additional_payer_notes":"APC"}]}]},{"description":"Tissue culture lymphocyte","code_information":[{"code":"88230","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":87.37,"maximum":224.83,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":116.49,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":100.79},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":145.61},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":145.61},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":145.61},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":224.83,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":87.37,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":203.86},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":116.49},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":118.82,"additional_payer_notes":"APC"}]}]},{"description":"Chromosome analysis 50-100","code_information":[{"code":"88248","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":129.88,"maximum":350.42,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":173.17,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":350.42},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":216.46},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":216.46},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":216.46},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":334.22,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":129.88,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":303.05},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":173.17},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":176.63,"additional_payer_notes":"APC"}]}]},{"description":"Cytogenetics dna probe","code_information":[{"code":"88271","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":16.06,"maximum":41.34,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21.42,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":29.3},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26.78},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26.78},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26.78},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":41.34,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16.06,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37.49},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21.42},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21.85,"additional_payer_notes":"APC"}]}]},{"description":"Chromosome study additional","code_information":[{"code":"88289","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":25.82,"maximum":69.68,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":34.43,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":69.68},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43.04},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43.04},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43.04},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":66.45,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25.82,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":60.25},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34.43},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":35.12,"additional_payer_notes":"APC"}]}]},{"description":"Body fluid cell count","code_information":[{"code":"89051","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4.2,"maximum":11.15,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5.6,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":11.15},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":10.81,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4.2,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9.8},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5.6},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5.71,"additional_payer_notes":"APC"}]}]},{"description":"Semen anal vol/count/mot","code_information":[{"code":"89320","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":9.23,"maximum":24.38,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.31,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":24.38},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15.39},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15.39},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15.39},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":23.76,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9.23,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21.54},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12.31},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.56,"additional_payer_notes":"APC"}]}]},{"description":"PSA Screening","code_information":[{"code":"G0103","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":14.48,"maximum":37.27,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19.31,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":37.22},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24.14},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24.14},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24.14},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":37.27,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14.48,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33.79},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19.31},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19.7,"additional_payer_notes":"APC"}]}]},{"description":"CBC without platelet","code_information":[{"code":"G0307","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4.85,"maximum":13.08,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6.47,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":13.08},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8.09},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8.09},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8.09},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":12.49,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4.85,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11.32},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6.47},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6.6,"additional_payer_notes":"APC"}]}]},{"description":"Hiv combination assay","code_information":[{"code":"G0475","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":18.06,"maximum":49.06,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":24.08,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":49.06},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":30.1},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":30.1},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":30.1},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":46.47,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18.06,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":42.14},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24.08},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":24.56,"additional_payer_notes":"APC"}]}]},{"description":"Warfarin respon genetic test","code_information":[{"code":"G9143","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":120.72,"maximum":244.27,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":244.27},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":150.9},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":150.9},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":150.9},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":211.26},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":120.72}]}]},{"description":"Urine specimen collect mult","code_information":[{"code":"P9615","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3.0,"maximum":15.91,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4.45},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11.36},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11.36},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11.36},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15.91},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3.0}]}]},{"description":"Bone srgry cmptr fluor image","code_information":[{"code":"0054T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":2334.0,"payers_information":[{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Revise Lumb Artif Disc Addl","code_information":[{"code":"0165T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":2334.0,"payers_information":[{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Njx paravert w/us cer/thor","code_information":[{"code":"0215T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":2334.0,"payers_information":[{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Njx platelet plasma","code_information":[{"code":"0232T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":331.39,"maximum":2334.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":441.86,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":852.79,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":331.39,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":450.7,"additional_payer_notes":"APC"}]}]},{"description":"Im b1 mrw cel ther hrvst onl","code_information":[{"code":"0265T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3231.05,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4308.07,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":8314.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3231.05,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4394.23,"additional_payer_notes":"APC"}]}]},{"description":"Perq lamot/lam lumbar","code_information":[{"code":"0275T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":17314.0,"maximum":18364.0,"payers_information":[{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0}]}]},{"description":"Ercp w/optical endomicroscpy","code_information":[{"code":"0397T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":2334.0,"payers_information":[{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Rmvl cardiac modulj pls gen","code_information":[{"code":"0412T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2772.2,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3696.26,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7133.79,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2772.2,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3770.19,"additional_payer_notes":"APC"}]}]},{"description":"Vinorelbine tartrate inj","code_information":[{"code":"J9390","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3.72,"maximum":17.7,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7.25},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3.72},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3.72},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3.72},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7.04},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12.03},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17.7}]}]},{"description":"Ferumoxytol, non-esrd","code_information":[{"code":"Q0138","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":0.28,"maximum":1.04,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":0.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":0.36},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.59},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.59},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.59},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":0.71,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":0.28,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.7},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1.04},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":0.38,"additional_payer_notes":"APC"}]}]},{"description":"Sipuleucel-t auto cd54+","code_information":[{"code":"Q2043","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":41949.32,"maximum":151198.13,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":55932.43,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":62718.81},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":106297.34},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":106297.34},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":106297.34},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":107949.58,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":41949.32,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":102742.53},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":151198.13},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":57051.08,"additional_payer_notes":"APC"}]}]},{"description":"Epoetin alfa, 100 units ESRD","code_information":[{"code":"Q4081","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":0.78,"maximum":1.77,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":0.78},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1.46},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1.46},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1.46},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1.2},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1.77}]}]},{"description":"Gammagraft","code_information":[{"code":"Q4111","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8.36,"maximum":237.56,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":123.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":8.36},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13.52},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13.52},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13.52},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":237.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":92.32,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13.56},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19.95},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":125.55,"additional_payer_notes":"APC"}]}]},{"description":"Talymed","code_information":[{"code":"Q4127","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":75.34,"maximum":237.56,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":123.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":75.34},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":130.13},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":130.13},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":130.13},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":237.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":92.32,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":126.71},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":186.47},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":125.55,"additional_payer_notes":"APC"}]}]},{"description":"Repriza, 1cm","code_information":[{"code":"Q4143","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":37.31,"maximum":237.56,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":123.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":37.31},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":64.45},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":64.45},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":64.45},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":237.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":92.32,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":125.55,"additional_payer_notes":"APC"}]}]},{"description":"Neoxflo or clarixflo 1 mg","code_information":[{"code":"Q4155","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":28.94,"maximum":78.19,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":28.94},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":51.89},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":51.89},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":51.89},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":53.13},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":78.19}]}]},{"description":"Cytal, per square centimeter","code_information":[{"code":"Q4166","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":23.65,"maximum":237.56,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":123.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":23.65},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":39.61},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":39.61},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":39.61},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":237.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":92.32,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38.04},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":55.97},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":125.55,"additional_payer_notes":"APC"}]}]},{"description":"Cellesta, 1 sq cm","code_information":[{"code":"Q4184","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":88.04,"maximum":1699.76,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":123.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":88.04},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":152.08},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":152.08},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":152.08},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":237.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":92.32,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1155.03},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1699.76},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":125.55,"additional_payer_notes":"APC"}]}]},{"description":"Puraply 1 sq cm","code_information":[{"code":"Q4195","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":92.32,"maximum":279.84,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":123.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":110.19},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":205.04},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":205.04},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":205.04},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":237.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":92.32,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":190.16},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":279.84},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":125.55,"additional_payer_notes":"APC"}]}]},{"description":"Woundfix biowound plus xplus","code_information":[{"code":"Q4217","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":92.32,"maximum":1009.67,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":123.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":300.86},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":604.2},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":604.2},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":604.2},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":237.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":92.32,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":686.09},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1009.67},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":125.55,"additional_payer_notes":"APC"}]}]},{"description":"Amniorepair or altiply sq cm","code_information":[{"code":"Q4235","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":92.32,"maximum":259.05,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":123.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":104.42},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":152.92},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":152.92},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":152.92},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":237.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":92.32,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":176.03},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":259.05},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":125.55,"additional_payer_notes":"APC"}]}]},{"description":"Zenith amniotic membrane psc","code_information":[{"code":"Q4253","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":78.65,"maximum":325.15,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":123.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":78.65},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":158.03},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":158.03},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":158.03},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":237.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":92.32,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":220.95},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":325.15},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":125.55,"additional_payer_notes":"APC"}]}]},{"description":"Neostim tl per sq cm","code_information":[{"code":"Q4265","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":92.32,"maximum":5757.28,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":123.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1925.29},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3237.65},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3237.65},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3237.65},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":237.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":92.32,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3912.2},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5757.28},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":125.55,"additional_payer_notes":"APC"}]}]},{"description":"Epieffect, per sq cm","code_information":[{"code":"Q4278","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":92.32,"maximum":833.28,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":123.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":270.66},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":503.71},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":503.71},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":503.71},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":237.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":92.32,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":566.23},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":833.28},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":125.55,"additional_payer_notes":"APC"}]}]},{"description":"Acesso dl, per sq cm","code_information":[{"code":"Q4293","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":92.32,"maximum":4066.87,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":123.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1743.17},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3010.93},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3010.93},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3010.93},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":237.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":92.32,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":4066.87},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":125.55,"additional_payer_notes":"APC"}]}]},{"description":"Activate matrix, per sq cm","code_information":[{"code":"Q4301","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":92.32,"maximum":5267.84,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":123.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2086.44},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3432.04},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3432.04},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3432.04},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":237.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":92.32,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3579.62},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5267.84},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":125.55,"additional_payer_notes":"APC"}]}]},{"description":"Caregraft, per sq cm","code_information":[{"code":"Q4322","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":92.32,"maximum":6427.01,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":123.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2040.5},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3403.45},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3403.45},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3403.45},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":237.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":92.32,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6427.01},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":125.55,"additional_payer_notes":"APC"}]}]},{"description":"Simplimax, per sq cm","code_information":[{"code":"Q4341","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":92.32,"maximum":9612.03,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":123.09,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5835.43},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5835.43},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5835.43},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":237.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":92.32,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9612.03},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":125.55,"additional_payer_notes":"APC"}]}]},{"description":"Injection, inflectra","code_information":[{"code":"Q5103","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":17.5,"maximum":53.48,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27.71,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":17.5},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":37.39},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":37.39},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":37.39},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":53.48,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20.78,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21.37},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31.45},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":28.26,"additional_payer_notes":"APC"}]}]},{"description":"Inj ontruzant 10 mg","code_information":[{"code":"Q5112","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":15.74,"maximum":71.79,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20.99,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":31.61},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":41.77},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":41.77},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":41.77},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":40.51,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15.74,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":48.78},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":71.79},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21.41,"additional_payer_notes":"APC"}]}]},{"description":"Inj pegfilgrastim-bmez 0.5mg","code_information":[{"code":"Q5120","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":27.18,"maximum":254.95,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":132.1,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":27.18},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":53.18},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":53.18},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":53.18},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":254.95,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":99.07,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":45.71},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":67.27},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":134.74,"additional_payer_notes":"APC"}]}]},{"description":"Inj, cimerli, 0.1 mg","code_information":[{"code":"Q5128","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":61.9,"maximum":459.39,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":82.53,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":161.44},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":164.37},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":164.37},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":164.37},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":159.28,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":61.9,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":312.17},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":459.39},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":84.18,"additional_payer_notes":"APC"}]}]},{"description":"Inj octafluoropropane mic,ml","code_information":[{"code":"Q9956","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":46.07,"maximum":113.29,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":46.07},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":78.28},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":78.28},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":78.28},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":76.98},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":113.29}]}]},{"description":"Buprenorph xr 100 mg or less","code_information":[{"code":"Q9991","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1551.12,"maximum":5259.36,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2068.16,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2117.75},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3755.45},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3755.45},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3755.45},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3991.54,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1551.12,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3573.85},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5259.36},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2109.52,"additional_payer_notes":"APC"}]}]},{"description":"Smn1 gene dos/deletion alys","code_information":[{"code":"81329","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":102.75,"maximum":264.41,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":137.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":203.51},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":171.25},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":171.25},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":171.25},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":264.41,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":102.75,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":239.75},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":137.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":139.74,"additional_payer_notes":"APC"}]}]},{"description":"Smn1 gen nown famil seq vrnt","code_information":[{"code":"81337","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":138.9,"maximum":357.44,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":185.2,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":275.11},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":231.5},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":231.5},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":231.5},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":357.44,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":138.9,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":324.1},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":185.2},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":188.9,"additional_payer_notes":"APC"}]}]},{"description":"Tert gene targeted seq alys","code_information":[{"code":"81345","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":138.9,"maximum":357.44,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":185.2,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":275.11},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":231.5},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":231.5},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":231.5},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":357.44,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":138.9,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":324.1},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":185.2},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":188.9,"additional_payer_notes":"APC"}]}]},{"description":"Tp53 gene known famil vrnt","code_information":[{"code":"81353","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":231.0,"maximum":594.44,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":308.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":457.52},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":385.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":385.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":385.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":594.44,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":231.0,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":539.0},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":308.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":314.16,"additional_payer_notes":"APC"}]}]},{"description":"Hla i & ii typing lr","code_information":[{"code":"81370","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":301.59,"maximum":813.71,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":402.12,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":813.71},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":502.65},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":502.65},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":502.65},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":776.09,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":301.59,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":703.71},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":402.12},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":410.16,"additional_payer_notes":"APC"}]}]},{"description":"Hla i & ii typing hr","code_information":[{"code":"81378","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":259.18,"maximum":699.25,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":345.57,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":699.25},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":431.96},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":431.96},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":431.96},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":666.95,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":259.18,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":604.75},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":345.57},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":352.48,"additional_payer_notes":"APC"}]}]},{"description":"Mopath procedure level 3","code_information":[{"code":"81402","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":112.75,"maximum":290.14,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":150.33,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":223.31},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":187.91},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":187.91},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":187.91},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":290.14,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":112.75,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":263.08},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":150.33},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":153.34,"additional_payer_notes":"APC"}]}]},{"description":"Aortic dysfunction/dilation","code_information":[{"code":"81411","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1012.64,"maximum":2605.87,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1350.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2005.67},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1687.74},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1687.74},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1687.74},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2605.87,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1012.64,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2362.83},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1350.19},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1377.19,"additional_payer_notes":"APC"}]}]},{"description":"Epilepsy gen seq alys panel","code_information":[{"code":"81419","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1836.42,"maximum":4725.72,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2448.56,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3637.26},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3060.7},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3060.7},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3060.7},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4725.72,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1836.42,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":4284.98},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2448.56},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2497.53,"additional_payer_notes":"APC"}]}]},{"description":"Hrdtry brst ca-rlatd dsordrs","code_information":[{"code":"81432","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":679.05,"maximum":2516.62,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1303.95,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1383.7},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1629.94},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1629.94},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1629.94},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2516.62,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":977.96,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2281.91},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":679.05},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1330.03,"additional_payer_notes":"APC"}]}]},{"description":"Mitochondrial gene","code_information":[{"code":"81440","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2493.0,"maximum":6415.32,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3324.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4937.7},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4155.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4155.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4155.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6415.32,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2493.0,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5817.0},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3324.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3390.48,"additional_payer_notes":"APC"}]}]},{"description":"Tgsap hl neo 5-50 rna alys","code_information":[{"code":"81451","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":569.65,"maximum":1465.89,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":759.53,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1124.68},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":949.41},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":949.41},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":949.41},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1465.89,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":569.65,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1329.18},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":759.53},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":774.72,"additional_payer_notes":"APC"}]}]},{"description":"So gsap cl fr cpy nmbr&mcrst","code_information":[{"code":"81463","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1008.98,"maximum":2596.45,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1345.31,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1937.24},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1681.64},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1681.64},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1681.64},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2596.45,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1008.98,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2354.29},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1345.31},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1372.22,"additional_payer_notes":"APC"}]}]},{"description":"Onco (ovar) five proteins","code_information":[{"code":"81503","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":672.75,"maximum":1731.21,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":897.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1332.47},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1121.25},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1121.25},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1121.25},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1731.21,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":672.75,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1569.75},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":897.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":914.94,"additional_payer_notes":"APC"}]}]},{"description":"Ftl cgen abnor five anal","code_information":[{"code":"81512","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":52.14,"maximum":134.17,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":69.52,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":103.27},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":86.9},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":86.9},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":86.9},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":134.17,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":52.14,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":121.66},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":69.52},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":70.91,"additional_payer_notes":"APC"}]}]},{"description":"Onc breast mrna 70 genes","code_information":[{"code":"81521","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2904.75,"maximum":7474.89,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3873.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5753.22},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4841.25},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4841.25},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4841.25},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7474.89,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2904.75,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6777.75},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3873.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3950.46,"additional_payer_notes":"APC"}]}]},{"description":"Oncology lung","code_information":[{"code":"81538","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2153.25,"maximum":5541.03,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2871.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3159.28},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3588.75},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3588.75},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3588.75},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5541.03,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2153.25,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5024.25},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2871.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2928.42,"additional_payer_notes":"APC"}]}]},{"description":"Pulm ds ipf mrna 190 gen alg","code_information":[{"code":"81554","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4057.2,"maximum":10440.53,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5409.6,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":8170.08},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":6806.25},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":6806.25},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":6806.25},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":10440.53,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4057.2,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9528.75},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5500.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5517.79,"additional_payer_notes":"APC"}]}]},{"description":"Acylcarnitines qual","code_information":[{"code":"82016","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":12.37,"maximum":31.83,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16.49,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":28.07},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20.61},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20.61},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20.61},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":31.83,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.37,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28.86},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16.49},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16.82,"additional_payer_notes":"APC"}]}]},{"description":"Albumin ischemia modified","code_information":[{"code":"82045","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":25.46,"maximum":68.69,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":33.94,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":68.69},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":42.43},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":42.43},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":42.43},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":65.5,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25.46,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":59.4},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33.94},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":34.62,"additional_payer_notes":"APC"}]}]},{"description":"Alpha-fetoprotein amniotic","code_information":[{"code":"82106","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":12.75,"maximum":33.95,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":33.95},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21.25},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21.25},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21.25},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":32.81,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.75,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29.75},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17.34,"additional_payer_notes":"APC"}]}]},{"description":"Amino acids quant 2-5","code_information":[{"code":"82136","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":14.71,"maximum":37.85,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19.61,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":29.16},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24.51},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24.51},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24.51},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":37.85,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14.71,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34.32},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19.61},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20.0,"additional_payer_notes":"APC"}]}]},{"description":"Assay of angiotensin II","code_information":[{"code":"82163","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":15.39,"maximum":40.27,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20.52,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":40.27},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25.65},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25.65},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25.65},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":39.6,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15.39,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35.91},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20.52},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20.93,"additional_payer_notes":"APC"}]}]},{"description":"Insj/rplc nstim apnea compl","code_information":[{"code":"0424T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":54996.0,"maximum":54996.0,"payers_information":[{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":54996.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":54996.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":54996.0}]}]},{"description":"Repos nstim apnea stimj ld","code_information":[{"code":"0432T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8770.0,"maximum":8770.0,"payers_information":[{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0}]}]},{"description":"Occult blood feces","code_information":[{"code":"82270","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3.28,"maximum":8.45,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4.38,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6.58},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5.48},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5.48},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5.48},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":8.45,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3.28,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7.67},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":4.38},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4.47,"additional_payer_notes":"APC"}]}]},{"description":"Assay of calcium","code_information":[{"code":"82310","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3.87,"maximum":10.44,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5.16,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":10.44},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":6.45},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":6.45},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":6.45},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":9.96,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3.87,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9.03},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5.16},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5.26,"additional_payer_notes":"APC"}]}]},{"description":"Assay c-d transfer measure","code_information":[{"code":"82373","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":13.54,"maximum":36.53,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18.06,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":36.53},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22.58},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22.58},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22.58},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":34.86,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.54,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31.61},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18.06},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18.42,"additional_payer_notes":"APC"}]}]},{"description":"Assay blood catecholamines","code_information":[{"code":"82383","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":21.81,"maximum":56.12,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":29.08,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":50.74},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":36.35},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":36.35},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":36.35},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":56.12,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21.81,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":50.89},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29.08},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":29.66,"additional_payer_notes":"APC"}]}]},{"description":"Assay other fluid chlorides","code_information":[{"code":"82438","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3.75,"maximum":9.9,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":9.9},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":6.25},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":6.25},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":6.25},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":9.65,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3.75,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8.75},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5.1,"additional_payer_notes":"APC"}]}]},{"description":"Collagen crosslinks","code_information":[{"code":"82523","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":14.01,"maximum":36.05,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18.68,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":21.08},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23.35},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23.35},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23.35},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":36.05,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14.01,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32.69},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18.68},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19.05,"additional_payer_notes":"APC"}]}]},{"description":"Assay of cpk in blood","code_information":[{"code":"82552","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":10.04,"maximum":27.11,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.39,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":27.11},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16.74},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16.74},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16.74},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":25.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10.04,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23.43},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13.39},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.66,"additional_payer_notes":"APC"}]}]},{"description":"Assay of cyanide","code_information":[{"code":"82600","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":14.55,"maximum":39.26,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19.4,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":39.26},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24.25},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24.25},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24.25},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":37.44,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14.55,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33.95},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19.4},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19.79,"additional_payer_notes":"APC"}]}]},{"description":"Deoxycortisol","code_information":[{"code":"82634","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":21.96,"maximum":59.24,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":29.28,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":59.24},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":36.6},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":36.6},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":36.6},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":56.51,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21.96,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":51.24},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29.28},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":29.87,"additional_payer_notes":"APC"}]}]},{"description":"Electrophoretic test","code_information":[{"code":"82664","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":46.12,"maximum":118.7,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":61.5,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":69.52},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":76.88},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":76.88},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":76.88},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":118.7,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":46.12,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":107.63},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":61.5},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":62.73,"additional_payer_notes":"APC"}]}]},{"description":"Assay of ethylene glycol","code_information":[{"code":"82693","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":11.18,"maximum":28.76,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14.9,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":11.45},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18.63},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18.63},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18.63},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":28.76,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11.18,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26.08},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14.9},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15.2,"additional_payer_notes":"APC"}]}]},{"description":"Assay of fetal fibronectin","code_information":[{"code":"82731","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":48.31,"maximum":130.33,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":64.41,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":130.33},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":80.51},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":80.51},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":80.51},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":124.31,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":48.31,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":112.72},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":64.41},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":65.7,"additional_payer_notes":"APC"}]}]},{"description":"Galactose transferase test","code_information":[{"code":"82776","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8.8,"maximum":22.66,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11.74,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":16.98},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14.68},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14.68},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14.68},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":22.66,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8.8,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20.55},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11.74},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11.97,"additional_payer_notes":"APC"}]}]},{"description":"Blood gases o2 sat only","code_information":[{"code":"82810","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7.33,"maximum":18.86,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9.77,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":17.66},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12.21},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12.21},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12.21},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":18.86,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7.33,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17.1},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9.77},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9.97,"additional_payer_notes":"APC"}]}]},{"description":"Assay glucose blood quant","code_information":[{"code":"82947","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2.95,"maximum":7.93,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3.93,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7.93},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4.91},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4.91},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4.91},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7.58,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2.95,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6.88},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3.93},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4.01,"additional_payer_notes":"APC"}]}]},{"description":"Assay of glucosidase","code_information":[{"code":"82963","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":16.11,"maximum":43.48,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21.48,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":43.48},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26.85},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26.85},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26.85},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":41.46,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16.11,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37.59},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21.48},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21.91,"additional_payer_notes":"APC"}]}]},{"description":"Assay growth hormone (hgh)","code_information":[{"code":"83003","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":12.5,"maximum":33.76,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16.67,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":33.76},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20.84},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20.84},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20.84},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":32.17,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.5,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29.17},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16.67},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17.0,"additional_payer_notes":"APC"}]}]},{"description":"Heavy metal quant each nes","code_information":[{"code":"83018","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":16.47,"maximum":44.45,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21.96,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":44.45},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27.45},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27.45},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27.45},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":42.38,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16.47,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38.43},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21.96},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22.4,"additional_payer_notes":"APC"}]}]},{"description":"Blood methemoglobin test","code_information":[{"code":"83045","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4.87,"maximum":12.53,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6.49,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":10.02},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8.11},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8.11},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8.11},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":12.53,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4.87,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11.36},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6.49},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6.62,"additional_payer_notes":"APC"}]}]},{"description":"Assay of b hexosaminidase","code_information":[{"code":"83080","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":12.65,"maximum":32.56,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16.87,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":29.16},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21.09},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21.09},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21.09},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":32.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.65,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29.52},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16.87},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17.21,"additional_payer_notes":"APC"}]}]},{"description":"Assay total hydroxyproline","code_information":[{"code":"83505","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":18.22,"maximum":49.2,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":24.3,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":49.2},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":30.38},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":30.38},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":30.38},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":46.9,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18.22,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":42.53},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24.3},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":24.79,"additional_payer_notes":"APC"}]}]},{"description":"Assay of intrinsic factor","code_information":[{"code":"83528","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":14.86,"maximum":38.25,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19.82,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":32.2},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24.78},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24.78},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24.78},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":38.25,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14.86,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34.69},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19.82},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20.22,"additional_payer_notes":"APC"}]}]},{"description":"Assay of lactic acid","code_information":[{"code":"83605","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8.68,"maximum":22.33,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11.57,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":21.6},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14.46},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14.46},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14.46},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":22.33,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8.68,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20.25},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11.57},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11.8,"additional_payer_notes":"APC"}]}]},{"description":"L/s ratio fetal lung","code_information":[{"code":"83661","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":16.49,"maximum":44.5,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21.99,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":44.5},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27.49},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27.49},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27.49},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":42.44,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16.49,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38.48},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21.99},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22.43,"additional_payer_notes":"APC"}]}]},{"description":"Lipopro bld electrophoretic","code_information":[{"code":"83700","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8.44,"maximum":22.76,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11.26,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":22.76},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14.08},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14.08},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14.08},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":21.73,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8.44,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19.71},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11.26},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11.49,"additional_payer_notes":"APC"}]}]},{"description":"Assay of magnesium","code_information":[{"code":"83735","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5.02,"maximum":13.54,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6.7,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":13.54},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8.38},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8.38},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8.38},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":12.93,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5.02,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11.73},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6.7},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6.83,"additional_payer_notes":"APC"}]}]},{"description":"Mucopolysaccharides","code_information":[{"code":"83864","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":21.38,"maximum":55.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":28.5,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":40.31},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":35.63},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":35.63},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":35.63},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":55.0,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21.38,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":49.88},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28.5},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":29.07,"additional_payer_notes":"APC"}]}]},{"description":"Assay of nickel","code_information":[{"code":"83885","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":18.38,"maximum":49.58,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":24.51,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":49.58},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":30.64},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":30.64},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":30.64},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":47.3,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18.38,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":42.89},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24.51},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25.0,"additional_payer_notes":"APC"}]}]},{"description":"Assay of osteocalcin","code_information":[{"code":"83937","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":22.39,"maximum":60.42,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":29.85,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":60.42},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":37.31},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":37.31},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":37.31},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":57.61,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22.39,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":52.24},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29.85},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":30.45,"additional_payer_notes":"APC"}]}]},{"description":"Assay of blood pku","code_information":[{"code":"84030","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4.12,"maximum":11.12,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5.5,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":11.12},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":6.88},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":6.88},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":6.88},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":10.62,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4.12,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9.63},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5.5},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5.61,"additional_payer_notes":"APC"}]}]},{"description":"Assay of rbc pg6d enzyme","code_information":[{"code":"84085","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7.08,"maximum":18.22,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9.44,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":13.64},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11.8},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11.8},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11.8},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":18.22,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7.08,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16.52},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9.44},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9.63,"additional_payer_notes":"APC"}]}]},{"description":"Assay of urine porphyrins","code_information":[{"code":"84120","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":11.03,"maximum":29.77,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14.71,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":29.77},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18.39},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18.39},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18.39},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":28.39,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11.03,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25.74},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14.71},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15.0,"additional_payer_notes":"APC"}]}]},{"description":"Assay of 17-hydroxypregneno","code_information":[{"code":"84143","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":17.11,"maximum":46.16,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22.81,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":46.16},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28.51},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28.51},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28.51},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":44.02,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17.11,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":39.92},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22.81},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23.27,"additional_payer_notes":"APC"}]}]},{"description":"Assay of protein serum","code_information":[{"code":"84155","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2.75,"maximum":7.43,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3.67,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7.43},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4.59},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4.59},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4.59},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7.08,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2.75,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6.42},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3.67},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3.74,"additional_payer_notes":"APC"}]}]},{"description":"Protein western blot test","code_information":[{"code":"84182","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":21.91,"maximum":56.38,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":29.21,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":36.43},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":36.51},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":36.51},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":36.51},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":56.38,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21.91,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":51.12},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29.21},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":29.79,"additional_payer_notes":"APC"}]}]},{"description":"Assay of estrogen","code_information":[{"code":"84233","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":65.91,"maximum":169.61,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":87.88,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":130.33},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":109.85},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":109.85},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":109.85},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":169.61,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":65.91,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":153.79},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":87.88},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":89.64,"additional_payer_notes":"APC"}]}]},{"description":"Assay of sex hormone globul","code_information":[{"code":"84270","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":16.3,"maximum":43.98,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21.73,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":43.98},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27.16},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27.16},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27.16},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":41.94,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16.3,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38.03},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21.73},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22.16,"additional_payer_notes":"APC"}]}]},{"description":"Spectrophotometry","code_information":[{"code":"84311","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6.08,"maximum":15.63,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8.1,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":14.14},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10.13},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10.13},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10.13},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":15.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6.08,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14.18},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8.1},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8.26,"additional_payer_notes":"APC"}]}]},{"description":"Assay of thyroglobulin","code_information":[{"code":"84432","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":12.04,"maximum":32.51,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16.06,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":32.51},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20.08},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20.08},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20.08},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":31.0,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.04,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28.11},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16.06},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16.38,"additional_payer_notes":"APC"}]}]},{"description":"Assay of vitamin e","code_information":[{"code":"84446","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":10.64,"maximum":28.68,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14.18,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":28.68},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17.73},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17.73},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17.73},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":27.37,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10.64,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24.82},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14.18},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14.46,"additional_payer_notes":"APC"}]}]},{"description":"Free assay (FT-3)","code_information":[{"code":"84481","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":12.7,"maximum":32.69,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16.94,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":23.92},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21.18},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21.18},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21.18},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":32.69,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.7,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29.65},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16.94},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17.28,"additional_payer_notes":"APC"}]}]},{"description":"Assay of urea nitrogen","code_information":[{"code":"84520","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2.96,"maximum":8.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3.95,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":8.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4.94},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4.94},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4.94},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7.62,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2.96,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6.91},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3.95},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4.03,"additional_payer_notes":"APC"}]}]},{"description":"Assay of urine urobilinogen","code_information":[{"code":"84580","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7.16,"maximum":18.43,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9.55,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":14.35},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11.94},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11.94},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11.94},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":18.43,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7.16,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16.71},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9.55},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9.74,"additional_payer_notes":"APC"}]}]},{"description":"Assay of volatiles","code_information":[{"code":"84600","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":12.83,"maximum":33.02,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17.11,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":32.53},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21.39},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21.39},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21.39},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":33.02,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.83,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29.94},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17.11},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17.45,"additional_payer_notes":"APC"}]}]},{"description":"Bleeding time test","code_information":[{"code":"85002","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3.62,"maximum":9.3,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4.82,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6.85},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":6.03},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":6.03},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":6.03},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":9.3,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3.62,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8.44},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":4.82},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4.92,"additional_payer_notes":"APC"}]}]},{"description":"Complete cbc w/auto diff wbc","code_information":[{"code":"85025","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5.83,"maximum":15.72,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7.77,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":15.72},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":9.71},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":9.71},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":9.71},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":15.0,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5.83,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13.6},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7.77},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7.93,"additional_payer_notes":"APC"}]}]},{"description":"Automated platelet count","code_information":[{"code":"85049","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3.36,"maximum":9.06,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4.48,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":9.06},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5.6},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5.6},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5.6},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":8.65,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3.36,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7.84},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":4.48},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4.57,"additional_payer_notes":"APC"}]}]},{"description":"Clot factor viii ahg 1 stage","code_information":[{"code":"85240","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":13.42,"maximum":34.55,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17.9,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":14.15},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22.38},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22.38},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22.38},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":34.55,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.42,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31.33},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17.9},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18.26,"additional_payer_notes":"APC"}]}]},{"description":"Clot factor xii hageman","code_information":[{"code":"85280","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":14.51,"maximum":39.14,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19.35,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":39.14},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24.19},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24.19},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24.19},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":37.35,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14.51,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33.86},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19.35},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19.74,"additional_payer_notes":"APC"}]}]},{"description":"Clot inhibit prot c activity","code_information":[{"code":"85303","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":10.38,"maximum":27.98,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.84,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":27.98},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17.3},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17.3},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17.3},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":26.71,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10.38,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24.22},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13.84},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14.12,"additional_payer_notes":"APC"}]}]},{"description":"Coagulation time otr method","code_information":[{"code":"85348","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3.37,"maximum":8.67,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4.49,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3.96},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5.61},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5.61},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5.61},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":8.67,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3.37,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7.86},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":4.49},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4.58,"additional_payer_notes":"APC"}]}]},{"description":"Fibrinogen activity","code_information":[{"code":"85384","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7.29,"maximum":18.76,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9.72,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":17.18},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12.15},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12.15},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12.15},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":18.76,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7.29,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17.01},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9.72},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9.91,"additional_payer_notes":"APC"}]}]},{"description":"Fibrinolytic plasminogen","code_information":[{"code":"85421","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7.64,"maximum":20.63,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10.18,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":20.63},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12.73},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12.73},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12.73},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":19.65,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7.64,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17.82},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10.18},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10.38,"additional_payer_notes":"APC"}]}]},{"description":"Heparin-protamine tolerance","code_information":[{"code":"85530","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":9.82,"maximum":28.68,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":28.68},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16.36},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16.36},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16.36},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":25.26,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9.82,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22.91},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13.09},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.35,"additional_payer_notes":"APC"}]}]},{"description":"Phospholipid pltlt neutraliz","code_information":[{"code":"85597","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":13.48,"maximum":36.38,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17.98,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":36.38},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22.48},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22.48},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22.48},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":34.7,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.48,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31.47},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17.98},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18.34,"additional_payer_notes":"APC"}]}]},{"description":"Rbc sed rate automated","code_information":[{"code":"85652","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2.02,"maximum":5.47,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2.7,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5.47},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3.38},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3.38},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3.38},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5.21,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2.02,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":4.73},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2.7},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2.75,"additional_payer_notes":"APC"}]}]},{"description":"Agglutinins febrile antigen","code_information":[{"code":"86000","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5.24,"maximum":14.12,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6.98,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":14.12},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8.73},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8.73},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8.73},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13.47,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5.24,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12.22},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6.98},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7.12,"additional_payer_notes":"APC"}]}]},{"description":"Immunoglobulin assay","code_information":[{"code":"86023","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":9.34,"maximum":25.21,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.46,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":25.21},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15.58},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15.58},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15.58},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":24.05,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9.34,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21.81},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12.46},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.71,"additional_payer_notes":"APC"}]}]},{"description":"Aquaporin-4 antb elisa","code_information":[{"code":"86051","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8.65,"maximum":22.25,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11.53,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":17.12},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14.41},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14.41},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14.41},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":22.25,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8.65,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20.18},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11.53},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11.76,"additional_payer_notes":"APC"}]}]},{"description":"Cardiolipin antibody ea ig","code_information":[{"code":"86147","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":11.77,"maximum":49.12,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25.45,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":11.77},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":31.81},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":31.81},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":31.81},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":49.12,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19.09,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":44.54},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25.45},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25.96,"additional_payer_notes":"APC"}]}]},{"description":"Complement total (ch50)","code_information":[{"code":"86162","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":15.24,"maximum":39.22,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20.32,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":38.29},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25.4},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25.4},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25.4},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":39.22,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15.24,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35.56},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20.32},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20.73,"additional_payer_notes":"APC"}]}]},{"description":"Fluorescent antibody screen","code_information":[{"code":"86255","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":9.04,"maximum":24.38,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.05,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":24.38},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15.06},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15.06},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15.06},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":23.26,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9.04,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21.09},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12.05},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.29,"additional_payer_notes":"APC"}]}]},{"description":"Immunoassay tumor ca 125","code_information":[{"code":"86304","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":15.61,"maximum":42.11,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20.81,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":42.11},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26.01},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26.01},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26.01},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":40.16,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15.61,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36.42},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20.81},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21.23,"additional_payer_notes":"APC"}]}]},{"description":"Serum immunoelectrophoresis","code_information":[{"code":"86320","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":22.44,"maximum":57.75,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":29.92,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":45.35},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":37.4},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":37.4},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":37.4},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":57.75,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22.44,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":52.36},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29.92},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":30.52,"additional_payer_notes":"APC"}]}]},{"description":"Immunfix e-phorsis/urine/csf","code_information":[{"code":"86335","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":22.01,"maximum":59.38,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":29.35,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":59.38},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":36.69},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":36.69},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":36.69},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":56.65,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22.01,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":51.36},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29.35},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":29.94,"additional_payer_notes":"APC"}]}]},{"description":"Lymphocyte transformation","code_information":[{"code":"86353","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":36.77,"maximum":99.22,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":49.03,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":99.22},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":61.29},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":61.29},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":61.29},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":94.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":36.77,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":85.8},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":49.03},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":50.01,"additional_payer_notes":"APC"}]}]},{"description":"Mog-igg1 antb flo cytmtry ea","code_information":[{"code":"86363","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":12.05,"maximum":72.82,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":37.73,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":17.89},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":47.16},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":47.16},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":47.16},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":72.82,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":28.3,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":66.03},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12.05},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":38.48,"additional_payer_notes":"APC"}]}]},{"description":"Nuclear matrix protein 22","code_information":[{"code":"86386","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":16.34,"maximum":42.04,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21.78,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":32.33},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27.23},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27.23},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27.23},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":42.04,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16.34,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38.12},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21.78},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22.22,"additional_payer_notes":"APC"}]}]},{"description":"Tb test cell immun measure","code_information":[{"code":"86480","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":46.48,"maximum":125.42,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":61.98,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":125.42},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":77.48},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":77.48},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":77.48},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":119.62,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":46.48,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":108.47},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":61.98},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":63.22,"additional_payer_notes":"APC"}]}]},{"description":"Adenovirus antibody","code_information":[{"code":"86603","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":9.65,"maximum":24.84,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.87,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":11.77},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16.09},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16.09},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16.09},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":24.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9.65,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22.52},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12.87},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.13,"additional_payer_notes":"APC"}]}]},{"description":"Borrelia antibody","code_information":[{"code":"86619","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":10.04,"maximum":27.07,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.38,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":27.07},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16.73},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16.73},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16.73},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":25.82,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10.04,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23.42},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13.38},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.65,"additional_payer_notes":"APC"}]}]},{"description":"Cryptococcus antibody","code_information":[{"code":"86641","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":10.81,"maximum":27.81,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14.41,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":11.77},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18.01},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18.01},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18.01},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":27.81,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10.81,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25.22},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14.41},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14.7,"additional_payer_notes":"APC"}]}]},{"description":"Enterovirus antibody","code_information":[{"code":"86658","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":9.77,"maximum":25.15,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.03,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":11.77},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16.29},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16.29},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16.29},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":25.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9.77,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22.8},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13.03},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.29,"additional_payer_notes":"APC"}]}]},{"description":"Helicobacter pylori antibody","code_information":[{"code":"86677","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":11.77,"maximum":32.52,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16.85,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":11.77},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21.06},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21.06},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21.06},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":32.52,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.64,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29.49},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16.85},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17.19,"additional_payer_notes":"APC"}]}]},{"description":"Herpes simplex type 1 test","code_information":[{"code":"86695","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":9.89,"maximum":26.7,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":26.7},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16.49},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16.49},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16.49},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":25.46,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9.89,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23.08},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13.19},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.45,"additional_payer_notes":"APC"}]}]},{"description":"Hep b surface antibody","code_information":[{"code":"86706","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8.06,"maximum":21.74,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10.74,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":21.74},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13.43},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13.43},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13.43},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":20.73,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8.06,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18.8},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10.74},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10.95,"additional_payer_notes":"APC"}]}]},{"description":"Leptospira antibody","code_information":[{"code":"86720","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":11.77,"maximum":31.27,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16.2,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":11.77},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20.25},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20.25},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20.25},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":31.27,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.15,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28.35},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16.2},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16.52,"additional_payer_notes":"APC"}]}]},{"description":"Parvovirus antibody","code_information":[{"code":"86747","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":11.27,"maximum":30.43,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15.03,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":30.43},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18.79},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18.79},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18.79},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":29.01,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11.27,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26.3},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15.03},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15.33,"additional_payer_notes":"APC"}]}]},{"description":"Salmonella antibody","code_information":[{"code":"86768","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":9.89,"maximum":25.46,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":16.55},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16.49},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16.49},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16.49},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":25.46,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9.89,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23.08},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13.19},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.45,"additional_payer_notes":"APC"}]}]},{"description":"Varicella-zoster antibody","code_information":[{"code":"86787","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":9.66,"maximum":24.86,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.88,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":11.77},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16.1},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16.1},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16.1},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":24.86,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9.66,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22.54},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12.88},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.14,"additional_payer_notes":"APC"}]}]},{"description":"Hep c ab test confirm","code_information":[{"code":"86804","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":11.62,"maximum":31.33,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15.49,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":31.33},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19.36},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19.36},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19.36},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":29.9,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11.62,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27.11},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15.49},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15.8,"additional_payer_notes":"APC"}]}]},{"description":"Hla typing dr/dq","code_information":[{"code":"86817","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":79.6,"maximum":204.85,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":106.14,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":130.28},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":132.68},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":132.68},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":132.68},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":204.85,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":79.6,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":185.75},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":106.14},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":108.26,"additional_payer_notes":"APC"}]}]},{"description":"Hla class i high defin qual","code_information":[{"code":"86832","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":242.81,"maximum":624.84,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":323.75,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":256.74},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":404.69},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":404.69},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":404.69},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":624.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":242.81,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":566.56},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":323.75},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":330.22,"additional_payer_notes":"APC"}]}]},{"description":"Blood typing serologic abo","code_information":[{"code":"86900","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2.99,"maximum":253.99,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":131.6,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5.54},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3.74},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3.74},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3.74},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":253.99,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":98.7,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5.23},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2.99},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":134.23,"additional_payer_notes":"APC"}]}]},{"description":"Small animal inoculation","code_information":[{"code":"87003","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":12.63,"maximum":34.07,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16.84,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":34.07},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21.05},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21.05},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21.05},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":32.5,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.63,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29.47},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16.84},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17.18,"additional_payer_notes":"APC"}]}]},{"description":"Cultr bacteria except blood","code_information":[{"code":"87075","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7.1,"maximum":19.16,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9.47,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":19.16},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11.84},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11.84},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11.84},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":18.28,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7.1,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16.57},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9.47},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9.66,"additional_payer_notes":"APC"}]}]},{"description":"Fungus isolation culture","code_information":[{"code":"87102","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6.31,"maximum":17.02,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8.41,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":17.02},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10.51},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10.51},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10.51},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":16.23,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6.31,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14.72},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8.41},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8.58,"additional_payer_notes":"APC"}]}]},{"description":"Culture type immunofluoresc","code_information":[{"code":"87140","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4.18,"maximum":10.75,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5.57,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":9.23},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":6.96},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":6.96},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":6.96},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":10.75,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4.18,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9.75},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5.57},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5.68,"additional_payer_notes":"APC"}]}]},{"description":"Culture typing added method","code_information":[{"code":"87158","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5.8,"maximum":14.94,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7.74,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":10.6},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":9.68},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":9.68},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":9.68},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":14.94,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5.8,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13.55},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7.74},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7.89,"additional_payer_notes":"APC"}]}]},{"description":"Microbe susceptible diffuse","code_information":[{"code":"87181","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3.56,"maximum":9.62,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4.75,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":9.62},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5.94},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5.94},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5.94},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":9.17,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3.56,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8.31},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":4.75},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4.84,"additional_payer_notes":"APC"}]}]},{"description":"Smear gram stain","code_information":[{"code":"87205","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3.2,"maximum":8.64,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4.27,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":8.64},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5.34},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5.34},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5.34},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":8.24,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3.2,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7.47},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":4.27},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4.36,"additional_payer_notes":"APC"}]}]},{"description":"Virus inoculation tissue","code_information":[{"code":"87252","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":19.55,"maximum":52.74,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26.07,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":52.74},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":32.59},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":32.59},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":32.59},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":50.32,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19.55,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":45.62},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26.07},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26.59,"additional_payer_notes":"APC"}]}]},{"description":"Chlamydia trachomatis ag if","code_information":[{"code":"87270","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8.98,"maximum":24.26,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11.98,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":24.26},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14.98},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14.98},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14.98},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":23.12,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8.98,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20.97},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11.98},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.22,"additional_payer_notes":"APC"}]}]},{"description":"Parainfluenza ag if","code_information":[{"code":"87279","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":12.32,"maximum":31.71,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16.43,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":24.26},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20.54},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20.54},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20.54},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":31.71,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.32,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28.75},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16.43},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16.76,"additional_payer_notes":"APC"}]}]},{"description":"Adenovirus ag ia","code_information":[{"code":"87301","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8.98,"maximum":24.26,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11.98,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":24.26},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14.98},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14.98},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14.98},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":23.12,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8.98,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20.97},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11.98},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.22,"additional_payer_notes":"APC"}]}]},{"description":"E coli 0157 ag ia","code_information":[{"code":"87335","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":9.5,"maximum":24.43,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.66,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":24.26},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15.83},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15.83},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15.83},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":24.43,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9.5,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22.16},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12.66},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.91,"additional_payer_notes":"APC"}]}]},{"description":"Hepatitis delta ag ia","code_information":[{"code":"87380","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":13.77,"maximum":35.43,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":33.2},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22.95},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22.95},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22.95},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":35.43,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.77,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32.13},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18.36},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18.73,"additional_payer_notes":"APC"}]}]},{"description":"Coronavirus ag ia","code_information":[{"code":"87426","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":26.5,"maximum":68.19,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":35.33,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":52.48},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":44.16},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":44.16},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":44.16},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":68.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26.5,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":61.83},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":45.37},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":36.04,"additional_payer_notes":"APC"}]}]},{"description":"Babesia microti amp prb","code_information":[{"code":"87469","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":26.32,"maximum":67.72,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":35.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":51.96},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43.86},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43.86},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43.86},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":67.72,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26.32,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":61.41},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35.09},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":35.79,"additional_payer_notes":"APC"}]}]},{"description":"Candida dna quant","code_information":[{"code":"87482","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":41.8,"maximum":107.58,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":55.74,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":84.49},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":69.68},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":69.68},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":69.68},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":107.58,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":41.8,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":97.55},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":55.74},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":56.85,"additional_payer_notes":"APC"}]}]},{"description":"Chylmd trach dna quant","code_information":[{"code":"87492","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":40.1,"maximum":103.2,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":53.47,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":70.74},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":66.84},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":66.84},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":66.84},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":103.2,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":40.1,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":93.57},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":53.47},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":54.54,"additional_payer_notes":"APC"}]}]},{"description":"Influenza dna amp probe","code_information":[{"code":"87502","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":71.85,"maximum":184.89,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":95.8,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":172.2},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":119.75},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":119.75},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":119.75},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":184.89,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":71.85,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":167.65},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":95.8},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":97.72,"additional_payer_notes":"APC"}]}]},{"description":"H pylri clrthmcn rst amp prb","code_information":[{"code":"87513","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":26.32,"maximum":67.72,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":35.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":50.53},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43.86},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43.86},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43.86},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":67.72,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26.32,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":61.41},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35.09},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":35.79,"additional_payer_notes":"APC"}]}]},{"description":"Hepatitis g dna amp probe","code_information":[{"code":"87526","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":29.44,"maximum":75.77,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":39.26,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":71.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":49.08},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":49.08},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":49.08},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":75.77,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":29.44,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":68.71},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":39.26},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":40.05,"additional_payer_notes":"APC"}]}]},{"description":"Hiv-1 dna dir probe","code_information":[{"code":"87534","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":16.44,"maximum":42.31,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21.92,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":40.58},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27.4},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27.4},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27.4},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":42.31,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16.44,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38.36},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21.92},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22.36,"additional_payer_notes":"APC"}]}]},{"description":"Legion pneumo dna quant","code_information":[{"code":"87542","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":31.32,"maximum":84.49,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":41.76,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":84.49},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":52.2},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":52.2},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":52.2},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":80.6,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":31.32,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":73.08},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":41.76},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":42.6,"additional_payer_notes":"APC"}]}]},{"description":"M.avium-intra dna amp prob","code_information":[{"code":"87561","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":26.32,"maximum":71.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":35.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":71.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43.86},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43.86},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43.86},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":67.72,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26.32,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":61.41},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35.09},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":35.79,"additional_payer_notes":"APC"}]}]},{"description":"N.gonorrhoeae dna amp prob","code_information":[{"code":"87591","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":26.32,"maximum":71.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":35.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":71.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43.86},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43.86},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43.86},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":67.72,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26.32,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":61.41},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35.09},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":35.79,"additional_payer_notes":"APC"}]}]},{"description":"Resp virus 3-5 targets","code_information":[{"code":"87631","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":106.97,"maximum":275.28,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":142.63,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":259.61},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":178.29},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":178.29},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":178.29},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":275.28,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":106.97,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":249.6},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":142.63},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":145.48,"additional_payer_notes":"APC"}]}]},{"description":"Mr-staph dna amp probe","code_information":[{"code":"87641","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":26.32,"maximum":71.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":35.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":71.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43.86},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43.86},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43.86},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":67.72,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26.32,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":61.41},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35.09},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":35.79,"additional_payer_notes":"APC"}]}]},{"description":"Detect agent nos dna dir","code_information":[{"code":"87797","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":22.52,"maximum":57.96,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":30.03,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":40.58},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":37.54},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":37.54},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":37.54},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":57.96,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22.52,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":52.55},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30.03},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":30.63,"additional_payer_notes":"APC"}]}]},{"description":"Hiv antigen w/hiv antibodies","code_information":[{"code":"87806","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":24.58,"maximum":63.25,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":32.77,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":48.72},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":40.96},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":40.96},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":40.96},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":63.25,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":24.58,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":57.35},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32.77},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":33.43,"additional_payer_notes":"APC"}]}]},{"description":"Agent nos assay w/optic","code_information":[{"code":"87899","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":12.05,"maximum":31.02,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16.07,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":24.26},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20.09},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20.09},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20.09},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":31.02,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.05,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28.12},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16.07},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16.39,"additional_payer_notes":"APC"}]}]},{"description":"Genotype cytomegalovirus","code_information":[{"code":"87910","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":193.09,"maximum":520.94,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":257.45,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":520.94},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":321.81},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":321.81},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":321.81},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":496.88,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":193.09,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":450.54},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":257.45},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":262.6,"additional_payer_notes":"APC"}]}]},{"description":"Cytopath c/v auto rescreen","code_information":[{"code":"88148","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":13.9,"maximum":35.78,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18.54,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":21.4},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22.74},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22.74},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22.74},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":35.78,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.9,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31.83},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18.91,"additional_payer_notes":"APC"}]}]},{"description":"Cytopath tbs c/v select","code_information":[{"code":"88167","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":13.9,"maximum":35.78,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18.54,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":21.4},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22.74},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22.74},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22.74},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":35.78,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.9,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31.83},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15.12},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18.91,"additional_payer_notes":"APC"}]}]},{"description":"Cell cryopreserve/storage","code_information":[{"code":"88240","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":9.8,"maximum":25.23,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.07,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":14.14},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16.34},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16.34},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16.34},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":25.23,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9.8,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22.87},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13.07},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.33,"additional_payer_notes":"APC"}]}]},{"description":"Chromosome analysis 20-25","code_information":[{"code":"88264","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":108.46,"maximum":279.1,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":144.61,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":252.2},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":180.76},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":180.76},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":180.76},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":279.1,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":108.46,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":253.07},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":144.61},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":147.5,"additional_payer_notes":"APC"}]}]},{"description":"Chromosome karyotype study","code_information":[{"code":"88280","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":25.1,"maximum":64.6,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":33.47,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":50.8},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":41.84},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":41.84},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":41.84},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":64.6,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25.1,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":58.57},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33.47},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":34.14,"additional_payer_notes":"APC"}]}]},{"description":"Transcutaneous carboxyhb","code_information":[{"code":"88740","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7.03,"maximum":18.08,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":10.15},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11.71},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11.71},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11.71},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":18.08,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7.03,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16.4},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9.37},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9.56,"additional_payer_notes":"APC"}]}]},{"description":"Nasal smear for eosinophils","code_information":[{"code":"89190","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4.34,"maximum":11.17,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5.79,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":9.62},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7.24},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7.24},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7.24},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11.17,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4.34,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10.13},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5.79},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5.91,"additional_payer_notes":"APC"}]}]},{"description":"Evaluation cervical mucus","code_information":[{"code":"89330","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7.78,"maximum":20.03,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10.38,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":11.27},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12.98},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12.98},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12.98},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":20.03,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7.78,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18.17},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10.38},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10.59,"additional_payer_notes":"APC"}]}]},{"description":"Scr c/v cyto, automated sys","code_information":[{"code":"G0147","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":13.9,"maximum":35.78,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18.54,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":21.4},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22.74},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22.74},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22.74},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":35.78,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.9,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31.83},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15.12},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18.91,"additional_payer_notes":"APC"}]}]},{"description":"Oral hiv-1/hiv-2 screen","code_information":[{"code":"G0435","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8.98,"maximum":24.26,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11.98,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":24.26},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14.98},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14.98},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14.98},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":23.12,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8.98,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20.97},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11.98},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.22,"additional_payer_notes":"APC"}]}]},{"description":"Drug test def 22+ classes","code_information":[{"code":"G0483","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":185.19,"maximum":476.56,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":246.92,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":319.73},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":308.65},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":308.65},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":308.65},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":476.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":185.19,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":432.11},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":246.92},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":251.86,"additional_payer_notes":"APC"}]}]},{"description":"Blood mucoprotein","code_information":[{"code":"P2038","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3.71,"maximum":10.18,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4.95,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":10.18},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":6.19},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":6.19},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":6.19},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":9.55,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3.71,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8.66},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":4.95},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5.05,"additional_payer_notes":"APC"}]}]},{"description":"Post-coital mucous exam","code_information":[{"code":"Q0115","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":11.27,"maximum":48.25,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":11.27},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":31.25},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":31.25},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":31.25},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":48.25,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18.75,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":43.75},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25.5,"additional_payer_notes":"APC"}]}]},{"description":"Extracorp shockwv tx hi enrg","code_information":[{"code":"0101T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":182.99,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":243.98,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":470.88,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":182.99,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":248.86,"additional_payer_notes":"APC"}]}]},{"description":"Clear eyelid gland w/heat","code_information":[{"code":"0207T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":98.7,"maximum":2334.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":131.6,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":253.99,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":98.7,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":134.23,"additional_payer_notes":"APC"}]}]},{"description":"Plmt post facet implt thor","code_information":[{"code":"0220T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":9524.15,"maximum":24508.8,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12698.86,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":24508.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9524.15,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12952.84,"additional_payer_notes":"APC"}]}]},{"description":"Insert aqueous drain device","code_information":[{"code":"0253T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3066.31,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4088.41,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7890.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3066.31,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4170.17,"additional_payer_notes":"APC"}]}]},{"description":"Rev/remvl crtd sns dev lead","code_information":[{"code":"0270T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8657.0,"maximum":8770.0,"payers_information":[{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0}]}]},{"description":"Trnscth renal symp denrv bil","code_information":[{"code":"0339T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4222.18,"maximum":10865.09,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5629.58,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":10865.09,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4222.18,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5742.17,"additional_payer_notes":"APC"}]}]},{"description":"Insj/rplc car modulj pls gn","code_information":[{"code":"0409T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":16501.0,"maximum":54996.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22001.33,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":54996.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":54996.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":54996.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":42462.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16501.0,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":51942.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22441.36,"additional_payer_notes":"APC"}]}]},{"description":"Dstrj neurofibroma xtnsv","code_information":[{"code":"0419T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":548.27,"maximum":2334.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":731.02,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1410.87,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":548.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":745.64,"additional_payer_notes":"APC"}]}]},{"description":"Rmvl nstim apnea sen ld","code_information":[{"code":"0429T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8770.0,"maximum":8770.0,"payers_information":[{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0}]}]},{"description":"Abltj perc plex/trncl nrv","code_information":[{"code":"0442T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6510.21,"maximum":16752.93,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8680.28,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":16752.93,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6510.21,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8853.88,"additional_payer_notes":"APC"}]}]},{"description":"Insj aqueous drain dev each","code_information":[{"code":"0450T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":2334.0,"payers_information":[{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Rmvl&rinsj sinus tarsi implt","code_information":[{"code":"0511T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":13851.98,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Rmvl&rplcmt pg wcs new eltrd","code_information":[{"code":"0520T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7753.63,"maximum":54996.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10338.17,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":54996.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":54996.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":54996.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":19952.66,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7753.63,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":51942.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10544.93,"additional_payer_notes":"APC"}]}]},{"description":"Removal iims implt mntr only","code_information":[{"code":"0532T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2772.2,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3696.26,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7133.79,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2772.2,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3770.19,"additional_payer_notes":"APC"}]}]},{"description":"Rmvl ss impl dfb pg only","code_information":[{"code":"0580T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2772.2,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3696.26,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7133.79,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2772.2,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3770.19,"additional_payer_notes":"APC"}]}]},{"description":"Perq njx algc fluor lmbr ea","code_information":[{"code":"0628T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":2334.0,"payers_information":[{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Perq trluml coronry lithotrp","code_information":[{"code":"0715T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":1887.0,"payers_information":[{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0}]}]},{"description":"Capillary blood draw","code_information":[{"code":"36416","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2.89,"maximum":4.08,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4.08},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2.89}]}]},{"description":"Alkaloids nos","code_information":[{"code":"80323","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":35.06,"maximum":35.06,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":35.06}]}]},{"description":"Drug screening barbiturates","code_information":[{"code":"80345","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":35.06,"maximum":35.06,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":35.06}]}]},{"description":"Ketamine and norketamine","code_information":[{"code":"80357","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":35.06,"maximum":35.06,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":35.06}]}]},{"description":"Drug screening propoxyphene","code_information":[{"code":"80367","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":35.06,"maximum":35.06,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":35.06}]}]},{"description":"Drug/substance nos 4-6","code_information":[{"code":"80376","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":35.06,"maximum":35.06,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":35.06}]}]},{"description":"Sbsqt plmt drug elut oc ins","code_information":[{"code":"0445T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":2334.0,"payers_information":[{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Insj/rplcmt compl iims","code_information":[{"code":"0525T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":14288.94,"maximum":36770.21,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19051.92,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":36770.21,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14288.94,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":27583.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19432.96,"additional_payer_notes":"APC"}]}]},{"description":"Autol cell implt adps njx","code_information":[{"code":"0566T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":2334.0,"payers_information":[{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Revision/removal isdns ptn","code_information":[{"code":"0588T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2593.52,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3458.03,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6674.0,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2593.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3527.19,"additional_payer_notes":"APC"}]}]},{"description":"Insj iris prosth w/rmvl&insj","code_information":[{"code":"0617T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":15691.0,"maximum":16106.0,"payers_information":[{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0}]}]},{"description":"Perq tcat us abltj nrv p-art","code_information":[{"code":"0632T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":13599.0,"maximum":34994.75,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18131.99,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":34994.75,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13599.0,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":27583.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18494.63,"additional_payer_notes":"APC"}]}]},{"description":"Prep tum cav iort prim crnot","code_information":[{"code":"0735T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":2334.0,"payers_information":[{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Perq dev soft tiss add imag","code_information":[{"code":"10036","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":2334.0,"payers_information":[{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Laryngoplasty laryngeal sten","code_information":[{"code":"31554","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Injection(s) spider veins","code_information":[{"code":"36468","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":301.57,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":402.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":776.03,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":301.57,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":410.13,"additional_payer_notes":"APC"}]}]},{"description":"Declot vascular device","code_information":[{"code":"36593","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":245.03,"maximum":2334.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":326.71,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":630.55,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":245.03,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":333.24,"additional_payer_notes":"APC"}]}]},{"description":"Thrmbc/nfs dialysis circuit","code_information":[{"code":"36904","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4222.18,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5629.58,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":10865.09,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4222.18,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5742.17,"additional_payer_notes":"APC"}]}]},{"description":"Trluml balo angiop addl art","code_information":[{"code":"37247","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":2334.0,"payers_information":[{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Io map of sent lymph node","code_information":[{"code":"38900","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Lap gastr bypass incl smll i","code_information":[{"code":"43645","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5257.0,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5257.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0}]}]},{"description":"Tx gastro intub w/asp","code_information":[{"code":"43753","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":160.18,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":213.57,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":412.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":160.18,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":217.84,"additional_payer_notes":"APC"}]}]},{"description":"Drainage of rectal abscess","code_information":[{"code":"45020","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2059.07,"maximum":5298.68,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2745.43,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5298.68,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2059.07,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2800.34,"additional_payer_notes":"APC"}]}]},{"description":"Insj stablj dev w/dcmprn","code_information":[{"code":"22868","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":2334.0,"payers_information":[{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Injection for cholangiogram","code_information":[{"code":"47532","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2656.06,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3541.41,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6834.92,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2656.06,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3612.24,"additional_payer_notes":"APC"}]}]},{"description":"Perq plmt bile duct stent","code_information":[{"code":"47540","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4484.77,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5979.69,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5257.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11540.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4484.77,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6099.28,"additional_payer_notes":"APC"}]}]},{"description":"Biliary endoscopy thru skin","code_information":[{"code":"47554","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5257.0,"maximum":20292.15,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10514.07,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5257.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":20292.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7885.55,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10724.35,"additional_payer_notes":"APC"}]}]},{"description":"Sclerotx fluid collection","code_information":[{"code":"49185","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1225.21,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1633.61,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3152.87,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1225.21,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1666.28,"additional_payer_notes":"APC"}]}]},{"description":"Attach bladder/urethra","code_information":[{"code":"51841","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0}]}]},{"description":"Circumcision w/regionl block","code_information":[{"code":"54150","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1550.71,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2067.62,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3990.5,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1550.71,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2108.97,"additional_payer_notes":"APC"}]}]},{"description":"Treatment of penis lesion","code_information":[{"code":"54220","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":185.35,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":247.13,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":476.96,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":185.35,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":252.07,"additional_payer_notes":"APC"}]}]},{"description":"Reconstruction of urethra","code_information":[{"code":"54308","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3977.55,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5303.4,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":10235.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3977.55,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5409.47,"additional_payer_notes":"APC"}]}]},{"description":"Revise penis/urethra","code_information":[{"code":"54332","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2614.94,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3486.59,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6729.12,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2614.94,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3556.32,"additional_payer_notes":"APC"}]}]},{"description":"Repair penis","code_information":[{"code":"54385","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1550.71,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2067.62,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3990.5,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1550.71,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2108.97,"additional_payer_notes":"APC"}]}]},{"description":"Remov/replc penis pros comp","code_information":[{"code":"54411","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":39565.78,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20500.4,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":10765.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":8923.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":10765.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":39565.78,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15375.3,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20910.41,"additional_payer_notes":"APC"}]}]},{"description":"Harvest art for cabg add-on","code_information":[{"code":"35600","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Art byp aor-celiac-msn-renal","code_information":[{"code":"35631","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Art byp subclav-vertebrl","code_information":[{"code":"35645","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Art byp iliofemoral","code_information":[{"code":"35665","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Art trnsposj vertbrl carotid","code_information":[{"code":"35691","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Explore chest vessels","code_information":[{"code":"35820","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Insertion of catheter vein","code_information":[{"code":"36500","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Insert non-tunnel cv cath","code_information":[{"code":"36555","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2342.32,"maximum":6027.57,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3123.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6027.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2342.32,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3185.56,"additional_payer_notes":"APC"}]}]},{"description":"Insert tunneled cv cath","code_information":[{"code":"36566","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4127.91,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5503.89,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":10622.5,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4127.91,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5613.96,"additional_payer_notes":"APC"}]}]},{"description":"Remove hepatic shunt (tips)","code_information":[{"code":"37183","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4222.18,"maximum":27583.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5629.58,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":7398.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6019.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":7398.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":10865.09,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4222.18,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":27583.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5742.17,"additional_payer_notes":"APC"}]}]},{"description":"Rem endovas vena cava filter","code_information":[{"code":"37193","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2342.32,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3123.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6027.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2342.32,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3185.56,"additional_payer_notes":"APC"}]}]},{"description":"Transcath stent cca w/eps","code_information":[{"code":"37215","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Ligation of neck vein","code_information":[{"code":"37565","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2342.32,"maximum":6027.57,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3123.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6027.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2342.32,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3185.56,"additional_payer_notes":"APC"}]}]},{"description":"Removal of leg veins/lesion","code_information":[{"code":"37735","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2342.32,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3123.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6027.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2342.32,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3185.56,"additional_payer_notes":"APC"}]}]},{"description":"Injection for spleen x-ray","code_information":[{"code":"38200","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Bone marrow harvest autolog","code_information":[{"code":"38232","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3231.05,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4308.07,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":8314.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3231.05,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4394.23,"additional_payer_notes":"APC"}]}]},{"description":"Thoracic duct procedure","code_information":[{"code":"38380","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Biopsy/removal lymph nodes","code_information":[{"code":"38530","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2904.59,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3872.79,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7474.49,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2904.59,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3950.25,"additional_payer_notes":"APC"}]}]},{"description":"Repair vagina","code_information":[{"code":"57335","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3388.0,"maximum":9549.58,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4947.97,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":9549.58,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3710.98,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5046.93,"additional_payer_notes":"APC"}]}]},{"description":"Revise prosth vag graft lap","code_information":[{"code":"57426","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5501.01,"maximum":14155.93,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7334.68,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":14155.93,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5501.01,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7481.37,"additional_payer_notes":"APC"}]}]},{"description":"Treat ectopic pregnancy","code_information":[{"code":"59120","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0}]}]},{"description":"Remove cranial cavity fluid","code_information":[{"code":"61001","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":523.65,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":698.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1347.51,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":523.65,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":712.16,"additional_payer_notes":"APC"}]}]},{"description":"Replace/irrigate catheter","code_information":[{"code":"62194","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1448.59,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1931.46,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3727.72,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1448.59,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1970.09,"additional_payer_notes":"APC"}]}]},{"description":"Njx interlaminar lmbr/sac","code_information":[{"code":"62326","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":656.13,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":874.84,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1688.44,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":656.13,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":892.34,"additional_payer_notes":"APC"}]}]},{"description":"Injection treatment of nerve","code_information":[{"code":"64640","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":656.13,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":874.84,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1688.44,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":656.13,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":892.34,"additional_payer_notes":"APC"}]}]},{"description":"Chemodenerv eccrine glands","code_information":[{"code":"64653","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":227.71,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":303.61,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":585.96,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":227.71,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":309.68,"additional_payer_notes":"APC"}]}]},{"description":"Revise low back nerve(s)","code_information":[{"code":"64714","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1448.59,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1931.46,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3727.72,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1448.59,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1970.09,"additional_payer_notes":"APC"}]}]},{"description":"Incision of brow nerve","code_information":[{"code":"64732","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1448.59,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1931.46,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3727.72,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1448.59,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1970.09,"additional_payer_notes":"APC"}]}]},{"description":"Laparoscopy lymphadenectomy","code_information":[{"code":"38572","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":20292.15,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10514.07,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":20292.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7885.55,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10724.35,"additional_payer_notes":"APC"}]}]},{"description":"Remove abdominal lymph nodes","code_information":[{"code":"38747","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5257.0,"maximum":6462.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5257.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6462.0}]}]},{"description":"Chest procedure","code_information":[{"code":"39499","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":10779.0,"maximum":13249.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":13249.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":10779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":13249.0}]}]},{"description":"Diaphragm surgery procedure","code_information":[{"code":"39599","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":10779.0,"maximum":13249.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":13249.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":10779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":13249.0}]}]},{"description":"Tongue mouth jaw surgery","code_information":[{"code":"41150","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Partial removal of pharynx","code_information":[{"code":"42890","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Control throat bleeding","code_information":[{"code":"42961","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0}]}]},{"description":"Incision of esophagus","code_information":[{"code":"43045","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Partial removal of esophagus","code_information":[{"code":"43117","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Rpr nsl vlv collapse w/implt","code_information":[{"code":"30468","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Cricotracheal resection","code_information":[{"code":"31592","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Thrmbc/nfs dialysis circuit","code_information":[{"code":"36906","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":13599.0,"maximum":44873.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18131.99,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":44873.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":44873.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":44873.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":34994.75,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13599.0,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":43285.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18494.63,"additional_payer_notes":"APC"}]}]},{"description":"Trluml balo angiop addl vein","code_information":[{"code":"37249","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":2334.0,"payers_information":[{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Laps esophgl sphnctr agmntj","code_information":[{"code":"43284","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7885.55,"maximum":20292.15,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10514.07,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":20292.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7885.55,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10724.35,"additional_payer_notes":"APC"}]}]},{"description":"Lap rmvl gastr adj device","code_information":[{"code":"43772","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2860.11,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3813.48,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7360.02,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2860.11,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3889.75,"additional_payer_notes":"APC"}]}]},{"description":"Esoph imped function test","code_information":[{"code":"91037","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":160.18,"maximum":2334.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":213.57,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":412.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":160.18,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":217.84,"additional_payer_notes":"APC"}]}]},{"description":"Rectal sensation test","code_information":[{"code":"91120","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":2334.0,"payers_information":[{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Prq cardiac angioplast 1 art","code_information":[{"code":"92920","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4222.18,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5629.58,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":10865.09,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4222.18,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5742.17,"additional_payer_notes":"APC"}]}]},{"description":"Prq revasc byp graft 1 vsl","code_information":[{"code":"92937","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8563.85,"maximum":22037.64,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11418.47,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":22037.64,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8563.85,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11646.84,"additional_payer_notes":"APC"}]}]},{"description":"Cardioversion electric int","code_information":[{"code":"92961","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":490.31,"maximum":3030.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":653.75,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1261.73,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":490.31,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":666.82,"additional_payer_notes":"APC"}]}]},{"description":"Revision of pulmonary valve","code_information":[{"code":"92990","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8563.85,"maximum":22037.64,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11418.47,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":22037.64,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8563.85,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11646.84,"additional_payer_notes":"APC"}]}]},{"description":"Exercise w/hemodynamic meas","code_information":[{"code":"93464","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":2334.0,"payers_information":[{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Inject pulm art hrt cath","code_information":[{"code":"93568","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":2334.0,"payers_information":[{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Transcath closure of vsd","code_information":[{"code":"93581","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":13599.0,"maximum":43643.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18131.99,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43643.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43643.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43643.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":34994.75,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13599.0,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":41120.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18494.63,"additional_payer_notes":"APC"}]}]},{"description":"Intraventricular pacing","code_information":[{"code":"93612","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3579.0,"maximum":14889.41,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7714.72,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":14889.41,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5786.04,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7869.01,"additional_payer_notes":"APC"}]}]},{"description":"Electrophysiology evaluation","code_information":[{"code":"93622","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":2334.0,"payers_information":[{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Ablate heart dysrhythm focus","code_information":[{"code":"93650","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5786.04,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7714.72,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":14889.41,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5786.04,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7869.01,"additional_payer_notes":"APC"}]}]},{"description":"Set-up cardiovert-defibrill","code_information":[{"code":"93745","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":227.84,"maximum":2334.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":303.79,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":586.32,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":227.84,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":309.87,"additional_payer_notes":"APC"}]}]},{"description":"Reconstruction of anus","code_information":[{"code":"46753","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2059.07,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2745.43,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5298.68,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2059.07,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2800.34,"additional_payer_notes":"APC"}]}]},{"description":"Excision of anal lesion(s)","code_information":[{"code":"46922","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2059.07,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2745.43,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5298.68,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2059.07,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2800.34,"additional_payer_notes":"APC"}]}]},{"description":"Exc abd tum over 5 cm","code_information":[{"code":"49204","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":17314.0,"maximum":18364.0,"payers_information":[{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0}]}]},{"description":"Lap insert tunnel ip cath","code_information":[{"code":"49324","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4484.77,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5979.69,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5257.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11540.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4484.77,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6099.28,"additional_payer_notes":"APC"}]}]},{"description":"Image cath fluid peri/retro","code_information":[{"code":"49406","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1225.21,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1633.61,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3152.87,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1225.21,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1666.28,"additional_payer_notes":"APC"}]}]},{"description":"Change nephroureteral cath","code_information":[{"code":"50387","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1550.71,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2067.62,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3990.5,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1550.71,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2108.97,"additional_payer_notes":"APC"}]}]},{"description":"Njx px nfrosgrm &/urtrgrm","code_information":[{"code":"50431","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":517.28,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":689.7,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1331.13,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":517.28,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":703.5,"additional_payer_notes":"APC"}]}]},{"description":"Pdt dstr prmlg les phys/qhp","code_information":[{"code":"96573","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":148.84,"maximum":2334.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":198.45,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":383.01,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":148.84,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":202.42,"additional_payer_notes":"APC"}]}]},{"description":"Low cost skin substitute app","code_information":[{"code":"C5275","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":2334.0,"payers_information":[{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Blue light cysto imag agent","code_information":[{"code":"C9738","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":2334.0,"payers_information":[{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Nsl/sins cryo post nasal tis","code_information":[{"code":"C9771","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7529.0,"maximum":7529.0,"payers_information":[{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0}]}]},{"description":"Dstry eye lesn,fdr vssl tech","code_information":[{"code":"G0186","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":408.01,"maximum":3030.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":544.01,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1049.93,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":408.01,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":554.89,"additional_payer_notes":"APC"}]}]},{"description":"Robt lin-radsurg fractx 2-5","code_information":[{"code":"G0340","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8657.0,"maximum":8770.0,"payers_information":[{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0}]}]},{"description":"Iiv3 vaccine splt 0.25 ml im","code_information":[{"code":"90657","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":12.02,"maximum":29.75,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":12.02},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20.77},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20.77},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20.77},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20.22},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29.75}]}]},{"description":"Rabies vaccine im","code_information":[{"code":"90675","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":248.98,"maximum":892.39,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":331.98,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":349.44},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":592.86},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":592.86},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":592.86},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":640.72,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":248.98,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":606.39},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":892.39},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":338.62,"additional_payer_notes":"APC"}]}]},{"description":"Hepb vacc 2 dose adolesc im","code_information":[{"code":"90743","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":82.67,"maximum":204.6,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":82.67},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":142.78},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":142.78},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":142.78},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":139.03},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":204.6}]}]},{"description":"Sarscv2 vac 30mcg trs-suc im","code_information":[{"code":"91320","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":171.49,"maximum":424.45,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":171.49},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":296.2},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":296.2},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":296.2},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":288.42},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":424.45}]}]},{"description":"Gad-base MR contrast NOS,1ml","code_information":[{"code":"A9579","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1.64,"maximum":4.03,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1.64},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2.8},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2.8},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2.8},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2.74},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":4.03}]}]},{"description":"Acetaminophen injection","code_information":[{"code":"J0131","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":0.06,"maximum":0.13,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":0.06},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.1},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.1},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.1},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.06},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.09},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.13}]}]},{"description":"Inj epinephrine nos 0.1 mg","code_information":[{"code":"J0165","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1.1,"maximum":1.1,"payers_information":[{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1.1},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1.1},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1.1}]}]},{"description":"Inj, aflibercept hd, 1 mg","code_information":[{"code":"J0177","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":224.01,"maximum":895.87,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":298.68,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":353.3},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":607.5},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":607.5},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":607.5},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":576.46,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":356.27},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":224.01,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":608.76},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":895.87},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":304.66,"additional_payer_notes":"APC"}]}]},{"description":"Inj olipudase alfa-rpcp 1mg","code_information":[{"code":"J0218","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":303.71,"maximum":1038.86,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":404.95,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":419.36},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":748.26},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":748.26},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":748.26},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":781.55,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":413.15},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":303.71,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":705.92},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1038.86},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":413.05,"additional_payer_notes":"APC"}]}]},{"description":"Alpha 1 proteinase inhibitor","code_information":[{"code":"J0256","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3.85,"maximum":13.86,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5.13,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5.68},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":9.85},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":9.85},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":9.85},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":9.91,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5.51},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3.85,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9.42},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13.86},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5.24,"additional_payer_notes":"APC"}]}]},{"description":"Amphotericin b lipid complex","code_information":[{"code":"J0287","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":11.33,"maximum":28.05,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":11.33},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19.57},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19.57},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19.57},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28.05}]}]},{"description":"Inj aripiprazole ext rel 1mg","code_information":[{"code":"J0401","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5.6,"maximum":19.26,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7.46,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7.73},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13.75},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13.75},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13.75},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":14.4,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7.65},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5.6,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13.08},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19.26},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7.61,"additional_payer_notes":"APC"}]}]},{"description":"Belatacept injection","code_information":[{"code":"J0485","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2.91,"maximum":10.69,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3.88,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4.28},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7.39},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7.39},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7.39},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7.5,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":4.26},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2.91,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7.27},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10.69},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3.96,"additional_payer_notes":"APC"}]}]},{"description":"Inj, bezlotoxumab, 10 mg","code_information":[{"code":"J0565","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":29.87,"maximum":108.55,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":39.82,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":43.86},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":75.67},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":75.67},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":75.67},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":76.86,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":43.16},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":29.87,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":73.76},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":108.55},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":40.62,"additional_payer_notes":"APC"}]}]},{"description":"Incobotulinumtoxin a","code_information":[{"code":"J0588","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3.96,"maximum":14.45,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5.28,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5.86},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10.08},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10.08},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10.08},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":10.2,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5.74},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3.96,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9.82},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14.45},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5.39,"additional_payer_notes":"APC"}]}]},{"description":"C-1 esterase, cinryze","code_information":[{"code":"J0598","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":50.06,"maximum":174.44,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":66.75,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":70.27},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":124.88},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":124.88},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":124.88},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":128.83,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":69.37},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":50.06,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":118.53},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":174.44},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":68.09,"additional_payer_notes":"APC"}]}]},{"description":"Levoleucovorin injection","code_information":[{"code":"J0641","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":0.02,"maximum":0.12,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":0.02},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.07},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.07},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.07},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.05},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.07},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.12}]}]},{"description":"Inj cefazolin (wg crit care)","code_information":[{"code":"J0687","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1.07,"maximum":3.02,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1.07},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1.9},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1.9},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1.9},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1.21},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2.05},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3.02}]}]},{"description":"Sterile cefuroxime injection","code_information":[{"code":"J0697","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2.04,"maximum":5.15,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2.21},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4.35},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4.35},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4.35},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2.04},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3.5},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5.15}]}]},{"description":"Certolizumab pegol inj 1mg","code_information":[{"code":"J0717","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2.58,"maximum":10.63,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3.44,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4.38},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8.52},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8.52},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8.52},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6.65,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":4.22},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2.58,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7.22},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10.63},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3.51,"additional_payer_notes":"APC"}]}]},{"description":"Inj imip 4 cilas 4 releb 2mg","code_information":[{"code":"J0742","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2.7,"maximum":6.81,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2.75},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4.96},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4.96},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4.96},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2.7},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":4.63},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6.81}]}]},{"description":"Inj crizanlizumab-tmca 5mg","code_information":[{"code":"J0791","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":97.45,"maximum":350.33,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":129.94,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":142.45},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":246.2},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":246.2},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":246.2},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":250.78,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":139.32},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":97.45,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":238.06},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":350.33},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":132.54,"additional_payer_notes":"APC"}]}]},{"description":"Daptomycin (xellia) unrefrig","code_information":[{"code":"J0872","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":0.05,"maximum":0.12,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":0.06},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.1},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.1},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.1},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.05},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.07},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.12}]}]},{"description":"Argatroban nonesrd use 1mg","code_information":[{"code":"J0883","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":0.65,"maximum":2.18,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":0.86,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1.05},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1.4},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1.4},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1.4},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1.67,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":0.65,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2.18},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":0.88,"additional_payer_notes":"APC"}]}]},{"description":"Inj luspatercept-aamt 0.25mg","code_information":[{"code":"J0896","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":32.64,"maximum":112.38,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":43.51,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":45.36},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":79.73},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":79.73},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":79.73},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":83.98,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":44.69},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":32.64,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":76.37},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":112.38},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":44.38,"additional_payer_notes":"APC"}]}]},{"description":"Injection for bladder x-ray","code_information":[{"code":"51610","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Treatment of bladder lesion","code_information":[{"code":"51720","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":517.28,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":689.7,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1331.13,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":517.28,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":703.5,"additional_payer_notes":"APC"}]}]},{"description":"Anal/urinary muscle study","code_information":[{"code":"51784","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":95.45,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":127.27,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":245.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":95.45,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":129.82,"additional_payer_notes":"APC"}]}]},{"description":"Destruction penis lesion(s)","code_information":[{"code":"54050","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":301.57,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":402.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":776.03,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":301.57,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":410.13,"additional_payer_notes":"APC"}]}]},{"description":"Treatment of penis lesion","code_information":[{"code":"54110","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2614.94,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3486.59,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6729.12,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2614.94,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3556.32,"additional_payer_notes":"APC"}]}]},{"description":"Dexametha opth insert 0.1 mg","code_information":[{"code":"J1096","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":67.51,"maximum":307.51,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":90.02,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":121.75},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":192.82},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":192.82},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":192.82},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":173.74,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":122.29},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":67.51,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":208.96},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":307.51},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":91.82,"additional_payer_notes":"APC"}]}]},{"description":"Inj, hydromorphone, 0.1 mg","code_information":[{"code":"J1171","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":0.09,"maximum":0.25,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":0.15},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.16},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.16},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.16},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.09},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.17},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.25}]}]},{"description":"Dimenhydrinate injection","code_information":[{"code":"J1240","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":9.19,"maximum":23.61,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":9.19},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14.71},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14.71},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14.71},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9.39},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16.04},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23.61}]}]},{"description":"Injection, edaravone, 1 mg","code_information":[{"code":"J1301","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4.85,"maximum":59.02,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6.46,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":22.45},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":35.79},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":35.79},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":35.79},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":12.47,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23.47},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4.85,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":40.11},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":59.02},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6.59,"additional_payer_notes":"APC"}]}]},{"description":"Inj, elranatamab-bcmm, 1 mg","code_information":[{"code":"J1323","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":144.36,"maximum":483.65,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":192.48,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":201.28},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":352.09},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":352.09},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":352.09},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":371.49,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":192.34},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":144.36,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":328.65},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":483.65},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":196.33,"additional_payer_notes":"APC"}]}]},{"description":"Inj, focinvez, 1mg","code_information":[{"code":"J1434","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1.84,"maximum":8.5,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2.46,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3.32},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5.45},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5.45},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5.45},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4.74,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1.84,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8.5},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2.51,"additional_payer_notes":"APC"}]}]},{"description":"Fluconazole","code_information":[{"code":"J1450","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2.58,"maximum":6.5,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3.94},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4.29},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4.29},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4.29},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2.58},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":4.42},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6.5}]}]},{"description":"Inj cutaquig 100 mg","code_information":[{"code":"J1551","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":10.52,"maximum":39.5,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14.03,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":15.77},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26.99},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26.99},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26.99},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":27.08,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15.71},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10.52,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26.84},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":39.5},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14.31,"additional_payer_notes":"APC"}]}]},{"description":"Gamma globulin > 10 CC inj","code_information":[{"code":"J1560","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":121.89,"maximum":1345.34,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":162.52,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":537.74},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":317.42},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":317.42},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":317.42},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":313.66,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":535.05},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":121.89,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":914.2},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1345.34},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":165.77,"additional_payer_notes":"APC"}]}]},{"description":"Hyqvia 100mg immuneglobulin","code_information":[{"code":"J1575","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":13.76,"maximum":48.16,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18.35,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":19.33},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":34.93},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":34.93},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":34.93},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":35.41,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19.15},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.76,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32.73},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":48.16},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18.71,"additional_payer_notes":"APC"}]}]},{"description":"Granisetron hcl injection","code_information":[{"code":"J1626","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":0.24,"maximum":0.63,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":0.29},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.43},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.43},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.43},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.24},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.43},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.63}]}]},{"description":"Inj heparin sodium per 1000u","code_information":[{"code":"J1644","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":0.22,"maximum":0.54,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":0.24},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.41},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.41},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.41},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.22},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.37},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.54}]}]},{"description":"Idursulfase injection","code_information":[{"code":"J1743","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":427.53,"maximum":1476.19,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":570.04,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":596.83},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1061.26},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1061.26},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1061.26},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1100.18,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":587.07},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":427.53,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1003.11},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1476.19},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":581.44,"additional_payer_notes":"APC"}]}]},{"description":"Droperidol injection","code_information":[{"code":"J1790","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":9.43,"maximum":33.18,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":9.43},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10.19},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10.19},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10.19},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33.18}]}]},{"description":"Inj, metronidazole, 10 mg","code_information":[{"code":"J1836","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":0.03,"maximum":0.08,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":0.03},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.06},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.06},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.06},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.03},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.06},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.08}]}]},{"description":"Inj, bumetanide, 0.5 mg","code_information":[{"code":"J1939","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":0.63,"maximum":1.58,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":0.63},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1.16},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1.16},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1.16},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.63},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1.07},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1.58}]}]},{"description":"Inj levocarnitine per 1 gm","code_information":[{"code":"J1955","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":26.82,"maximum":69.58,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":26.82},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":46.15},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":46.15},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":46.15},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27.68},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":47.29},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":69.58}]}]},{"description":"Mannitol injection","code_information":[{"code":"J2150","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2.49,"maximum":6.91,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2.49},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4.25},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4.25},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4.25},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2.75},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":4.7},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6.91}]}]},{"description":"Inj, micafungin (par pharm)","code_information":[{"code":"J2247","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":0.34,"maximum":0.84,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":0.34},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.68},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.68},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.68},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.34},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.57},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.84}]}]},{"description":"In morphine preservativ free","code_information":[{"code":"J2274","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":10.8,"maximum":31.45,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":10.8},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20.5},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20.5},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20.5},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12.5},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21.37},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31.45}]}]},{"description":"Inj naloxone hcl nos, 0.01mg","code_information":[{"code":"J2312","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":0.13,"maximum":0.13,"payers_information":[{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.13},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.13},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.13}]}]},{"description":"Octreotide injection, depot","code_information":[{"code":"J2353","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":156.07,"maximum":594.51,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":208.1,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":225.05},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":403.18},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":403.18},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":403.18},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":401.62,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":236.44},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":156.07,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":403.98},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":594.51},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":212.26,"additional_payer_notes":"APC"}]}]},{"description":"Inj, biorphen, 20 micrograms","code_information":[{"code":"J2372","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":0.18,"maximum":0.46,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":0.2},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.32},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.32},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.32},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.18},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.31},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.46}]}]},{"description":"Palifermin injection","code_information":[{"code":"J2425","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":29.02,"maximum":92.53,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":38.69,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":37.39},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":68.24},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":68.24},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":68.24},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":74.67,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36.8},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":29.02,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":62.88},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":92.53},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":39.46,"additional_payer_notes":"APC"}]}]},{"description":"Inj pegfilgrast ex bio 0.5mg","code_information":[{"code":"J2506","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":21.64,"maximum":276.44,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":143.23,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":21.98},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":110.96},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":110.96},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":110.96},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":276.44,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21.64},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":107.42,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36.96},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":54.4},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":146.1,"additional_payer_notes":"APC"}]}]},{"description":"Plerixafor injection","code_information":[{"code":"J2562","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":21.37,"maximum":226.99,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":28.49,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":27.48},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":226.99},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":226.99},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":226.99},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":54.98,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":40.15},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21.37,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":68.6},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":100.95},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":29.06,"additional_payer_notes":"APC"}]}]},{"description":"Procainamide hcl injection","code_information":[{"code":"J2690","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":198.18,"maximum":570.05,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":295.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":312.77},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":369.2},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":369.2},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":369.2},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":570.05,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":198.18},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":221.52,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":338.61},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":498.3},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":301.27,"additional_payer_notes":"APC"}]}]},{"description":"Ranibizumab injection","code_information":[{"code":"J2778","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":38.32,"maximum":337.54,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":51.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":99.45},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":173.11},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":173.11},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":173.11},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":98.6,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":134.24},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":38.32,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":229.36},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":337.54},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":52.11,"additional_payer_notes":"APC"}]}]},{"description":"Rho d immune globulin inj","code_information":[{"code":"J2790","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":84.88,"maximum":226.94,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":84.88},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":156.6},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":156.6},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":156.6},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":90.26},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":154.22},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":226.94}]}]},{"description":"Inj, romiplostim 1 microgram","code_information":[{"code":"J2802","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8.71,"maximum":28.69,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11.62,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":11.57},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20.89},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20.89},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20.89},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":22.42,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11.41},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8.71,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19.5},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28.69},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11.85,"additional_payer_notes":"APC"}]}]},{"description":"Alteplase recombinant","code_information":[{"code":"J2997","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":73.94,"maximum":249.05,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":98.59,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":100.61},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":178.89},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":178.89},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":178.89},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":190.27,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":99.05},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":73.94,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":169.24},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":249.05},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":100.56,"additional_payer_notes":"APC"}]}]},{"description":"Tenecteplase injection","code_information":[{"code":"J3101","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":163.07,"maximum":442.22,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":217.42,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":178.71},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":326.68},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":326.68},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":326.68},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":419.62,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":175.87},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":163.07,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":300.5},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":442.22},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":221.77,"additional_payer_notes":"APC"}]}]},{"description":"Tigecycline injection","code_information":[{"code":"J3243","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":0.33,"maximum":1.72,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":0.33},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.96},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.96},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.96},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.68},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1.17},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1.72}]}]},{"description":"Treprostinil injection","code_information":[{"code":"J3285","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":41.06,"maximum":152.33,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":54.74,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":62.51},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":105.42},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":105.42},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":105.42},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":105.65,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":60.58},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":41.06,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":103.51},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":152.33},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":55.83,"additional_payer_notes":"APC"}]}]},{"description":"Diazepam injection","code_information":[{"code":"J3360","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6.37,"maximum":23.28,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6.37},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11.72},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11.72},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11.72},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9.25},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15.82},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23.28}]}]},{"description":"Laparoscope proc esoph","code_information":[{"code":"43289","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4484.77,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5979.69,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5257.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11540.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4484.77,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6099.28,"additional_payer_notes":"APC"}]}]},{"description":"Revise esophagus & stomach","code_information":[{"code":"43325","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Transthor diaphrag hern rpr","code_information":[{"code":"43335","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5257.0,"maximum":6462.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5257.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6462.0}]}]},{"description":"Gastrointestinal repair","code_information":[{"code":"43360","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Removal of stomach partial","code_information":[{"code":"43631","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Gastric bypass incl small i","code_information":[{"code":"43847","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Decompress small bowel","code_information":[{"code":"44021","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Removal of small intestine","code_information":[{"code":"44121","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Intestine transplnt cadaver","code_information":[{"code":"44135","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Partial removal of colon","code_information":[{"code":"44145","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Colectomy w/Neo-Rectum Pouch","code_information":[{"code":"44158","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Laparo partial colectomy","code_information":[{"code":"44204","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5257.0,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5257.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0}]}]},{"description":"Lap mobil splenic fl add-on","code_information":[{"code":"44213","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5257.0,"maximum":6462.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5257.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6462.0}]}]},{"description":"Colostomy","code_information":[{"code":"44320","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Small bowel endoscopy","code_information":[{"code":"44364","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1423.51,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1898.01,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3663.16,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1423.51,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1935.97,"additional_payer_notes":"APC"}]}]},{"description":"Small bowel endoscopy/biopsy","code_information":[{"code":"44377","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1423.51,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1898.01,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3663.16,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1423.51,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1935.97,"additional_payer_notes":"APC"}]}]},{"description":"Endoscopy bowel pouch/biop","code_information":[{"code":"44386","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":689.87,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":919.83,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1775.27,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":689.87,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":938.23,"additional_payer_notes":"APC"}]}]},{"description":"Colonoscopy w/stent plcmt","code_information":[{"code":"44402","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3579.0,"maximum":11589.23,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6004.78,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11589.23,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4503.59,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6124.88,"additional_payer_notes":"APC"}]}]},{"description":"Suture small intestine","code_information":[{"code":"44602","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2860.11,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3813.48,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7360.02,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2860.11,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3889.75,"additional_payer_notes":"APC"}]}]},{"description":"Repair bowel-skin fistula","code_information":[{"code":"44640","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Prepare donor intestine","code_information":[{"code":"44715","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Drain appendix abscess open","code_information":[{"code":"44900","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3388.0,"maximum":4106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0}]}]},{"description":"Partial removal of rectum","code_information":[{"code":"45116","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Excise ileoanal reservior","code_information":[{"code":"45136","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Hydroxyzine hcl injection","code_information":[{"code":"J3410","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":13.33,"maximum":33.51,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":19.54},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":32.16},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":32.16},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":32.16},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13.33},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22.77},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33.51}]}]},{"description":"Ovine, up to 999 usp units","code_information":[{"code":"J3471","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":0.55,"maximum":1.01,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":0.55},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.95},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.95},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.95},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1.01}]}]},{"description":"Normal saline solution infus","code_information":[{"code":"J7040","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1.36,"maximum":3.4,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1.36},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2.61},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2.61},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2.61},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1.36},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2.31},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3.4}]}]},{"description":"Inj marstacim-hncq, 0.5 mg","code_information":[{"code":"J7172","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":38.39,"maximum":98.8,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":51.19,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":96.36},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":96.36},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":96.36},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":98.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":38.39,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":52.21,"additional_payer_notes":"APC"}]}]},{"description":"Wilate injection","code_information":[{"code":"J7183","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":0.99,"maximum":3.48,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1.33,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1.41},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2.41},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2.41},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2.41},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2.56,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1.39},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":0.99,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2.37},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3.48},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1.35,"additional_payer_notes":"APC"}]}]},{"description":"Factor ix non-recombinant","code_information":[{"code":"J7193","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1.05,"maximum":3.65,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1.4,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1.52},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2.54},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2.54},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2.54},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2.71,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1.45},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1.05,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2.48},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3.65},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1.43,"additional_payer_notes":"APC"}]}]},{"description":"Factor ix recomb gly rebinyn","code_information":[{"code":"J7203","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3.51,"maximum":11.95,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4.67,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4.75},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8.7},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8.7},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8.7},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":9.02,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":4.75},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3.51,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8.12},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11.95},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4.77,"additional_payer_notes":"APC"}]}]},{"description":"Factor viia recomb sevenfact","code_information":[{"code":"J7212","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1.65,"maximum":6.4,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2.63},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4.56},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4.56},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4.56},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4.23,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2.54},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1.65,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":4.35},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6.4},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2.24,"additional_payer_notes":"APC"}]}]},{"description":"Inj, durolane 1 mg","code_information":[{"code":"J7318","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4.68,"maximum":18.25,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6.24,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7.62},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12.7},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12.7},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12.7},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":12.04,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7.26},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4.68,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12.4},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18.25},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6.36,"additional_payer_notes":"APC"}]}]},{"description":"Monovisc inj per dose","code_information":[{"code":"J7327","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":423.96,"maximum":1537.26,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":565.28,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":730.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1004.29},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1004.29},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1004.29},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1090.98,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":611.36},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":423.96,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1044.6},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1537.26},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":576.58,"additional_payer_notes":"APC"}]}]},{"description":"Inj bimatoprost itc imp 1mcg","code_information":[{"code":"J7351","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":160.32,"maximum":571.43,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":213.76,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":230.9},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":403.49},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":403.49},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":403.49},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":412.55,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":227.25},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":160.32,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":388.3},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":571.43},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":218.03,"additional_payer_notes":"APC"}]}]},{"description":"Tacrolimus imme rel oral 1mg","code_information":[{"code":"J7507","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":0.19,"maximum":0.5,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":0.21},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.29},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.29},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.29},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.19},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.33},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.5}]}]},{"description":"Mycophenolate mofetil oral","code_information":[{"code":"J7517","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":0.16,"maximum":0.41,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":0.17},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.3},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.3},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.3},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.16},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.28},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.41}]}]},{"description":"Arformoterol non-comp unit","code_information":[{"code":"J7605","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":0.76,"maximum":2.21,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":0.76},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1.5},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1.5},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1.5},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.88},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1.5},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2.21}]}]},{"description":"Budesonide non-comp unit","code_information":[{"code":"J7626","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1.31,"maximum":3.84,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1.31},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2.42},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2.42},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2.42},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1.53},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2.61},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3.84}]}]},{"description":"Oral aprepitant","code_information":[{"code":"J8501","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3.1,"maximum":7.79,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3.34},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5.16},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5.16},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5.16},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3.1},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5.29},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7.79}]}]},{"description":"Netupitant palonosetron oral","code_information":[{"code":"J8655","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":355.53,"maximum":1088.65,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":474.04,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":449.91},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":778.09},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":778.09},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":778.09},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":914.89,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":432.95},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":355.53,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":739.76},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1088.65},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":483.52,"additional_payer_notes":"APC"}]}]},{"description":"Injection, avelumab, 10 mg","code_information":[{"code":"J9023","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":81.48,"maximum":263.95,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":108.64,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":106.85},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":190.57},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":190.57},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":190.57},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":209.67,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":104.97},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":81.48,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":179.36},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":263.95},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":110.81,"additional_payer_notes":"APC"}]}]},{"description":"Injection, belinostat, 10mg","code_information":[{"code":"J9032","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":40.83,"maximum":136.88,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":54.45,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":56.01},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":98.88},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":98.88},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":98.88},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":105.08,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":54.44},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":40.83,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":93.02},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":136.88},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":55.53,"additional_payer_notes":"APC"}]}]},{"description":"Brentuximab vedotin inj","code_information":[{"code":"J9042","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":209.41,"maximum":677.7,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":279.21,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":273.82},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":491.18},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":491.18},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":491.18},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":538.87,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":269.52},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":209.41,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":460.52},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":677.7},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":284.79,"additional_payer_notes":"APC"}]}]},{"description":"Cisplatin 10 mg injection","code_information":[{"code":"J9060","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2.91,"maximum":7.33,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3.15},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3.7},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3.7},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3.7},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2.91},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":4.98},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7.33}]}]},{"description":"Inj, cyclophosphamide, nos","code_information":[{"code":"J9075","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":0.43,"maximum":2.39,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":0.58,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":0.88},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1.19},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1.19},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1.19},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1.11,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.95},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":0.43,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1.63},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2.39},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":0.59,"additional_payer_notes":"APC"}]}]},{"description":"Injection, daratumumab 10 mg","code_information":[{"code":"J9145","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":55.33,"maximum":177.84,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":73.77,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":74.39},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":132.69},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":132.69},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":132.69},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":142.38,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":70.72},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":55.33,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":120.84},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":177.84},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":75.25,"additional_payer_notes":"APC"}]}]},{"description":"Inj enfort vedo-ejfv 0.25mg","code_information":[{"code":"J9177","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":27.49,"maximum":99.78,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":36.66,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":40.3},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":69.66},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":69.66},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":69.66},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":70.75,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":39.67},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27.49,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":67.8},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":99.78},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":37.39,"additional_payer_notes":"APC"}]}]},{"description":"Gemcitabine hcl injection","code_information":[{"code":"J9201","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3.1,"maximum":7.82,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3.28},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5.62},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5.62},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5.62},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3.1},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5.31},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7.82}]}]},{"description":"Mesna injection","code_information":[{"code":"J9209","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1.5,"maximum":4.31,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1.5},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2.53},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2.53},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2.53},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1.71},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2.92},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":4.31}]}]},{"description":"Inj inotuzumab ozogam 0.1 mg","code_information":[{"code":"J9229","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2154.83,"maximum":7236.75,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2873.1,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2923.94},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5126.3},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5126.3},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5126.3},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5545.09,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2878.02},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2154.83,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":4917.54},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7236.75},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2930.57,"additional_payer_notes":"APC"}]}]},{"description":"Pegaspargase injection","code_information":[{"code":"J9266","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":22247.97,"maximum":73699.51,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":29663.96,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":29777.58},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":54005.71},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":54005.71},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":54005.71},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":57251.45,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29309.94},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22247.97,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":50080.48},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":73699.51},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":30257.24,"additional_payer_notes":"APC"}]}]},{"description":"Inj zanidatamab-hrii, 2 mg","code_information":[{"code":"J9276","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":19.25,"maximum":49.53,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25.66,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":47.65},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":47.65},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":47.65},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":49.53,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19.25,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26.18,"additional_payer_notes":"APC"}]}]},{"description":"Inj pemetrexed (accord) 10mg","code_information":[{"code":"J9296","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7.3,"maximum":26.52,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9.74,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":10.71},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18.5},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18.5},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18.5},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":18.79,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7.3,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26.52},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9.93,"additional_payer_notes":"APC"}]}]},{"description":"Injection, pertuzumab, 1 mg","code_information":[{"code":"J9306","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":12.9,"maximum":44.07,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17.2,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":17.85},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":32.09},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":32.09},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":32.09},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":33.2,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17.53},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.9,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29.95},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":44.07},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17.54,"additional_payer_notes":"APC"}]}]},{"description":"Sacituzumab govitecan-hziy","code_information":[{"code":"J9317","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":28.23,"maximum":96.49,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":37.64,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":39.38},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":68.89},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":68.89},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":68.89},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":72.65,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38.37},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":28.23,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":65.56},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":96.49},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":38.39,"additional_payer_notes":"APC"}]}]},{"description":"Inj, tislelizumab-jsgr","code_information":[{"code":"J9329","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":43.63,"maximum":1501.78,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":58.17,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":109.09},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":109.09},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":109.09},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":112.27,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":43.63,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1501.78},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":59.33,"additional_payer_notes":"APC"}]}]},{"description":"Inj, tremelimumab-actl, 1 mg","code_information":[{"code":"J9347","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":110.17,"maximum":376.88,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":146.89,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":152.06},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":268.21},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":268.21},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":268.21},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":283.51,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":149.89},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":110.17,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":256.1},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":376.88},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":149.83,"additional_payer_notes":"APC"}]}]},{"description":"Trastuzumab injection","code_information":[{"code":"J9355","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":52.68,"maximum":209.76,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":70.24,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":83.26},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":144.74},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":144.74},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":144.74},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":135.57,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":83.43},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":52.68,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":142.54},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":209.76},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":71.65,"additional_payer_notes":"APC"}]}]},{"description":"Repair rectum-vagina fistula","code_information":[{"code":"57300","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2401.4,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3201.87,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6179.61,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2401.4,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3265.91,"additional_payer_notes":"APC"}]}]},{"description":"Vag hyst w/urinary repair","code_information":[{"code":"58267","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0}]}]},{"description":"Laps abltj uterine fibroids","code_information":[{"code":"58674","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7885.55,"maximum":20292.15,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10514.07,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":20292.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7885.55,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10724.35,"additional_payer_notes":"APC"}]}]},{"description":"Correct rectal prolapse","code_information":[{"code":"45540","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Repair rectourethral fistula","code_information":[{"code":"45820","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Placement of seton","code_information":[{"code":"46020","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2059.07,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2745.43,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5298.68,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2059.07,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2800.34,"additional_payer_notes":"APC"}]}]},{"description":"Incise external hemorrhoid","code_information":[{"code":"46083","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":185.35,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":247.13,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":476.96,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":185.35,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":252.07,"additional_payer_notes":"APC"}]}]},{"description":"Remove in/ex hem grp w/fistu","code_information":[{"code":"46258","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2059.07,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2745.43,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5298.68,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2059.07,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2800.34,"additional_payer_notes":"APC"}]}]},{"description":"Repair anal fistula","code_information":[{"code":"46288","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2059.07,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2745.43,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5298.68,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2059.07,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2800.34,"additional_payer_notes":"APC"}]}]},{"description":"Diagnostic anoscopy & biopsy","code_information":[{"code":"46607","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":887.71,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1183.61,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2284.37,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":887.71,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1207.28,"additional_payer_notes":"APC"}]}]},{"description":"Repair of anal stricture","code_information":[{"code":"46705","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Construction of absent anus","code_information":[{"code":"46735","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Partial removal of liver","code_information":[{"code":"47125","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Prep donor liver 3-segment","code_information":[{"code":"47144","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Repair liver wound","code_information":[{"code":"47362","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Removal of gallbladder","code_information":[{"code":"47600","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Excision of bile duct tumor","code_information":[{"code":"47712","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Fuse bile ducts and bowel","code_information":[{"code":"47780","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Removal of pancreatic stone","code_information":[{"code":"48020","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Removal of pancreatic duct","code_information":[{"code":"48148","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Surgery of pancreatic cyst","code_information":[{"code":"48500","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Prep donor pancreas","code_information":[{"code":"48551","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Drainage abdom abscess open","code_information":[{"code":"49020","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Inj teplizumab mzwv 5 mcg","code_information":[{"code":"J9381","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":29.41,"maximum":101.39,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":39.22,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":41.04},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":71.54},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":71.54},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":71.54},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":75.69,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":40.32},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":29.41,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":68.89},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":101.39},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":40.0,"additional_payer_notes":"APC"}]}]},{"description":"Albumin (human), 25%, 50ml","code_information":[{"code":"P9047","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":39.99,"maximum":144.51,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":53.32,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":58.39},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":100.85},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":100.85},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":100.85},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":102.92,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":39.99,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":98.2},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":144.51},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":54.39,"additional_payer_notes":"APC"}]}]},{"description":"Tisagenlecleucel car-pos t","code_information":[{"code":"Q2042","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":458769.88,"maximum":1539910.91,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":611693.17,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":636648.23},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1098816.7},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1098816.7},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1098816.7},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1180567.82,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":458769.88,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1046404.1},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1539910.91},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":623927.03,"additional_payer_notes":"APC"}]}]},{"description":"Iloprost non-comp unit dose","code_information":[{"code":"Q4074","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":163.64,"maximum":403.59,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":163.64},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":301.94},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":301.94},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":301.94},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":274.24},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":403.59}]}]},{"description":"Primatrix","code_information":[{"code":"Q4110","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":71.95,"maximum":237.56,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":123.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":71.95},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":124.27},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":124.27},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":124.27},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":237.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":92.32,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":121.01},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":178.08},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":125.55,"additional_payer_notes":"APC"}]}]},{"description":"Memoderm/derma/tranz/integup","code_information":[{"code":"Q4126","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":69.63,"maximum":237.56,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":123.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":69.63},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":113.64},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":113.64},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":113.64},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":237.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":92.32,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":110.15},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":162.1},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":125.55,"additional_payer_notes":"APC"}]}]},{"description":"Alloskin ac, 1 cm","code_information":[{"code":"Q4141","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":41.66,"maximum":237.56,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":123.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":41.66},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":123.02},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":123.02},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":123.02},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":237.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":92.32,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":70.26},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":103.41},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":125.55,"additional_payer_notes":"APC"}]}]},{"description":"Biovance 1 square cm","code_information":[{"code":"Q4154","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":92.32,"maximum":393.01,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":123.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":147.03},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":271.43},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":271.43},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":271.43},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":237.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":92.32,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":267.07},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":393.01},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":125.55,"additional_payer_notes":"APC"}]}]},{"description":"Helicoll, per square cm","code_information":[{"code":"Q4164","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":92.32,"maximum":4111.19,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":123.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":354.37},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3117.77},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3117.77},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3117.77},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":237.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":92.32,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":4111.19},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":125.55,"additional_payer_notes":"APC"}]}]},{"description":"Revita, per sq cm","code_information":[{"code":"Q4180","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":92.32,"maximum":4541.67,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":123.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1133.15},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2071.13},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2071.13},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2071.13},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":237.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":92.32,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":4541.67},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":125.55,"additional_payer_notes":"APC"}]}]},{"description":"Novachor 1 sq cm","code_information":[{"code":"Q4194","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":92.32,"maximum":2338.41,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":123.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":791.31},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1363.78},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1363.78},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1363.78},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":237.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":92.32,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1589.0},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2338.41},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":125.55,"additional_payer_notes":"APC"}]}]},{"description":"Membrane graft or wrap sq cm","code_information":[{"code":"Q4205","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":92.32,"maximum":3157.04,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":123.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1161.57},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2261.83},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2261.83},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2261.83},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":237.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":92.32,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2145.28},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3157.04},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":125.55,"additional_payer_notes":"APC"}]}]},{"description":"Xcellerate, per sq cm","code_information":[{"code":"Q4234","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":92.32,"maximum":694.62,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":123.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":272.71},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":370.18},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":370.18},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":370.18},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":237.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":92.32,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":472.01},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":694.62},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":125.55,"additional_payer_notes":"APC"}]}]},{"description":"Vendaje, per square centimet","code_information":[{"code":"Q4252","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":92.32,"maximum":237.56,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":123.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":109.02},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":100.7},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":100.7},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":100.7},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":237.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":92.32,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":142.39},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":209.55},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":125.55,"additional_payer_notes":"APC"}]}]},{"description":"Cocoon membrane, per sq cm","code_information":[{"code":"Q4264","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":92.32,"maximum":8820.52,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":123.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":525.87},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":708.49},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":708.49},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":708.49},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":237.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":92.32,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8820.52},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":125.55,"additional_payer_notes":"APC"}]}]},{"description":"Orion, per sq cm","code_information":[{"code":"Q4276","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":92.32,"maximum":1317.11,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":123.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":510.77},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":496.38},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":496.38},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":496.38},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":237.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":92.32,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":895.01},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1317.11},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":125.55,"additional_payer_notes":"APC"}]}]},{"description":"Membrane wrap hydr per sq cm","code_information":[{"code":"Q4290","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":92.32,"maximum":6042.37,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":123.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2025.1},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3542.94},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3542.94},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3542.94},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":237.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":92.32,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6042.37},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":125.55,"additional_payer_notes":"APC"}]}]},{"description":"Acesso tl, per sq cm","code_information":[{"code":"Q4300","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":92.32,"maximum":5757.28,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":123.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2326.17},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4017.93},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4017.93},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4017.93},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":237.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":92.32,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3912.2},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5757.28},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":125.55,"additional_payer_notes":"APC"}]}]},{"description":"Amchoplast, per sq cm","code_information":[{"code":"Q4316","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":92.32,"maximum":8390.34,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":123.09,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8390.34},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8390.34},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8390.34},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":237.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":92.32,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":125.55,"additional_payer_notes":"APC"}]}]},{"description":"Artacent vericlen, per sq cm","code_information":[{"code":"Q4339","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":92.32,"maximum":7742.53,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":123.09,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3905.15},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3905.15},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3905.15},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":237.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":92.32,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7742.53},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":125.55,"additional_payer_notes":"APC"}]}]},{"description":"Inj filgrastim gcsf biosimil","code_information":[{"code":"Q5101","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":0.26,"maximum":0.97,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":0.35,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":0.36},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.7},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.7},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.7},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":0.68,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":0.26,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.67},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.97},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":0.36,"additional_payer_notes":"APC"}]}]},{"description":"Injection, udenyca 0.5 mg","code_information":[{"code":"Q5111","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":111.85,"maximum":369.04,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":149.13,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":179.96},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":258.48},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":258.48},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":258.48},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":287.83,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":111.85,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":250.77},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":369.04},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":152.12,"additional_payer_notes":"APC"}]}]},{"description":"Inj ruxience, 10 mg","code_information":[{"code":"Q5119","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":12.12,"maximum":64.22,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16.16,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":27.43},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":50.36},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":50.36},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":50.36},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":31.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.12,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":43.64},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":64.22},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16.48,"additional_payer_notes":"APC"}]}]},{"description":"Inj, stimufend, 0.5 mg","code_information":[{"code":"Q5127","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":107.75,"maximum":812.15,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":143.67,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":276.38},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":435.31},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":435.31},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":435.31},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":277.29,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":107.75,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":551.87},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":812.15},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":146.55,"additional_payer_notes":"APC"}]}]},{"description":"Inj sulf hexa lipid microsph","code_information":[{"code":"Q9950","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":20.59,"maximum":50.85,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":20.59},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":35.32},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":35.32},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":35.32},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34.56},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":50.85}]}]},{"description":"LOCM 300-399mg/ml iodine,1ml","code_information":[{"code":"Q9967","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":0.15,"maximum":0.38,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":0.15},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.29},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.29},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.29},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.26},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.38}]}]},{"description":"Removal of kidney stone","code_information":[{"code":"50081","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7022.52,"maximum":18071.3,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9363.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":18071.3,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7022.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9550.63,"additional_payer_notes":"APC"}]}]},{"description":"Removal kidney open complex","code_information":[{"code":"50225","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Remove cadaver donor kidney","code_information":[{"code":"50300","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Transplantation of kidney","code_information":[{"code":"50360","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8923.0,"maximum":10765.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":10765.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":8923.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":10765.0}]}]},{"description":"Close nephrovisceral fistula","code_information":[{"code":"50526","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Laparo removal donor kidney","code_information":[{"code":"50547","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5257.0,"maximum":6462.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5257.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6462.0}]}]},{"description":"Renal scope w/tumor resect","code_information":[{"code":"50562","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2959.0,"maximum":18071.3,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9363.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":18071.3,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7022.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9550.63,"additional_payer_notes":"APC"}]}]},{"description":"Perc rf ablate renal tumor","code_information":[{"code":"50592","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4484.77,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5979.69,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5257.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11540.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4484.77,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6099.28,"additional_payer_notes":"APC"}]}]},{"description":"Removal of ureter","code_information":[{"code":"50650","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Revise ureter","code_information":[{"code":"50728","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Reimplant ureter in bladder","code_information":[{"code":"50785","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Appendico-vesicostomy","code_information":[{"code":"50845","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Laparo New Ureter/Bladder","code_information":[{"code":"50948","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":20292.15,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10514.07,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":20292.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7885.55,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10724.35,"additional_payer_notes":"APC"}]}]},{"description":"Ureter endoscopy & catheter","code_information":[{"code":"50972","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2614.94,"maximum":6729.12,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3486.59,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6729.12,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2614.94,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3556.32,"additional_payer_notes":"APC"}]}]},{"description":"Remove bladder/revise tract","code_information":[{"code":"51580","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Correction of bladder defect","code_information":[{"code":"51940","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Repair of penis","code_information":[{"code":"54440","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2614.94,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3486.59,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6729.12,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2614.94,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3556.32,"additional_payer_notes":"APC"}]}]},{"description":"Extensive testis surgery","code_information":[{"code":"54535","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2614.94,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3486.59,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6729.12,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2614.94,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3556.32,"additional_payer_notes":"APC"}]}]},{"description":"Repair testis injury","code_information":[{"code":"54670","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2614.94,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3486.59,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6729.12,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2614.94,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3556.32,"additional_payer_notes":"APC"}]}]},{"description":"Remove epididymis lesion","code_information":[{"code":"54840","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1550.71,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2067.62,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3990.5,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1550.71,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2108.97,"additional_payer_notes":"APC"}]}]},{"description":"Removal of hydroceles","code_information":[{"code":"55041","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2656.06,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3541.41,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6834.92,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2656.06,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3612.24,"additional_payer_notes":"APC"}]}]},{"description":"Incision of sperm duct","code_information":[{"code":"55200","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2614.94,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3486.59,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6729.12,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2614.94,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3556.32,"additional_payer_notes":"APC"}]}]},{"description":"Revise hernia & sperm veins","code_information":[{"code":"55540","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2656.06,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3541.41,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6834.92,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2656.06,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3612.24,"additional_payer_notes":"APC"}]}]},{"description":"Biopsy of prostate","code_information":[{"code":"55705","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2614.94,"maximum":6729.12,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3486.59,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6729.12,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2614.94,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3556.32,"additional_payer_notes":"APC"}]}]},{"description":"Removal of prostate","code_information":[{"code":"55821","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Laparo radical prostatectomy","code_information":[{"code":"55866","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":27583.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10514.07,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":20292.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7885.55,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":27583.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10724.35,"additional_payer_notes":"APC"}]}]},{"description":"Sex transformation f to m","code_information":[{"code":"55980","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2614.94,"maximum":6729.12,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3486.59,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6729.12,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2614.94,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3556.32,"additional_payer_notes":"APC"}]}]},{"description":"Exam of vulva w/scope","code_information":[{"code":"56820","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":149.98,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":199.97,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":385.94,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":149.98,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":203.97,"additional_payer_notes":"APC"}]}]},{"description":"Destroy vag lesions complex","code_information":[{"code":"57065","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2401.4,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3201.87,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6179.61,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2401.4,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3265.91,"additional_payer_notes":"APC"}]}]},{"description":"Nerve graft hand/foot <=4 cm","code_information":[{"code":"64890","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":16752.93,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8680.28,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":16752.93,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6510.21,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8853.88,"additional_payer_notes":"APC"}]}]},{"description":"Nerve graft add-on","code_information":[{"code":"64901","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Nps surg dilat eust tube uni","code_information":[{"code":"69705","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Esophgl motil w/stim/perfus","code_information":[{"code":"91013","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":2334.0,"payers_information":[{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Esoph balloon distension tst","code_information":[{"code":"91040","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":276.82,"maximum":2334.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":369.09,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":712.35,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":276.82,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":376.48,"additional_payer_notes":"APC"}]}]},{"description":"Electrogastrography","code_information":[{"code":"91132","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":160.18,"maximum":2334.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":213.57,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":412.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":160.18,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":217.84,"additional_payer_notes":"APC"}]}]},{"description":"Prq card angio/athrect 1 art","code_information":[{"code":"92924","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8563.85,"maximum":27583.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11418.47,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":22037.64,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8563.85,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":27583.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11646.84,"additional_payer_notes":"APC"}]}]},{"description":"Prq card revasc mi 1 vsl","code_information":[{"code":"92941","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":17314.0,"maximum":18364.0,"payers_information":[{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0}]}]},{"description":"Cath place cardio brachytx","code_information":[{"code":"92974","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":2334.0,"payers_information":[{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Pul art balloon repr percut","code_information":[{"code":"92998","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":17314.0,"maximum":18364.0,"payers_information":[{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0}]}]},{"description":"Heart flow reserve measure","code_information":[{"code":"93571","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":2334.0,"payers_information":[{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Perq transcath cls mitral","code_information":[{"code":"93590","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":13599.0,"maximum":44873.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18131.99,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":44873.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":44873.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":44873.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":34994.75,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13599.0,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":43285.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18494.63,"additional_payer_notes":"APC"}]}]},{"description":"Car outp meas drg cath chd","code_information":[{"code":"93598","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":2334.0,"payers_information":[{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Esophageal recording","code_information":[{"code":"93615","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":903.21,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1204.28,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2324.26,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":903.21,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1228.36,"additional_payer_notes":"APC"}]}]},{"description":"Electrophysiologic study","code_information":[{"code":"93624","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5786.04,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7714.72,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":14889.41,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5786.04,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7869.01,"additional_payer_notes":"APC"}]}]},{"description":"Ep & ablate ventric tachy","code_information":[{"code":"93654","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":19389.9,"maximum":49896.68,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25853.2,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43643.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43643.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43643.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":49896.68,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19389.9,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":41120.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26370.26,"additional_payer_notes":"APC"}]}]},{"description":"Cardiovascular procedure","code_information":[{"code":"93799","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":95.45,"maximum":2334.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":127.27,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":245.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":95.45,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":129.82,"additional_payer_notes":"APC"}]}]},{"description":"Rmvl devital tis 20 cm/<","code_information":[{"code":"97597","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":148.84,"maximum":2334.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":198.45,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":383.01,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":148.84,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":202.42,"additional_payer_notes":"APC"}]}]},{"description":"Low cost skin substitute app","code_information":[{"code":"C5277","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":2334.0,"payers_information":[{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Cysto impl 4 or more","code_information":[{"code":"C9740","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7022.52,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9363.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":18071.3,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7022.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9550.63,"additional_payer_notes":"APC"}]}]},{"description":"Revasc lithotr-stent tib/per","code_information":[{"code":"C9773","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":13599.0,"maximum":34994.75,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18131.99,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":34994.75,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13599.0,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":27583.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18494.63,"additional_payer_notes":"APC"}]}]},{"description":"Inj for sacroiliac jt anesth","code_information":[{"code":"G0260","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":523.65,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":698.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1347.51,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":523.65,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":712.16,"additional_payer_notes":"APC"}]}]},{"description":"Rabies ig im/sc","code_information":[{"code":"90375","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":210.89,"maximum":763.31,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":281.18,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":318.9},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":506.23},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":506.23},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":506.23},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":542.69,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":210.89,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":518.68},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":763.31},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":286.81,"additional_payer_notes":"APC"}]}]},{"description":"Laiv3 vaccine intranasal","code_information":[{"code":"90660","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":31.76,"maximum":78.61,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":31.76},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":54.85},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":54.85},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":54.85},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":53.41},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":78.61}]}]},{"description":"Pcv21 vaccine im","code_information":[{"code":"90684","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":360.68,"maximum":892.68,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":360.68},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":623.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":623.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":623.0},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":606.6},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":892.68}]}]},{"description":"Hepb vaccine 3 dose adult im","code_information":[{"code":"90746","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":77.42,"maximum":191.61,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":77.42},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":133.71},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":133.71},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":133.71},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":130.2},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":191.61}]}]},{"description":"Sarscov2 vac 50 mcg/0.5ml im","code_information":[{"code":"91322","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":177.82,"maximum":440.09,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":177.82},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":307.14},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":307.14},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":307.14},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":299.05},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":440.09}]}]},{"description":"Gadobutrol injection","code_information":[{"code":"A9585","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":0.29,"maximum":0.76,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":0.29},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.5},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.5},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.5},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.52},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.76}]}]},{"description":"Acyclovir injection","code_information":[{"code":"J0133","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":0.04,"maximum":0.13,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":0.04},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.06},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.06},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.06},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.06},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.09},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.13}]}]},{"description":"Inj epinephrine (hospira)","code_information":[{"code":"J0167","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1.4,"maximum":1.4,"payers_information":[{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1.4},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1.4},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1.4}]}]},{"description":"Inj, brolucizumab-dbll, 1 mg","code_information":[{"code":"J0179","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":269.78,"maximum":922.63,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":359.71,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":373.99},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":657.77},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":657.77},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":657.77},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":694.25,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":366.92},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":269.78,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":626.95},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":922.63},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":366.91,"additional_payer_notes":"APC"}]}]},{"description":"Lumizyme injection","code_information":[{"code":"J0221","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":158.35,"maximum":548.97,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":211.13,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":221.73},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":392.57},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":392.57},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":392.57},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":407.48,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":218.32},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":158.35,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":373.03},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":548.97},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":215.35,"additional_payer_notes":"APC"}]}]},{"description":"Amikacin sulfate injection","code_information":[{"code":"J0278","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":0.58,"maximum":1.47,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":0.66},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1.17},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1.17},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1.17},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.58},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1.0},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1.47}]}]},{"description":"Ampicillin 500 MG inj","code_information":[{"code":"J0290","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":0.66,"maximum":1.93,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":0.66},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.93},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.93},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.93},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.77},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1.31},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1.93}]}]},{"description":"Azithromycin","code_information":[{"code":"J0456","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2.31,"maximum":5.79,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2.44},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4.97},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4.97},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4.97},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2.31},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3.94},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5.79}]}]},{"description":"Inj anifrolumab-fnia 1mg","code_information":[{"code":"J0491","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":13.88,"maximum":48.35,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18.51,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":19.56},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":34.4},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":34.4},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":34.4},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":35.72,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19.23},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.88,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32.86},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":48.35},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18.88,"additional_payer_notes":"APC"}]}]},{"description":"Inj brixadi, more than 7 day","code_information":[{"code":"J0578","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1291.73,"maximum":4668.08,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1722.3,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1871.78},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3213.48},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3213.48},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3213.48},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3324.05,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1856.47},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1291.73,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3172.07},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":4668.08},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1756.75,"additional_payer_notes":"APC"}]}]},{"description":"Buprenorphine hydrochloride","code_information":[{"code":"J0592","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4.6,"maximum":11.72,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4.6},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7.85},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7.85},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7.85},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":4.66},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7.96},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11.72}]}]},{"description":"Calcium glucon (fresenius)","code_information":[{"code":"J0612","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":0.04,"maximum":0.12,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":0.06},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.08},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.08},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.08},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.04},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.07},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.12}]}]},{"description":"Inj, levothyroxine nos 10mcg","code_information":[{"code":"J0650","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5.84,"maximum":14.67,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7.99},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14.63},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14.63},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14.63},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5.84},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9.97},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14.67}]}]},{"description":"Inj cefazolin sodium, baxter","code_information":[{"code":"J0689","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1.34,"maximum":3.35,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1.38},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2.53},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2.53},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2.53},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1.34},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2.28},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3.35}]}]},{"description":"Inj. cefepime hcl (baxter)","code_information":[{"code":"J0701","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6.21,"maximum":15.63,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6.38},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11.15},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11.15},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11.15},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6.21},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10.62},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15.63}]}]},{"description":"Clonidine hydrochloride","code_information":[{"code":"J0735","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":17.82,"maximum":45.57,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":17.82},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":33.58},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":33.58},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":33.58},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18.12},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30.97},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":45.57}]}]},{"description":"Ciprofloxacin iv","code_information":[{"code":"J0744","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":0.89,"maximum":4.41,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2.31},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4.41},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4.41},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4.41},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.89},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1.54},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2.26}]}]},{"description":"Inj. (ani), up to 40 units","code_information":[{"code":"J0802","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2756.01,"maximum":9443.94,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3674.68,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3790.14},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":6739.91},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":6739.91},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":6739.91},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7092.13,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3755.81},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2756.01,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6417.37},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9443.94},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3748.17,"additional_payer_notes":"APC"}]}]},{"description":"Inj, daptomycin (baxter)","code_information":[{"code":"J0874","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":0.08,"maximum":0.2,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":0.08},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.12},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.12},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.12},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.08},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.13},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.2}]}]},{"description":"Epoetin alfa, non-esrd","code_information":[{"code":"J0885","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5.16,"maximum":17.59,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6.88,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7.79},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14.58},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14.58},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14.58},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13.27,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7.0},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5.16,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11.95},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17.59},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7.01,"additional_payer_notes":"APC"}]}]},{"description":"Argatroban nonesrd (auromed)","code_information":[{"code":"J0898","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1.47,"maximum":3.86,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1.47},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2.76},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2.76},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2.76},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3.86}]}]},{"description":"Inj dihydroergotamine mesylt","code_information":[{"code":"J1110","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":44.43,"maximum":184.44,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":94.33},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":184.44},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":184.44},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":184.44},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":44.43},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":75.92},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":111.74}]}]},{"description":"Diphenhydramine hcl injectio","code_information":[{"code":"J1200","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":0.73,"maximum":1.98,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":0.73},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1.72},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1.72},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1.72},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.79},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1.35},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1.98}]}]},{"description":"Inj dobutamine HCL/250 mg","code_information":[{"code":"J1250","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8.0,"maximum":20.11,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":8.97},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15.16},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15.16},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15.16},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8.0},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13.67},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20.11}]}]},{"description":"Inj., ravulizumab-cwvz 10 mg","code_information":[{"code":"J1303","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":170.19,"maximum":600.55,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":226.92,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":242.35},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":427.87},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":427.87},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":427.87},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":437.96,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":238.84},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":170.19,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":408.09},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":600.55},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":231.46,"additional_payer_notes":"APC"}]}]},{"description":"Inj, zolbetuximab-clzb, 2 mg","code_information":[{"code":"J1326","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":25.44,"maximum":65.47,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":33.92,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":63.76},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":63.76},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":63.76},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":65.47,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25.44,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":34.6,"additional_payer_notes":"APC"}]}]},{"description":"Inj ferric carboxymaltos 1mg","code_information":[{"code":"J1439","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":0.85,"maximum":3.02,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1.13,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1.24},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2.17},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2.17},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2.17},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2.18,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1.2},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":0.85,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2.05},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3.02},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1.15,"additional_payer_notes":"APC"}]}]},{"description":"Inj fosnetupitant, palonoset","code_information":[{"code":"J1454","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":377.89,"maximum":1791.69,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":503.85,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":696.17},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1152.07},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1152.07},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1152.07},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":972.43,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":712.55},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":377.89,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1217.49},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1791.69},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":513.92,"additional_payer_notes":"APC"}]}]},{"description":"Inj. asceniv","code_information":[{"code":"J1554","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":381.85,"maximum":1347.56,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":509.14,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":546.35},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":943.36},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":943.36},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":943.36},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":982.64,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":535.92},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":381.85,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":915.69},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1347.56},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":519.32,"additional_payer_notes":"APC"}]}]},{"description":"Immune globulin, powder","code_information":[{"code":"J1566","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":60.72,"maximum":221.69,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":80.96,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":89.11},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":155.23},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":155.23},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":155.23},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":156.25,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":88.17},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":60.72,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":150.65},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":221.69},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":82.58,"additional_payer_notes":"APC"}]}]},{"description":"Garamycin gentamicin inj","code_information":[{"code":"J1580","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2.67,"maximum":6.73,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2.72},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4.97},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4.97},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4.97},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2.67},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":4.57},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6.73}]}]},{"description":"Inj., guselkumab, 1 mg","code_information":[{"code":"J1628","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":50.19,"maximum":200.16,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":66.92,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":77.47},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":142.24},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":142.24},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":142.24},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":129.16,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":79.6},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":50.19,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":136.01},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":200.16},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":68.26,"additional_payer_notes":"APC"}]}]},{"description":"Inj enoxaparin sodium","code_information":[{"code":"J1650","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":0.57,"maximum":1.52,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":0.57},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1.08},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1.08},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1.08},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.61},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1.04},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1.52}]}]},{"description":"Inj., ibalizumab-uiyk, 10 mg","code_information":[{"code":"J1746","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":59.63,"maximum":209.98,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":79.51,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":84.65},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":150.83},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":150.83},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":150.83},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":153.46,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":83.51},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":59.63,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":142.69},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":209.98},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":81.1,"additional_payer_notes":"APC"}]}]},{"description":"Inj esmolol hcl wg crit care","code_information":[{"code":"J1806","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":0.39,"maximum":0.97,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":0.45},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.79},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.79},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.79},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.39},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.67},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.97}]}]},{"description":"Inj, labetalol hcl, 5mg","code_information":[{"code":"J1920","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":0.32,"maximum":0.79,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":0.46},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.74},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.74},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.74},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.32},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.54},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.79}]}]},{"description":"Aripirazole lauroxil 1 mg","code_information":[{"code":"J1944","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2.67,"maximum":8.79,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3.56,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3.59},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":6.33},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":6.33},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":6.33},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6.87,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3.5},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2.67,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5.98},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8.79},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3.63,"additional_payer_notes":"APC"}]}]},{"description":"Inj, lenacapavir, 1 mg","code_information":[{"code":"J1961","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":17.2,"maximum":59.85,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22.94,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":24.23},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":41.85},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":41.85},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":41.85},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":44.27,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23.8},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17.2,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":40.66},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":59.85},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23.39,"additional_payer_notes":"APC"}]}]},{"description":"Injection, mepolizumab, 1mg","code_information":[{"code":"J2182","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":24.21,"maximum":83.56,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":32.28,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":33.59},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":59.52},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":59.52},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":59.52},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":62.3,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33.23},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":24.21,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":56.78},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":83.56},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":32.93,"additional_payer_notes":"APC"}]}]},{"description":"Inj midazolam hydrochloride","code_information":[{"code":"J2250","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":0.14,"maximum":0.35,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":0.14},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.3},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.3},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.3},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.14},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.24},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.35}]}]},{"description":"Ziconotide injection","code_information":[{"code":"J2278","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8.09,"maximum":26.63,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10.79,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":10.67},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19.25},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19.25},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19.25},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":20.83,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10.58},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8.09,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18.09},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26.63},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11.01,"additional_payer_notes":"APC"}]}]},{"description":"Naltrexone, depot form","code_information":[{"code":"J2315","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3.39,"maximum":11.22,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4.52,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4.53},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8.05},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8.05},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8.05},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":8.73,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":4.46},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3.39,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7.62},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11.22},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4.62,"additional_payer_notes":"APC"}]}]},{"description":"Inj tezepelumab-ekko, 1mg","code_information":[{"code":"J2356","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":13.44,"maximum":49.43,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17.92,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":19.55},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":34.77},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":34.77},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":34.77},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":34.59,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19.66},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.44,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33.6},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":49.43},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18.28,"additional_payer_notes":"APC"}]}]},{"description":"Chloroprocaine hcl injection","code_information":[{"code":"J2401","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":0.04,"maximum":0.08,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":0.04},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.07},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.07},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.07},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.04},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.06},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.08}]}]},{"description":"Inj, invega hafyera/trinza","code_information":[{"code":"J2427","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":9.95,"maximum":34.35,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.26,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":13.94},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24.61},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24.61},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24.61},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":25.6,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13.67},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9.95,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23.35},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34.35},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.53,"additional_payer_notes":"APC"}]}]},{"description":"Pegunigalsidase alfa-iwxj","code_information":[{"code":"J2508","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":169.25,"maximum":617.43,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":225.66,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":249.62},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":437.53},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":437.53},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":437.53},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":435.53,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":245.55},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":169.25,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":419.56},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":617.43},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":230.18,"additional_payer_notes":"APC"}]}]},{"description":"Inj, vasopressin, 1 unit","code_information":[{"code":"J2598","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1.56,"maximum":4.44,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1.56},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2.38},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2.38},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2.38},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1.77},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3.02},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":4.44}]}]},{"description":"Inj, propofol, 10 mg","code_information":[{"code":"J2704","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":0.09,"maximum":0.21,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":0.1},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.17},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.17},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.17},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.09},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.15},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.21}]}]},{"description":"Inj, pegcetacoplan, 1mg","code_information":[{"code":"J2781","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":111.71,"maximum":398.49,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":148.94,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":158.39},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":269.63},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":269.63},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":269.63},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":287.46,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":158.47},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":111.71,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":270.78},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":398.49},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":151.92,"additional_payer_notes":"APC"}]}]},{"description":"Rho(D) immune globulin h, sd","code_information":[{"code":"J2792","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":26.84,"maximum":89.46,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":35.79,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":35.76},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":58.47},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":58.47},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":58.47},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":69.08,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35.58},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26.84,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":60.79},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":89.46},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":36.51,"additional_payer_notes":"APC"}]}]},{"description":"Sincalide injection","code_information":[{"code":"J2805","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":123.85,"maximum":311.42,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":157.59},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":258.35},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":258.35},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":258.35},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":123.85},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":211.62},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":311.42}]}]},{"description":"Fentanyl citrate injeciton","code_information":[{"code":"J3010","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":0.92,"maximum":2.31,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":0.92},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1.83},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1.83},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1.83},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.92},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1.57},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2.31}]}]},{"description":"Inj. romosozumab-aqqg 1 mg","code_information":[{"code":"J3111","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":9.55,"maximum":31.28,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.73,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":12.64},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22.81},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22.81},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22.81},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":24.57,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12.44},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9.55,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21.26},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31.28},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.99,"additional_payer_notes":"APC"}]}]},{"description":"Tirofiban hcl","code_information":[{"code":"J3246","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3.91,"maximum":9.85,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3.91},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":6.52},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":6.52},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":6.52},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3.93},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6.7},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9.85}]}]},{"description":"Triamcinolone A inj PRS-free","code_information":[{"code":"J3300","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":14.39,"maximum":77.1,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":27.52},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":46.57},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":46.57},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":46.57},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":37.03,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14.39,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":77.1},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19.57,"additional_payer_notes":"APC"}]}]},{"description":"Inj, vancomycin (mylan) 10mg","code_information":[{"code":"J3374","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":0.23,"maximum":0.23,"payers_information":[{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.23},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.23},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.23}]}]},{"description":"Pyridoxine hcl 100 mg","code_information":[{"code":"J3415","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":13.83,"maximum":42.97,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":13.83},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24.32},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24.32},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24.32},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17.09},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29.19},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":42.97}]}]},{"description":"Inj magnesium sulfate","code_information":[{"code":"J3475","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":0.53,"maximum":1.34,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":0.54},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.95},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.95},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.95},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.53},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.91},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1.34}]}]},{"description":"Normal saline solution infus","code_information":[{"code":"J7050","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":0.68,"maximum":1.72,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":0.68},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1.35},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1.35},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1.35},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.68},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1.17},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1.72}]}]},{"description":"Inj., fibryga, 1 mg","code_information":[{"code":"J7177","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":0.92,"maximum":3.02,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1.23,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1.21},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2.3},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2.3},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2.3},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2.38,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1.2},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":0.92,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2.05},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3.02},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1.26,"additional_payer_notes":"APC"}]}]},{"description":"Antihemophilic viii/vwf comp","code_information":[{"code":"J7186","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":0.95,"maximum":3.27,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1.27,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1.32},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2.33},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2.33},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2.33},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2.45,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1.3},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":0.95,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2.22},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3.27},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1.29,"additional_payer_notes":"APC"}]}]},{"description":"Factor ix recombinant nos","code_information":[{"code":"J7195","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1.4,"maximum":5.02,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1.86,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2.04},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3.56},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3.56},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3.56},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3.6,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2.0},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1.4,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3.4},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5.02},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1.9,"additional_payer_notes":"APC"}]}]},{"description":"Factor viii fc fusion recomb","code_information":[{"code":"J7205","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1.93,"maximum":6.37,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2.58,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2.55},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4.6},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4.6},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4.6},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4.98,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2.53},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1.93,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":4.33},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6.37},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2.63,"additional_payer_notes":"APC"}]}]},{"description":"Altuviiio per factor viii iu","code_information":[{"code":"J7214","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3.47,"maximum":12.64,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4.63,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5.06},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8.88},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8.88},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8.88},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":8.94,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5.02},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3.47,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8.58},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12.64},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4.72,"additional_payer_notes":"APC"}]}]},{"description":"Hyalgan/supartz inj per dose","code_information":[{"code":"J7321","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":79.07,"maximum":198.83,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":81.36},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":139.44},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":139.44},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":139.44},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":79.07},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":135.11},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":198.83}]}]},{"description":"Inj, trivisc 1 mg","code_information":[{"code":"J7329","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2.28,"maximum":16.62,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3.04,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6.15},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10.35},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10.35},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10.35},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5.86,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6.61},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2.28,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11.29},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16.62},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3.1,"additional_payer_notes":"APC"}]}]},{"description":"Inj travoprost intra impl","code_information":[{"code":"J7355","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":147.56,"maximum":536.76,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":196.75,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":213.85},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":370.98},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":370.98},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":370.98},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":379.72,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":147.56,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":536.76},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":200.68,"additional_payer_notes":"APC"}]}]},{"description":"Methylprednisolone oral","code_information":[{"code":"J7509","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":0.26,"maximum":0.68,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":0.26},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.44},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.44},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.44},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.26},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.46},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.68}]}]},{"description":"Inj. mycophenolate mofetil","code_information":[{"code":"J7519","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":0.34,"maximum":1.12,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":0.34},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.79},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.79},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.79},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.44},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.76},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1.12}]}]},{"description":"Acetylcysteine non-comp unit","code_information":[{"code":"J7608","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8.82,"maximum":22.19,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":9.28},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16.89},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16.89},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16.89},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8.82},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15.08},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22.19}]}]},{"description":"Dornase alfa non-comp unit","code_information":[{"code":"J7639","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":58.02,"maximum":145.89,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":58.95},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":104.8},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":104.8},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":104.8},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":58.02},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":99.14},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":145.89}]}]},{"description":"Cyclophosphamide oral 25 MG","code_information":[{"code":"J8530","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":0.9,"maximum":3.77,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1.25},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3.77},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3.77},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3.77},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.9},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1.55},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2.29}]}]},{"description":"Temozolomide","code_information":[{"code":"J8700","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":0.28,"maximum":0.74,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":0.42},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.69},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.69},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.69},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.28},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.5},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.74}]}]},{"description":"Azacitidine injection","code_information":[{"code":"J9025","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":0.31,"maximum":0.79,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":0.35},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.4},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.4},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.4},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.31},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.54},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.79}]}]},{"description":"Inj., bendeka 1 mg","code_information":[{"code":"J9034","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":9.4,"maximum":36.61,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.53,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":14.94},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24.93},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24.93},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24.93},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":24.19,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14.57},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9.4,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24.88},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36.61},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.78,"additional_payer_notes":"APC"}]}]},{"description":"Carboplatin injection","code_information":[{"code":"J9045","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3.22,"maximum":9.88,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3.22},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4.01},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4.01},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4.01},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3.93},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6.72},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9.88}]}]},{"description":"Inj, elahere, 1 mg","code_information":[{"code":"J9063","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":53.99,"maximum":185.43,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":71.99,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":74.88},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":132.09},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":132.09},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":132.09},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":138.94,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":73.75},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":53.99,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":126.0},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":185.43},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":73.43,"additional_payer_notes":"APC"}]}]},{"description":"Cytarabine hcl 100 mg inj","code_information":[{"code":"J9100","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":0.86,"maximum":2.15,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":0.89},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1.53},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1.53},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1.53},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.86},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1.46},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2.15}]}]},{"description":"Inj daunorubicin, cytarabine","code_information":[{"code":"J9153","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":204.66,"maximum":676.3,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":272.89,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":273.92},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":484.67},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":484.67},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":484.67},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":526.67,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":268.96},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":204.66,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":459.56},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":676.3},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":278.34,"additional_payer_notes":"APC"}]}]},{"description":"Eribulin mesylate injection","code_information":[{"code":"J9179","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":44.98,"maximum":362.97,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":59.98,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":130.63},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":198.71},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":198.71},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":198.71},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":115.76,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":144.34},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":44.98,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":246.64},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":362.97},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":61.18,"additional_payer_notes":"APC"}]}]},{"description":"Gemtuzumab ozogamicin 0.1 mg","code_information":[{"code":"J9203","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":185.53,"maximum":634.67,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":247.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":256.43},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":449.57},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":449.57},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":449.57},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":477.42,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":252.41},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":185.53,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":431.27},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":634.67},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":252.32,"additional_payer_notes":"APC"}]}]},{"description":"Idarubicin hcl injection","code_information":[{"code":"J9211","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":47.86,"maximum":127.41,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":47.86},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":70.39},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":70.39},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":70.39},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":50.67},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":86.58},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":127.41}]}]},{"description":"Inj., evomela, 1 mg","code_information":[{"code":"J9246","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":13.53,"maximum":49.01,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18.04,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":20.35},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":33.01},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":33.01},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":33.01},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":34.82,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19.49},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.53,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33.3},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":49.01},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18.4,"additional_payer_notes":"APC"}]}]},{"description":"Pentostatin injection","code_information":[{"code":"J9268","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2023.49,"maximum":7439.31,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2697.99,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2940.77},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4833.4},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4833.4},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4833.4},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5207.11,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2958.58},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2023.49,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5055.18},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7439.31},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2751.95,"additional_payer_notes":"APC"}]}]},{"description":"Mitomycin instillation","code_information":[{"code":"J9281","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":247.45,"maximum":847.67,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":329.94,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":344.3},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":603.1},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":603.1},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":603.1},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":636.78,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":337.11},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":247.45,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":576.02},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":847.67},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":336.54,"additional_payer_notes":"APC"}]}]},{"description":"Inj nivol relatlimab 3mg/1mg","code_information":[{"code":"J9298","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":154.13,"maximum":527.79,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":205.51,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":213.49},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":375.53},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":375.53},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":375.53},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":396.64,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":209.9},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":154.13,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":358.64},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":527.79},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":209.62,"additional_payer_notes":"APC"}]}]},{"description":"Injection, ramucirumab","code_information":[{"code":"J9308","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":57.42,"maximum":198.5,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":76.56,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":80.71},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":141.46},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":141.46},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":141.46},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":147.77,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":78.94},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":57.42,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":134.88},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":198.5},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":78.1,"additional_payer_notes":"APC"}]}]},{"description":"Inj romidepsin lyophil 0.1mg","code_information":[{"code":"J9319","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":23.03,"maximum":82.73,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":30.71,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":34.69},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":59.04},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":59.04},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":59.04},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":59.28,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32.91},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23.03,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":56.22},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":82.73},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":31.33,"additional_payer_notes":"APC"}]}]},{"description":"Inj sirolimus prot part 1 mg","code_information":[{"code":"J9331","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":68.27,"maximum":319.75,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":91.03,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":129.39},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":160.61},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":160.61},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":160.61},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":175.69,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":127.17},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":68.27,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":217.28},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":319.75},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":92.85,"additional_payer_notes":"APC"}]}]},{"description":"Inj., tafasitamab-cxix","code_information":[{"code":"J9349","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":10.82,"maximum":38.03,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14.43,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":15.32},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26.74},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26.74},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26.74},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":27.85,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15.12},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10.82,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25.84},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38.03},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14.72,"additional_payer_notes":"APC"}]}]},{"description":"Valrubicin injection","code_information":[{"code":"J9357","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":935.29,"maximum":3791.14,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1247.05,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1589.01},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2615.89},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2615.89},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2615.89},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2406.8,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1507.72},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":935.29,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2576.16},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3791.14},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1271.99,"additional_payer_notes":"APC"}]}]},{"description":"Removal of residual cervix","code_information":[{"code":"57540","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Total hysterectomy","code_information":[{"code":"58152","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5257.0,"maximum":6462.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5257.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6462.0}]}]},{"description":"Hysteroscope procedure","code_information":[{"code":"58579","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":149.98,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":199.97,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":385.94,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":149.98,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":203.97,"additional_payer_notes":"APC"}]}]},{"description":"Repair oviduct","code_information":[{"code":"58750","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0}]}]},{"description":"Transposition ovary(s)","code_information":[{"code":"58825","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0}]}]},{"description":"Resect ovarian malignancy","code_information":[{"code":"58952","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Remove uterus after cesarean","code_information":[{"code":"59525","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3388.0,"maximum":4106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0}]}]},{"description":"Abortion","code_information":[{"code":"59855","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3388.0,"maximum":4106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0}]}]},{"description":"Maternity care procedure","code_information":[{"code":"59899","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":149.98,"maximum":13249.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":199.97,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":13249.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":10779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":13249.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":385.94,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":149.98,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":203.97,"additional_payer_notes":"APC"}]}]},{"description":"Removal of thyroid","code_information":[{"code":"60240","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4484.77,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5979.69,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5257.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11540.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4484.77,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6099.28,"additional_payer_notes":"APC"}]}]},{"description":"Aspir/inj thyroid cyst","code_information":[{"code":"60300","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":525.32,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":700.42,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1351.81,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":525.32,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":714.43,"additional_payer_notes":"APC"}]}]},{"description":"Explore adrenal gland","code_information":[{"code":"60540","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Drill skull for drainage","code_information":[{"code":"61108","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Open skull for drainage","code_information":[{"code":"61315","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6779.0,"maximum":8333.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0}]}]},{"description":"Subtemporal decompression","code_information":[{"code":"61340","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6779.0,"maximum":8333.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0}]}]},{"description":"Removal of brain lesion","code_information":[{"code":"61510","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6779.0,"maximum":8333.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0}]}]},{"description":"Inj, fulvestrant (fresenius)","code_information":[{"code":"J9394","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3.65,"maximum":52.33,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27.11,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3.65},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":6.31},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":6.31},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":6.31},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":52.33,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13.28},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20.33,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22.68},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33.38},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27.65,"additional_payer_notes":"APC"}]}]},{"description":"Ferumoxytol, esrd use","code_information":[{"code":"Q0139","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":0.28,"maximum":1.04,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":0.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":0.36},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.59},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.59},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.59},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":0.71,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":0.28,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.7},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1.04},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":0.38,"additional_payer_notes":"APC"}]}]},{"description":"Doxorubicin inj 10mg","code_information":[{"code":"Q2050","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":87.45,"maximum":370.39,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":116.6,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":165.45},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":207.64},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":207.64},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":207.64},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":225.05,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":87.45,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":251.69},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":370.39},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":118.94,"additional_payer_notes":"APC"}]}]},{"description":"Apligraf","code_information":[{"code":"Q4101","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":33.4,"maximum":237.56,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":123.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":33.4},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":57.58},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":57.58},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":57.58},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":237.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":92.32,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":56.39},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":82.98},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":125.55,"additional_payer_notes":"APC"}]}]},{"description":"Integra flowable wound matri","code_information":[{"code":"Q4114","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1643.79,"maximum":4357.67,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1643.79},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2930.26},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2930.26},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2930.26},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2961.13},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":4357.67}]}]},{"description":"Flexhd/allopatchhd/matrixhd","code_information":[{"code":"Q4128","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":26.92,"maximum":237.56,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":123.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":26.92},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":58.33},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":58.33},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":58.33},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":237.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":92.32,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":56.59},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":83.28},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":125.55,"additional_payer_notes":"APC"}]}]},{"description":"Epifix, inj, 1mg","code_information":[{"code":"Q4145","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":37.01,"maximum":37.01,"payers_information":[{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":37.01},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":37.01},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":37.01}]}]},{"description":"Neox 100 1 square cm","code_information":[{"code":"Q4156","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":71.23,"maximum":237.56,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":123.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":71.23},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":126.06},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":126.06},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":126.06},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":237.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":92.32,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":118.49},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":174.37},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":125.55,"additional_payer_notes":"APC"}]}]},{"description":"Artacent wound, per sq cm","code_information":[{"code":"Q4169","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":92.32,"maximum":9351.41,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":123.09,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4219.09},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4219.09},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4219.09},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":237.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":92.32,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9351.41},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":125.55,"additional_payer_notes":"APC"}]}]},{"description":"Epifix 1 sq cm","code_information":[{"code":"Q4186","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":92.32,"maximum":431.05,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":123.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":174.16},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":285.63},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":285.63},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":285.63},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":237.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":92.32,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":292.91},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":431.05},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":125.55,"additional_payer_notes":"APC"}]}]},{"description":"Puraply am 1 sq cm","code_information":[{"code":"Q4196","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":92.32,"maximum":287.74,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":123.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":116.01},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":187.23},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":187.23},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":187.23},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":237.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":92.32,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":195.53},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":287.74},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":125.55,"additional_payer_notes":"APC"}]}]},{"description":"Amniowrap2 per sq cm","code_information":[{"code":"Q4221","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":92.32,"maximum":5229.21,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":123.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2215.4},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3725.9},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3725.9},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3725.9},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":237.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":92.32,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5229.21},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":125.55,"additional_payer_notes":"APC"}]}]},{"description":"Carepatch per sq cm","code_information":[{"code":"Q4236","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":92.32,"maximum":1670.53,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":123.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":530.99},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":918.93},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":918.93},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":918.93},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":237.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":92.32,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1135.16},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1670.53},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":125.55,"additional_payer_notes":"APC"}]}]},{"description":"Mlg complet, per sq cm","code_information":[{"code":"Q4256","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":92.32,"maximum":2648.53,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":123.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1028.52},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1545.11},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1545.11},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1545.11},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":237.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":92.32,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1799.74},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2648.53},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":125.55,"additional_payer_notes":"APC"}]}]},{"description":"Neostim per sq cm","code_information":[{"code":"Q4266","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":92.32,"maximum":2420.09,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":123.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1088.64},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1065.08},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1065.08},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1065.08},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":237.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":92.32,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1644.5},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2420.09},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":125.55,"additional_payer_notes":"APC"}]}]},{"description":"Vendaje ac, per sq cm","code_information":[{"code":"Q4279","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":92.32,"maximum":6493.16,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":123.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2623.5},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4531.5},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4531.5},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4531.5},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":237.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":92.32,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":4412.25},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6493.16},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":125.55,"additional_payer_notes":"APC"}]}]},{"description":"Amnio quad-core, per sq cm","code_information":[{"code":"Q4294","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":92.32,"maximum":8169.3,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":123.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2915.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5538.5},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5538.5},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5538.5},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":237.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":92.32,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8169.3},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":125.55,"additional_payer_notes":"APC"}]}]},{"description":"Complete aca, per sq cm","code_information":[{"code":"Q4302","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":92.32,"maximum":5468.69,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":123.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2209.57},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2416.05},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2416.05},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2416.05},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":237.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":92.32,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3716.1},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5468.69},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":125.55,"additional_payer_notes":"APC"}]}]},{"description":"Alloply, per sq cm","code_information":[{"code":"Q4323","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":92.32,"maximum":5337.3,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":123.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1807.3},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2991.63},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2991.63},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2991.63},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":237.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":92.32,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5337.3},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":125.55,"additional_payer_notes":"APC"}]}]},{"description":"Theramend, per sq cm","code_information":[{"code":"Q4342","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":92.32,"maximum":11539.67,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":123.09,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4041.51},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4041.51},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4041.51},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":237.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":92.32,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11539.67},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":125.55,"additional_payer_notes":"APC"}]}]},{"description":"Injection, renflexis","code_information":[{"code":"Q5104","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":19.96,"maximum":71.49,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26.62,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":30.64},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":47.6},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":47.6},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":47.6},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":51.37,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19.96,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":48.58},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":71.49},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27.15,"additional_payer_notes":"APC"}]}]},{"description":"Inj herzuma 10 mg","code_information":[{"code":"Q5113","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":41.21,"maximum":195.97,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":54.94,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":81.3},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":147.23},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":147.23},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":147.23},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":106.04,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":41.21,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":133.16},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":195.97},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":56.04,"additional_payer_notes":"APC"}]}]},{"description":"Inj. avsola, 10 mg","code_information":[{"code":"Q5121","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":21.73,"maximum":59.5,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":30.83,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":21.73},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":39.68},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":39.68},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":39.68},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":59.5,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23.12,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36.69},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":53.99},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":31.45,"additional_payer_notes":"APC"}]}]},{"description":"Inj, vegzelma, 10 mg","code_information":[{"code":"Q5129","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":17.74,"maximum":141.57,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23.65,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":52.89},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":82.88},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":82.88},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":82.88},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":45.64,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17.74,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":96.2},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":141.57},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":24.12,"additional_payer_notes":"APC"}]}]},{"description":"Inj perflutren lip micros,ml","code_information":[{"code":"Q9957","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":46.07,"maximum":113.29,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":46.07},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":78.28},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":78.28},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":78.28},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":76.98},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":113.29}]}]},{"description":"Buprenorphine xr over 100 mg","code_information":[{"code":"Q9992","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1551.12,"maximum":5259.36,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2068.16,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2117.75},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3755.45},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3755.45},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3755.45},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3991.54,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1551.12,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3573.85},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5259.36},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2109.52,"additional_payer_notes":"APC"}]}]},{"description":"Removal of brain lesion","code_information":[{"code":"61521","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6779.0,"maximum":8333.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0}]}]},{"description":"Remove brain electrodes","code_information":[{"code":"61535","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6779.0,"maximum":8333.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0}]}]},{"description":"Remove & treat brain lesion","code_information":[{"code":"61544","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6779.0,"maximum":8333.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0}]}]},{"description":"Excision of skull/sutures","code_information":[{"code":"61558","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6779.0,"maximum":8333.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0}]}]},{"description":"Skull base/brainstem surgery","code_information":[{"code":"61575","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6779.0,"maximum":8333.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0}]}]},{"description":"Resect nasopharynx skull","code_information":[{"code":"61586","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6779.0,"maximum":8333.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0}]}]},{"description":"Resect/excise cranial lesion","code_information":[{"code":"61600","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6779.0,"maximum":8333.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0}]}]},{"description":"Resect/excise lesion skull","code_information":[{"code":"61615","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6779.0,"maximum":8333.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0}]}]},{"description":"Intracran angioplsty w/stent","code_information":[{"code":"61635","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6779.0,"maximum":8333.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0}]}]},{"description":"Intracranial vessel surgery","code_information":[{"code":"61682","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6779.0,"maximum":8333.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0}]}]},{"description":"Inner skull vessel surgery","code_information":[{"code":"61702","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6779.0,"maximum":8333.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0}]}]},{"description":"Incise skull/brain biopsy","code_information":[{"code":"61750","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6779.0,"maximum":8333.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0}]}]},{"description":"Treat trigeminal tract","code_information":[{"code":"61791","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1448.59,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1931.46,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3727.72,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1448.59,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1970.09,"additional_payer_notes":"APC"}]}]},{"description":"Implant neuroelectrode","code_information":[{"code":"61863","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6779.0,"maximum":8333.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0}]}]},{"description":"Repair of skull defect","code_information":[{"code":"62140","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Neuroendoscopy add-on","code_information":[{"code":"62160","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Remove brain cavity shunt","code_information":[{"code":"62256","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3388.0,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0}]}]},{"description":"Remove vert body dcmprn crvl","code_information":[{"code":"63081","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6779.0,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0}]}]},{"description":"Remove vert body dcmprn thrc","code_information":[{"code":"63101","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6779.0,"maximum":8333.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0}]}]},{"description":"Incise spine accessory nerve","code_information":[{"code":"63191","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6779.0,"maximum":27583.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":27583.0}]}]},{"description":"Excise intrspinl lesion lmbr","code_information":[{"code":"63267","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":13851.98,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Bx/exc xdrl spine lesn lmbr","code_information":[{"code":"63277","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6779.0,"maximum":27583.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":27583.0}]}]},{"description":"Remove vert idrl body thrc","code_information":[{"code":"63305","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6779.0,"maximum":8333.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":8333.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":8333.0}]}]},{"description":"Implant neuroelectrodes","code_information":[{"code":"63650","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4727.69,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6303.59,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":12165.93,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4727.69,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6429.66,"additional_payer_notes":"APC"}]}]},{"description":"Repair of spinal herniation","code_information":[{"code":"63700","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3735.0,"maximum":4589.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0}]}]},{"description":"Install spinal shunt","code_information":[{"code":"63741","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":16752.93,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8680.28,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":16752.93,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6510.21,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8853.88,"additional_payer_notes":"APC"}]}]},{"description":"N block inj axillary","code_information":[{"code":"64417","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":656.13,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":874.84,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1688.44,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":656.13,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":892.34,"additional_payer_notes":"APC"}]}]},{"description":"N blk inj sciatic cont inf","code_information":[{"code":"64446","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":656.13,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":874.84,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1688.44,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":656.13,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":892.34,"additional_payer_notes":"APC"}]}]},{"description":"Revise/rmv pn/gastr stimul","code_information":[{"code":"64595","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2593.52,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3458.03,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6674.0,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2593.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3527.19,"additional_payer_notes":"APC"}]}]},{"description":"Chemodener muscle larynx emg","code_information":[{"code":"64617","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":523.65,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":698.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1347.51,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":523.65,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":712.16,"additional_payer_notes":"APC"}]}]},{"description":"Incision of stomach nerves","code_information":[{"code":"64755","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":5441.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0}]}]},{"description":"Remove sympathetic nerves","code_information":[{"code":"64822","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Repair of leg nerve","code_information":[{"code":"64840","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4428.0,"maximum":16752.93,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8680.28,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":16752.93,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6510.21,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8853.88,"additional_payer_notes":"APC"}]}]},{"description":"Repair of facial nerve","code_information":[{"code":"64865","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2534.21,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3378.94,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6521.36,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2534.21,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3446.52,"additional_payer_notes":"APC"}]}]},{"description":"Revise eye with implant","code_information":[{"code":"65093","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2916.44,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3888.58,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7504.96,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2916.44,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3966.35,"additional_payer_notes":"APC"}]}]},{"description":"Insert ocular implant","code_information":[{"code":"65130","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2916.44,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3888.58,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7504.96,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2916.44,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3966.35,"additional_payer_notes":"APC"}]}]},{"description":"Remove foreign body from eye","code_information":[{"code":"65220","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":331.39,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":441.86,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":852.79,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":331.39,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":450.7,"additional_payer_notes":"APC"}]}]},{"description":"Incise inner eye strands","code_information":[{"code":"67030","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1712.02,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2282.69,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4405.59,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1712.02,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2328.34,"additional_payer_notes":"APC"}]}]},{"description":"Repair detached retina crtx","code_information":[{"code":"67101","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1712.02,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2282.69,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4405.59,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1712.02,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2328.34,"additional_payer_notes":"APC"}]}]},{"description":"Remove eye implant material","code_information":[{"code":"67121","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1712.02,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2282.69,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4405.59,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1712.02,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2328.34,"additional_payer_notes":"APC"}]}]},{"description":"Eye photodynamic ther add-on","code_information":[{"code":"67225","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Revise two eye muscles","code_information":[{"code":"67312","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2916.44,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3888.58,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7504.96,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2916.44,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3966.35,"additional_payer_notes":"APC"}]}]},{"description":"Eye suture during surgery","code_information":[{"code":"67335","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Explore/treat eye socket","code_information":[{"code":"67412","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1763.69,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2351.59,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4538.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1763.69,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2398.62,"additional_payer_notes":"APC"}]}]},{"description":"Explore/biopsy eye socket","code_information":[{"code":"67450","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2916.44,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3888.58,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7504.96,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2916.44,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3966.35,"additional_payer_notes":"APC"}]}]},{"description":"Drainage of eyelid abscess","code_information":[{"code":"67700","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":235.46,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":313.95,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":605.92,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":235.46,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":320.23,"additional_payer_notes":"APC"}]}]},{"description":"Revise eyelashes","code_information":[{"code":"67820","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":98.7,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":131.6,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":253.99,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":98.7,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":134.23,"additional_payer_notes":"APC"}]}]},{"description":"Revision of eyelid","code_information":[{"code":"67882","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1763.69,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2351.59,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4538.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1763.69,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2398.62,"additional_payer_notes":"APC"}]}]},{"description":"Revise eyelid defect","code_information":[{"code":"67909","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1763.69,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2351.59,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4538.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1763.69,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2398.62,"additional_payer_notes":"APC"}]}]},{"description":"Repair eyelid defect","code_information":[{"code":"67922","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1763.69,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2351.59,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4538.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1763.69,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2398.62,"additional_payer_notes":"APC"}]}]},{"description":"Revision of eyelid","code_information":[{"code":"67966","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1763.69,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2351.59,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4538.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1763.69,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2398.62,"additional_payer_notes":"APC"}]}]},{"description":"Biopsy of eyelid lining","code_information":[{"code":"68100","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1763.69,"maximum":4538.57,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2351.59,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4538.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1763.69,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2398.62,"additional_payer_notes":"APC"}]}]},{"description":"Revise/graft eyelid lining","code_information":[{"code":"68326","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2916.44,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3888.58,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7504.96,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2916.44,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3966.35,"additional_payer_notes":"APC"}]}]},{"description":"Eyelid lining surgery","code_information":[{"code":"68399","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":235.46,"maximum":13249.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":313.95,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":13249.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":10779.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":13249.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":605.92,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":235.46,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":320.23,"additional_payer_notes":"APC"}]}]},{"description":"Biopsy of tear sac","code_information":[{"code":"68525","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1763.69,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2351.59,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4538.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1763.69,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2398.62,"additional_payer_notes":"APC"}]}]},{"description":"Create tear duct drain","code_information":[{"code":"68750","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2916.44,"maximum":8770.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3888.58,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3735.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4589.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7504.96,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2916.44,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3966.35,"additional_payer_notes":"APC"}]}]},{"description":"Probe nl duct w/balloon","code_information":[{"code":"68816","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1763.69,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2351.59,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4538.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1763.69,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2398.62,"additional_payer_notes":"APC"}]}]},{"description":"Biopsy of external ear","code_information":[{"code":"69100","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":175.7,"maximum":3335.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":234.27,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2654.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":3335.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":452.14,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":175.7,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":238.96,"additional_payer_notes":"APC"}]}]},{"description":"Repair of eardrum","code_information":[{"code":"69620","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2459.51,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3279.35,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3388.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":4106.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6329.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2459.51,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3344.94,"additional_payer_notes":"APC"}]}]},{"description":"Revise middle ear & mastoid","code_information":[{"code":"69642","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Revise middle ear bone","code_information":[{"code":"69662","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Release facial nerve","code_information":[{"code":"69955","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4428.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":5441.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Root amputation","code_information":[{"code":"D3450","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":479.59,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":639.45,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1234.13,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":479.59,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":652.24,"additional_payer_notes":"APC"}]}]},{"description":"Liver dis 10 assays w/nash","code_information":[{"code":"0003M","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":377.55,"maximum":971.56,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":503.4,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":747.79},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":629.25},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":629.25},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":629.25},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":971.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":377.55,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":880.95},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":513.47,"additional_payer_notes":"APC"}]}]},{"description":"Onc brst ca erbb2 amp/nonamp","code_information":[{"code":"0009U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":80.25,"maximum":206.51,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":107.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":158.95},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":133.75},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":133.75},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":133.75},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":206.51,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":80.25,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":187.25},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":107.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":109.14,"additional_payer_notes":"APC"}]}]},{"description":"Onc hmtlmf neo rna bcr/abl1","code_information":[{"code":"0016U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":122.97,"maximum":316.44,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":163.96,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":300.7},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":204.95},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":204.95},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":204.95},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":316.44,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":122.97,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":286.93},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":163.96},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":167.24,"additional_payer_notes":"APC"}]}]},{"description":"Onc prst8 detcj 8 autoantb","code_information":[{"code":"0021U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":570.0,"maximum":1466.8,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":760.0,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":950.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":950.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":950.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1466.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":570.0,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1330.0},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":760.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":775.2,"additional_payer_notes":"APC"}]}]},{"description":"Rx metab warf trgt seq alys","code_information":[{"code":"0030U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":100.6,"maximum":258.87,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":134.13,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":167.66},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":167.66},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":167.66},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":258.87,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":100.6,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":234.73},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":134.13},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":136.81,"additional_payer_notes":"APC"}]}]},{"description":"Vitamin d srm microsamp quan","code_information":[{"code":"0038U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":22.2,"maximum":57.13,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":29.6,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":48.86},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":37.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":37.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":37.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":57.13,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22.2,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":51.8},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29.6},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":30.19,"additional_payer_notes":"APC"}]}]},{"description":"Flt3 gene itd variants quan","code_information":[{"code":"0046U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":165.65,"maximum":786.34,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":407.43,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":245.86},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":509.29},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":509.29},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":509.29},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":786.34,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":305.57,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":713.0},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":165.65},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":415.58,"additional_payer_notes":"APC"}]}]},{"description":"Card hrt trnspl 96 dna seq","code_information":[{"code":"0055U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2430.0,"maximum":6253.2,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3240.0,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4050.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4050.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4050.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6253.2,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2430.0,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5670.0},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3240.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3304.8,"additional_payer_notes":"APC"}]}]},{"description":"Syfls tst nontreponemal antb","code_information":[{"code":"0065U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":13.57,"maximum":34.91,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":26.87},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22.61},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22.61},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22.61},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":34.91,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.57,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31.66},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18.09},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18.45,"additional_payer_notes":"APC"}]}]},{"description":"Cyp2d6 gen cyp2d7-2d6 hybrid","code_information":[{"code":"0073U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":338.18,"maximum":870.26,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":450.91,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":669.83},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":563.64},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":563.64},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":563.64},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":870.26,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":338.18,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":789.09},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":450.91},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":459.93,"additional_payer_notes":"APC"}]}]},{"description":"Onc rspse chemo cntrst tomog","code_information":[{"code":"0083U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":125.51,"maximum":322.99,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":167.35,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":209.19},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":209.19},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":209.19},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":322.99,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":125.51,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":292.86},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":167.35},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":170.7,"additional_payer_notes":"APC"}]}]},{"description":"Rx mntr 65 com drugs urine","code_information":[{"code":"0093U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":46.6,"maximum":119.93,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":62.14,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":92.32},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":77.68},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":77.68},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":77.68},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":119.93,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":46.6,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":108.75},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":62.14},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":63.38,"additional_payer_notes":"APC"}]}]},{"description":"Gstr emptg 7 timed brth spec","code_information":[{"code":"0106U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":655.87,"maximum":1687.77,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":874.49,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1093.11},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1093.11},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1093.11},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1687.77,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":655.87,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1530.36},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":874.49},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":891.98,"additional_payer_notes":"APC"}]}]},{"description":"Gi barretts esoph vim&ccna1","code_information":[{"code":"0114U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1453.51,"maximum":3740.36,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1938.01,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2422.51},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2422.51},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2422.51},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3740.36,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1453.51,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3391.52},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1938.01},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1976.77,"additional_payer_notes":"APC"}]}]},{"description":"Sc dis p-selectin whl blood","code_information":[{"code":"0122U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":394.67,"maximum":1015.62,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":526.23,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":657.79},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":657.79},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":657.79},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1015.62,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":394.67,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":920.9},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":526.23},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":536.75,"additional_payer_notes":"APC"}]}]},{"description":"Hered gyn ca mrna pnl 12 gen","code_information":[{"code":"0135U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":700.56,"maximum":1225.98,"payers_information":[{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":875.7},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":875.7},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":875.7},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1225.98},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":700.56}]}]},{"description":"Onc breast mrna 101 genes","code_information":[{"code":"0153U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2369.56,"maximum":6097.68,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3159.42,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4693.22},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3949.28},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3949.28},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3949.28},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6097.68,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2369.56,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5528.99},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3159.42},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3222.61,"additional_payer_notes":"APC"}]}]},{"description":"Pms2 mrna seq alys","code_information":[{"code":"0161U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":212.16,"maximum":545.96,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":282.88,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":420.22},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":353.6},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":353.6},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":353.6},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":545.96,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":212.16,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":495.04},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":282.88},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":288.54,"additional_payer_notes":"APC"}]}]},{"description":"Trgt gen seq alys pnl dna 23","code_information":[{"code":"0171U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1139.3,"maximum":2931.79,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1519.06,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2256.5},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1898.83},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1898.83},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1898.83},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2931.79,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1139.3,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2658.36},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1519.06},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1549.44,"additional_payer_notes":"APC"}]}]},{"description":"Onc nonsm cll lng ca alys 23","code_information":[{"code":"0179U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1457.41,"maximum":3750.4,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1943.21,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2886.58},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2429.01},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2429.01},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2429.01},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3750.4,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1457.41,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3400.62},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1943.21},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1982.07,"additional_payer_notes":"APC"}]}]},{"description":"Fy gnotyp ackr1 exons 1-2","code_information":[{"code":"0187U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":206.12,"maximum":530.42,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":274.83,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":408.24},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":343.54},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":343.54},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":343.54},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":530.42,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":206.12,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":480.95},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":274.83},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":280.33,"additional_payer_notes":"APC"}]}]},{"description":"Klf1 targeted sequencing","code_information":[{"code":"0195U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":281.44,"maximum":724.23,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":375.25,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":557.42},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":469.06},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":469.06},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":469.06},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":724.23,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":281.44,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":656.69},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":375.25},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":382.76,"additional_payer_notes":"APC"}]}]},{"description":"Ai ibd mrna xprsn prfl 17","code_information":[{"code":"0203U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":570.0,"maximum":1466.8,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":760.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1128.96},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":950.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":950.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":950.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1466.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":570.0,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1330.0},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":760.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":775.2,"additional_payer_notes":"APC"}]}]},{"description":"Rare ds gen dna alys ea comp","code_information":[{"code":"0213U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2032.46,"maximum":5230.2,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2709.95,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4025.54},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3387.44},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3387.44},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3387.44},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5230.2,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2032.46,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":4742.41},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2709.95},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2764.15,"additional_payer_notes":"APC"}]}]},{"description":"Abo gnotyp next gnrj seq abo","code_information":[{"code":"0221U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":206.12,"maximum":530.42,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":274.83,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":408.24},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":343.54},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":343.54},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":343.54},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":530.42,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":206.12,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":480.95},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":274.83},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":280.33,"additional_payer_notes":"APC"}]}]},{"description":"Bcat1 promoter mthyltn alys","code_information":[{"code":"0229U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":192.0,"maximum":741.12,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":384.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":285.2},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":480.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":480.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":480.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":741.12,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":288.0,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":672.0},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":192.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":391.68,"additional_payer_notes":"APC"}]}]},{"description":"Car ion chnlpthy gen seq pnl","code_information":[{"code":"0237U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":438.68,"maximum":1128.86,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":584.9,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":868.86},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":731.13},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":731.13},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":731.13},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1128.86,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":438.68,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1023.58},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":584.9},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":596.6,"additional_payer_notes":"APC"}]}]},{"description":"Onc thyr mut alys 10 gen&37","code_information":[{"code":"0245U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":949.55,"maximum":2443.52,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1266.07,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1874.74},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1582.59},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1582.59},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1582.59},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2443.52,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":949.55,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2215.62},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1266.07},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1291.39,"additional_payer_notes":"APC"}]}]},{"description":"Rprdtve med rna gen prfl 238","code_information":[{"code":"0253U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2369.56,"maximum":6097.68,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3159.42,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4678.32},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3949.28},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3949.28},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3949.28},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6097.68,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2369.56,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5528.99},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3159.42},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3222.61,"additional_payer_notes":"APC"}]}]},{"description":"Onc clrct ca img alys w/ai","code_information":[{"code":"0261U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1884.94,"maximum":4850.57,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2513.25,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3733.36},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3141.56},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3141.56},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3141.56},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4850.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1884.94,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":4398.19},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2513.25},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2563.52,"additional_payer_notes":"APC"}]}]},{"description":"Hem aut dm cgen trmbctpna 14","code_information":[{"code":"0269U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":456.13,"maximum":1173.77,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":608.17,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":900.54},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":760.21},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":760.21},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":760.21},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1173.77,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":456.13,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1064.3},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":608.17},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":620.33,"additional_payer_notes":"APC"}]}]},{"description":"Hem gen pltlt funcj do 31","code_information":[{"code":"0277U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":456.13,"maximum":1173.77,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":608.17,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":900.54},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":760.21},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":760.21},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":760.21},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1173.77,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":456.13,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1064.3},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":608.17},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":620.33,"additional_payer_notes":"APC"}]}]},{"description":"Onc rsps radj cll fr dna tox","code_information":[{"code":"0285U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":332.48,"maximum":855.59,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":443.31,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":663.9},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":554.14},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":554.14},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":554.14},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":855.59,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":332.48,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":775.79},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":443.31},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":452.18,"additional_payer_notes":"APC"}]}]},{"description":"Psyc suicidal idea mrna 54","code_information":[{"code":"0293U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":570.0,"maximum":1466.8,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":760.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1125.37},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":950.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":950.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":950.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1466.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":570.0,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1330.0},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":760.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":775.2,"additional_payer_notes":"APC"}]}]},{"description":"Iadna bartonella ddpcr","code_information":[{"code":"0301U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":197.04,"maximum":507.05,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":262.72,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":393.44},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":328.4},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":328.4},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":328.4},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":507.05,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":197.04,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":459.76},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":262.72},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":267.97,"additional_payer_notes":"APC"}]}]},{"description":"Crd cv ds aly 4 prtn plm alg","code_information":[{"code":"0309U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":293.06,"maximum":754.15,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":390.75,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":578.62},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":488.44},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":488.44},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":488.44},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":754.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":293.06,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":683.81},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":390.75},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":398.56,"additional_payer_notes":"APC"}]}]},{"description":"Onc lung ca 4-prb fish assay","code_information":[{"code":"0317U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1522.5,"maximum":3917.9,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2030.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3005.93},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2537.5},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2537.5},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2537.5},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3917.9,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1522.5,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3552.5},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2070.6,"additional_payer_notes":"APC"}]}]},{"description":"Ftl aneuploidy trsmy dna seq","code_information":[{"code":"0327U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":596.25,"maximum":1534.35,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":795.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1177.2},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":993.75},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":993.75},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":993.75},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1534.35,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":596.25,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1391.25},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":795.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":810.9,"additional_payer_notes":"APC"}]}]},{"description":"Rare ds whl gen seq fetal","code_information":[{"code":"0335U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3918.45,"maximum":10083.48,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5224.6,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7736.34},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":6530.75},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":6530.75},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":6530.75},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":10083.48,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3918.45,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9143.05},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5224.6},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5329.09,"additional_payer_notes":"APC"}]}]},{"description":"Onc prst8 xom aly 442 sncrna","code_information":[{"code":"0343U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":570.0,"maximum":1466.8,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":760.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1125.37},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":950.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":950.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":950.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1466.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":570.0,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1330.0},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":760.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":775.2,"additional_payer_notes":"APC"}]}]},{"description":"Apol1 risk variants","code_information":[{"code":"0355U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":102.75,"maximum":264.41,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":137.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":205.18},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":171.25},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":171.25},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":171.25},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":264.41,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":102.75,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":239.75},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":137.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":139.74,"additional_payer_notes":"APC"}]}]},{"description":"Onc hl neo gen seq alys alg","code_information":[{"code":"0364U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1505.44,"maximum":3873.99,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2007.25,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2890.44},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2509.06},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2509.06},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2509.06},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3873.99,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1505.44,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3512.69},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2007.25},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2047.4,"additional_payer_notes":"APC"}]}]},{"description":"Nfct ds gu pthgn arg detcj","code_information":[{"code":"0372U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":312.58,"maximum":804.39,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":416.78,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":624.18},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":520.98},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":520.98},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":520.98},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":804.39,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":312.58,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":729.37},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":416.78},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":425.12,"additional_payer_notes":"APC"}]}]},{"description":"Maple syrup ur ds mntr quan","code_information":[{"code":"0381U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":33.09,"maximum":85.15,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":44.12,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":63.53},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":55.15},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":55.15},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":55.15},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":85.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":33.09,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":77.21},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":44.12},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":45.0,"additional_payer_notes":"APC"}]}]},{"description":"Ob pe kdr eng&rbp4 ia alg","code_information":[{"code":"0390U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":48.31,"maximum":124.31,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":64.41,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":96.46},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":80.51},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":80.51},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":80.51},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":124.31,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":48.31,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":112.72},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":64.41},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":65.7,"additional_payer_notes":"APC"}]}]},{"description":"Ob xpnd car scr 145 genes","code_information":[{"code":"0400U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1456.88,"maximum":2549.54,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2097.91},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1821.1},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1821.1},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1821.1},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2549.54},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1456.88}]}]},{"description":"Iaad blk ac wv bsnsr sarscv2","code_information":[{"code":"0408U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":10.6,"maximum":27.27,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14.13,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":20.35},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17.66},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17.66},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17.66},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":27.27,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10.6,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24.73},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14.13},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14.41,"additional_payer_notes":"APC"}]}]},{"description":"Rare ds alys 335 nuc genes","code_information":[{"code":"0417U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2131.9,"maximum":5486.08,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2842.53,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4093.25},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3553.16},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3553.16},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3553.16},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5486.08,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2131.9,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":4974.43},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2842.53},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2899.38,"additional_payer_notes":"APC"}]}]},{"description":"Rx metab advrs vrnt alys 25","code_information":[{"code":"0434U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":312.58,"maximum":804.39,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":416.78,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":600.17},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":520.98},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":520.98},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":520.98},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":804.39,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":312.58,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":729.37},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":416.78},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":425.12,"additional_payer_notes":"APC"}]}]},{"description":"Nfct ds respir nfctj mxa&crp","code_information":[{"code":"0442U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":31.04,"maximum":79.86,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":41.38,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":59.59},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":51.73},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":51.73},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":51.73},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":79.86,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":31.04,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":72.42},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":41.38},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":42.21,"additional_payer_notes":"APC"}]}]},{"description":"Onc mm lc-ms/ms pep ion quan","code_information":[{"code":"0451U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":43.43,"maximum":76.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":62.54},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":54.29},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":54.29},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":54.29},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":76.0},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":43.43}]}]},{"description":"Hep nash mir34a5p ?2m ykl40","code_information":[{"code":"0468U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":188.78,"maximum":485.78,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":251.7,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":362.45},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":314.63},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":314.63},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":314.63},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":485.78,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":188.78,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":440.48},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":251.7},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":256.73,"additional_payer_notes":"APC"}]}]},{"description":"Rx metab psyc 14gen&cyp2d6","code_information":[{"code":"0476U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":312.58,"maximum":804.39,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":416.78,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":600.17},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":520.98},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":520.98},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":520.98},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":804.39,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":312.58,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":729.37},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":416.78},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":425.12,"additional_payer_notes":"APC"}]}]},{"description":"Onc sol tum ctc slctn pd-l1","code_information":[{"code":"0492U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1826.25,"maximum":4699.55,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2435.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3506.4},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3043.75},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3043.75},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3043.75},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4699.55,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1826.25,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":4261.25},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2435.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2483.7,"additional_payer_notes":"APC"}]}]},{"description":"Autoinflam ds vexas synd dna","code_information":[{"code":"0500U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":131.55,"maximum":338.52,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":175.4,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":252.58},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":219.25},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":219.25},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":219.25},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":338.52,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":131.55,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":306.95},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":175.4},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":178.91,"additional_payer_notes":"APC"}]}]},{"description":"Rx metab rxgenomic gnotyp 40","code_information":[{"code":"0516U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":312.58,"maximum":804.39,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":416.78,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":600.17},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":520.98},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":520.98},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":520.98},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":804.39,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":312.58,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":729.37},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":416.78},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":425.12,"additional_payer_notes":"APC"}]}]},{"description":"Runx1 gene targeted seq alys","code_information":[{"code":"81334","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":247.13,"maximum":635.95,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":329.51,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":489.48},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":411.89},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":411.89},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":411.89},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":635.95,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":247.13,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":576.64},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":329.51},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":336.1,"additional_payer_notes":"APC"}]}]},{"description":"Trg gene rearrangement anal","code_information":[{"code":"81342","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":151.12,"maximum":407.74,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":201.5,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":407.74},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":251.88},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":251.88},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":251.88},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":388.9,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":151.12,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":352.63},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":201.5},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":205.53,"additional_payer_notes":"APC"}]}]},{"description":"Ugt1a1 gene","code_information":[{"code":"81350","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":175.5,"maximum":451.62,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":234.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":347.59},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":292.5},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":292.5},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":292.5},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":451.62,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":175.5,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":409.5},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":234.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":238.68,"additional_payer_notes":"APC"}]}]},{"description":"Hbb gene known fam variant","code_information":[{"code":"81362","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":281.44,"maximum":724.23,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":375.25,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":557.42},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":469.06},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":469.06},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":469.06},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":724.23,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":281.44,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":656.69},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":375.25},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":382.76,"additional_payer_notes":"APC"}]}]},{"description":"Hla ii typing ag equiv lr","code_information":[{"code":"81375","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":165.56,"maximum":446.69,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":220.74,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":446.69},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":275.93},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":275.93},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":275.93},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":426.03,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":165.56,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":386.3},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":220.74},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":225.15,"additional_payer_notes":"APC"}]}]},{"description":"Hla ii typing 1 allele hr","code_information":[{"code":"81383","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":81.85,"maximum":220.84,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":109.13,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":220.84},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":136.41},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":136.41},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":136.41},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":210.62,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":81.85,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":190.98},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":109.13},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":111.31,"additional_payer_notes":"APC"}]}]},{"description":"Mopath procedure level 8","code_information":[{"code":"81407","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":634.7,"maximum":1633.3,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":846.27,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1257.11},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1057.84},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1057.84},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1057.84},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1633.3,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":634.7,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1480.97},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":846.27},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":863.2,"additional_payer_notes":"APC"}]}]},{"description":"Exome sequence analysis","code_information":[{"code":"81416","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":9000.0,"maximum":23160.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12000.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":17825.63},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15000.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15000.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15000.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":23160.0,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9000.0,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21000.0},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12000.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12240.0,"additional_payer_notes":"APC"}]}]},{"description":"Genome re-evaluation","code_information":[{"code":"81427","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1753.24,"maximum":4511.66,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2337.65,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3472.51},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2922.06},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2922.06},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2922.06},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4511.66,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1753.24,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":4090.89},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2337.65},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2384.4,"additional_payer_notes":"APC"}]}]},{"description":"Heredtry nurondcrn tum dsrdr","code_information":[{"code":"81437","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":438.93,"maximum":2516.62,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1303.95,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":894.41},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1629.94},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1629.94},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1629.94},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2516.62,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":977.96,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2281.91},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":438.93},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1330.03,"additional_payer_notes":"APC"}]}]},{"description":"Hrdtry perph neurphy panel","code_information":[{"code":"81448","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":438.68,"maximum":1128.86,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":584.9,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1072.66},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":731.13},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":731.13},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":731.13},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1128.86,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":438.68,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1023.58},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":584.9},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":596.6,"additional_payer_notes":"APC"}]}]},{"description":"So neo gsap dna/dna&rna","code_information":[{"code":"81459","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2242.16,"maximum":5769.83,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2989.55,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4304.95},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3736.94},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3736.94},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3736.94},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5769.83,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2242.16,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5231.71},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2989.55},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3049.34,"additional_payer_notes":"APC"}]}]},{"description":"Autoimmune rheumatoid arthr","code_information":[{"code":"81490","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":630.49,"maximum":1622.45,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":840.65,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":877.33},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1050.81},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1050.81},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1050.81},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1622.45,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":630.49,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1471.14},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":840.65},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":857.46,"additional_payer_notes":"APC"}]}]},{"description":"Ftl cgen abnor 3 proteins","code_information":[{"code":"81509","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1115.53,"maximum":2870.62,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1487.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2209.44},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1859.21},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1859.21},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1859.21},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2870.62,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1115.53,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2602.9},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1487.37},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1517.12,"additional_payer_notes":"APC"}]}]},{"description":"Onc brst mrna 11 genes","code_information":[{"code":"81518","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2904.75,"maximum":7474.89,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3873.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5753.22},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4841.25},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4841.25},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4841.25},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7474.89,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2904.75,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6777.75},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3873.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3950.46,"additional_payer_notes":"APC"}]}]},{"description":"Onc cutan mlnma mrna 31 gene","code_information":[{"code":"81529","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5394.75,"maximum":13882.49,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7193.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":10684.98},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8991.25},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8991.25},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8991.25},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13882.49,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5394.75,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12587.75},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7193.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7336.86,"additional_payer_notes":"APC"}]}]},{"description":"Onc thyr mrna 10,196 gen alg","code_information":[{"code":"81546","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2700.0,"maximum":6948.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3600.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5347.69},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4500.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4500.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4500.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6948.0,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2700.0,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6300.0},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3600.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3672.0,"additional_payer_notes":"APC"}]}]},{"description":"Test for acetone/ketones","code_information":[{"code":"82009","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3.39,"maximum":9.16,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4.52,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":9.16},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5.65},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5.65},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5.65},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":8.72,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3.39,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7.91},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":4.52},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4.61,"additional_payer_notes":"APC"}]}]},{"description":"Assay of urine albumin","code_information":[{"code":"82042","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5.84,"maximum":15.02,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7.78,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":10.48},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":9.73},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":9.73},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":9.73},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":15.02,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5.84,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13.62},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7.78},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7.94,"additional_payer_notes":"APC"}]}]},{"description":"Alpha-1-antitrypsin total","code_information":[{"code":"82103","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":10.08,"maximum":27.18,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.44,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":27.18},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16.8},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16.8},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16.8},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":25.94,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10.08,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23.52},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13.44},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.71,"additional_payer_notes":"APC"}]}]},{"description":"Amino acids mult qual","code_information":[{"code":"82128","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":10.4,"maximum":28.07,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.87,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":28.07},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17.34},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17.34},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17.34},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":26.77,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10.4,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24.27},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13.87},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14.15,"additional_payer_notes":"APC"}]}]},{"description":"Androstanediol glucuronide","code_information":[{"code":"82154","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":21.62,"maximum":58.36,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":28.83,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":58.36},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":36.04},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":36.04},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":36.04},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":55.64,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21.62,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":50.45},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28.83},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":29.41,"additional_payer_notes":"APC"}]}]},{"description":"Assay of ascorbic acid","code_information":[{"code":"82180","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7.42,"maximum":19.99,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9.89,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":19.99},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12.36},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12.36},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12.36},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":19.09,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7.42,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17.31},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9.89},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10.09,"additional_payer_notes":"APC"}]}]},{"description":"Bilirubin direct","code_information":[{"code":"82248","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3.76,"maximum":10.15,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5.02,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":10.15},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":6.28},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":6.28},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":6.28},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":9.69,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3.76,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8.79},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5.02},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5.12,"additional_payer_notes":"APC"}]}]},{"description":"Assay of cadmium","code_information":[{"code":"82300","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":17.73,"maximum":46.82,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23.64,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":46.82},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":29.55},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":29.55},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":29.55},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":45.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17.73,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":41.37},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23.64},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":24.11,"additional_payer_notes":"APC"}]}]},{"description":"Calculus assay quant","code_information":[{"code":"82360","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":9.65,"maximum":26.03,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.87,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":26.03},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16.09},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16.09},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16.09},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":24.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9.65,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22.52},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12.87},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.13,"additional_payer_notes":"APC"}]}]},{"description":"Assay of carnitine","code_information":[{"code":"82379","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":12.65,"maximum":32.56,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16.87,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":29.16},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21.09},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21.09},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21.09},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":32.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.65,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29.52},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16.87},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17.21,"additional_payer_notes":"APC"}]}]},{"description":"Assay of chloramphenicol","code_information":[{"code":"82415","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":9.5,"maximum":25.64,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.67,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":25.64},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15.84},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15.84},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15.84},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":24.45,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9.5,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22.17},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12.67},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.92,"additional_payer_notes":"APC"}]}]},{"description":"Assay chondroitin sulfate","code_information":[{"code":"82485","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":15.49,"maximum":41.78,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20.65,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":41.78},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25.81},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25.81},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25.81},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":39.85,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15.49,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36.14},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20.65},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21.06,"additional_payer_notes":"APC"}]}]},{"description":"Assay of creatine","code_information":[{"code":"82540","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3.48,"maximum":9.38,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4.64,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":9.38},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5.8},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5.8},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5.8},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":8.96,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3.48,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8.12},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":4.64},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4.73,"additional_payer_notes":"APC"}]}]},{"description":"Creatinine clearance test","code_information":[{"code":"82575","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7.1,"maximum":19.14,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9.46,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":19.14},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11.83},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11.83},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11.83},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":18.26,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7.1,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16.56},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9.46},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9.65,"additional_payer_notes":"APC"}]}]},{"description":"Dehydroepiandrosterone","code_information":[{"code":"82626","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":18.95,"maximum":51.13,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25.27,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":51.13},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":31.59},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":31.59},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":31.59},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":48.77,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18.95,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":44.22},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25.27},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25.78,"additional_payer_notes":"APC"}]}]},{"description":"Pancreatic elastase fecal","code_information":[{"code":"82656","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8.65,"maximum":23.34,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11.53,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":23.34},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14.41},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14.41},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14.41},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":22.25,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8.65,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20.18},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11.53},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11.76,"additional_payer_notes":"APC"}]}]},{"description":"Assay of estriol","code_information":[{"code":"82677","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":18.14,"maximum":48.94,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":24.18,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":48.94},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":30.23},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":30.23},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":30.23},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":46.67,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18.14,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":42.32},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24.18},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":24.66,"additional_payer_notes":"APC"}]}]},{"description":"Assay of blood fatty acids","code_information":[{"code":"82725","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":14.08,"maximum":36.23,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18.77,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":26.94},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23.46},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23.46},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23.46},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":36.23,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14.08,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32.85},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18.77},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19.15,"additional_payer_notes":"APC"}]}]},{"description":"Assay of rbc galactokinase","code_information":[{"code":"82759","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":16.11,"maximum":43.48,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21.48,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":43.48},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26.85},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26.85},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26.85},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":41.46,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16.11,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37.59},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21.48},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21.91,"additional_payer_notes":"APC"}]}]},{"description":"Blood pH","code_information":[{"code":"82800","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8.25,"maximum":21.23,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":17.12},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13.75},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13.75},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13.75},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":21.23,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8.25,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19.25},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11.22,"additional_payer_notes":"APC"}]}]},{"description":"Assay of glucagon","code_information":[{"code":"82943","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":10.72,"maximum":27.58,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14.29,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":19.97},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17.86},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17.86},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17.86},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":27.58,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10.72,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25.01},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14.29},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14.58,"additional_payer_notes":"APC"}]}]},{"description":"Assay of g6pd enzyme","code_information":[{"code":"82955","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7.28,"maximum":19.63,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9.7,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":19.63},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12.13},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12.13},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12.13},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":18.72,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7.28,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16.98},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9.7},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9.89,"additional_payer_notes":"APC"}]}]},{"description":"Assay of glycated protein","code_information":[{"code":"82985","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":12.57,"maximum":32.35,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16.76,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":23.92},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20.95},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20.95},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20.95},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":32.35,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.57,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29.33},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16.76},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17.1,"additional_payer_notes":"APC"}]}]},{"description":"H pylori (c-13) breath","code_information":[{"code":"83013","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":50.52,"maximum":136.3,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":67.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":136.3},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":84.2},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":84.2},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":84.2},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":130.0,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":50.52,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":117.88},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":67.36},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":68.71,"additional_payer_notes":"APC"}]}]},{"description":"Fetal hemoglobin assay qual","code_information":[{"code":"83033","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6.0,"maximum":15.44,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":12.06},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":15.44,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6.0,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14.0},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8.16,"additional_payer_notes":"APC"}]}]},{"description":"Hemoglobin stability screen","code_information":[{"code":"83068","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7.1,"maximum":18.28,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9.47,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":17.12},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11.84},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11.84},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11.84},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":18.28,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7.1,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16.57},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9.47},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9.66,"additional_payer_notes":"APC"}]}]},{"description":"Assay of 5-hiaa","code_information":[{"code":"83497","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":9.68,"maximum":26.09,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.9,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":26.09},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16.13},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16.13},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16.13},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":24.9,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9.68,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22.58},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12.9},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.16,"additional_payer_notes":"APC"}]}]},{"description":"Ig light chains free each","code_information":[{"code":"83521","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":12.95,"maximum":33.33,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17.27,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":25.66},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21.59},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21.59},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21.59},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":33.33,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.95,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30.22},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17.27},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17.62,"additional_payer_notes":"APC"}]}]},{"description":"Assay of ketogenic steroids","code_information":[{"code":"83582","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":11.6,"maximum":29.86,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15.47,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":28.68},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19.34},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19.34},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19.34},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":29.86,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11.6,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27.07},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15.47},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15.78,"additional_payer_notes":"APC"}]}]},{"description":"Placental lactogen","code_information":[{"code":"83632","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":15.16,"maximum":40.91,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20.22,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":40.91},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25.28},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25.28},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25.28},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":39.02,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15.16,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35.39},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20.22},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20.62,"additional_payer_notes":"APC"}]}]},{"description":"Assay of lipase","code_information":[{"code":"83690","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5.17,"maximum":13.94,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6.89,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":13.94},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8.61},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8.61},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8.61},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13.3,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5.17,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12.06},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6.89},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7.03,"additional_payer_notes":"APC"}]}]},{"description":"Assay of blood lipoprotein","code_information":[{"code":"83721","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7.88,"maximum":20.26,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10.5,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":19.32},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13.13},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13.13},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13.13},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":20.26,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7.88,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18.38},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10.5},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10.71,"additional_payer_notes":"APC"}]}]},{"description":"Assay of metanephrines","code_information":[{"code":"83835","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":12.7,"maximum":34.27,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16.94,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":34.27},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21.18},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21.18},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21.18},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":32.69,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.7,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29.65},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16.94},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17.28,"additional_payer_notes":"APC"}]}]},{"description":"Assay of natriuretic peptide","code_information":[{"code":"83880","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":29.44,"maximum":75.77,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":39.26,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":68.69},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":49.08},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":49.08},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":49.08},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":75.77,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":29.44,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":68.71},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":39.26},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":40.05,"additional_payer_notes":"APC"}]}]},{"description":"Organic acid single quant","code_information":[{"code":"83921","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":15.91,"maximum":40.94,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21.21,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":33.3},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26.51},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26.51},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26.51},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":40.94,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15.91,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37.12},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21.21},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21.63,"additional_payer_notes":"APC"}]}]},{"description":"Assay ph body fluid nos","code_information":[{"code":"83986","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2.68,"maximum":7.26,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3.58,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7.26},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4.48},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4.48},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4.48},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6.91,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2.68,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6.27},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3.58},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3.65,"additional_payer_notes":"APC"}]}]},{"description":"Assay alkaline phosphatase","code_information":[{"code":"84078","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6.2,"maximum":15.94,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8.26,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":14.77},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10.33},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10.33},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10.33},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":15.94,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6.2,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14.46},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8.26},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8.43,"additional_payer_notes":"APC"}]}]},{"description":"Assay of porphobilinogen","code_information":[{"code":"84110","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6.33,"maximum":17.09,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8.44,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":17.09},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10.55},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10.55},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10.55},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":16.29,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6.33,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14.77},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8.44},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8.61,"additional_payer_notes":"APC"}]}]},{"description":"Assay of pregnanediol","code_information":[{"code":"84135","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":15.95,"maximum":41.05,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21.27,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":38.71},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26.59},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26.59},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26.59},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":41.05,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15.95,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37.22},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21.27},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21.7,"additional_payer_notes":"APC"}]}]},{"description":"Assay of psa complexed","code_information":[{"code":"84152","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":13.79,"maximum":37.22,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18.39,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":37.22},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22.99},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22.99},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22.99},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":35.49,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.79,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32.18},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18.39},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18.76,"additional_payer_notes":"APC"}]}]},{"description":"Ana crown exp 1-3 per quad","code_information":[{"code":"D4231","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1151.01,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1534.69,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2961.94,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1151.01,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1565.38,"additional_payer_notes":"APC"}]}]},{"description":"Bone replce graft each add","code_information":[{"code":"D4264","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5512.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0}]}]},{"description":"Con tissue w dble ped graft","code_information":[{"code":"D4276","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1151.01,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1534.69,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2961.94,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1151.01,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1565.38,"additional_payer_notes":"APC"}]}]},{"description":"Odontics transosteal implnt","code_information":[{"code":"D6050","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5512.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0}]}]},{"description":"Impact tooth remov part bony","code_information":[{"code":"D7230","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":479.59,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":639.45,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1234.13,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":479.59,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":652.24,"additional_payer_notes":"APC"}]}]},{"description":"Tooth transplantation","code_information":[{"code":"D7272","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":479.59,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":639.45,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1234.13,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":479.59,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":652.24,"additional_payer_notes":"APC"}]}]},{"description":"Repositioning of teeth","code_information":[{"code":"D7290","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5512.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0}]}]},{"description":"Alveoplasty w/o extraction","code_information":[{"code":"D7320","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1151.01,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1534.69,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2961.94,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1151.01,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1565.38,"additional_payer_notes":"APC"}]}]},{"description":"Excision malig lesion>1.25cm","code_information":[{"code":"D7414","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1151.01,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1534.69,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2961.94,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1151.01,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1565.38,"additional_payer_notes":"APC"}]}]},{"description":"Lesion destruction","code_information":[{"code":"D7465","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5512.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0}]}]},{"description":"I&d abscess extraoral","code_information":[{"code":"D7520","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":525.32,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":700.42,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1351.81,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":525.32,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":714.43,"additional_payer_notes":"APC"}]}]},{"description":"Open red simp malar/zygom fx","code_information":[{"code":"D7650","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5512.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0}]}]},{"description":"Tmj open reduct-dislocation","code_information":[{"code":"D7810","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5512.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0}]}]},{"description":"Tmj cutting into joint","code_information":[{"code":"D7860","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5512.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0}]}]},{"description":"Tmj arthroscopy discectomy","code_information":[{"code":"D7876","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5512.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0}]}]},{"description":"Bone cutting ramus closed","code_information":[{"code":"D7941","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5512.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0}]}]},{"description":"Mandible graft","code_information":[{"code":"D7950","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":11300.84,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Surg redct fibrous tuberosit","code_information":[{"code":"D7972","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5512.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0}]}]},{"description":"Implant mandible for augment","code_information":[{"code":"D7996","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5512.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0}]}]},{"description":"Laser in situ keratomileusis (LASIK)","code_information":[{"code":"S0800","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5512.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0}]}]},{"description":"Sim Panc/renal transplant","code_information":[{"code":"S2065","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5512.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0}]}]},{"description":"percut occlusion tumor dest, yttrium-90","code_information":[{"code":"S2095","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5512.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0}]}]},{"description":"Minimally invasive direct co","code_information":[{"code":"S2207","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5512.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0}]}]},{"description":"Diskectomy, anterior, with d","code_information":[{"code":"S2351","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5512.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0}]}]},{"description":"Robotic surgical system","code_information":[{"code":"S2900","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5512.0,"maximum":6822.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6822.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5512.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6822.0}]}]},{"description":"Prep & cannulj cdvr don lung","code_information":[{"code":"0494T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5257.0,"maximum":6462.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":6462.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5257.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":6462.0}]}]},{"description":"Nsl/sins ndsc sphn tiss rmvl","code_information":[{"code":"31259","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5235.45,"maximum":13472.56,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6980.6,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":7398.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6019.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":7398.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13472.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5235.45,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7120.21,"additional_payer_notes":"APC"}]}]},{"description":"Evasc rpr a-unilac ndgft","code_information":[{"code":"34703","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7609.0,"maximum":9356.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"fee schedule","standard_charge_dollar":9356.0},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7609.0},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"fee schedule","standard_charge_dollar":9356.0}]}]},{"description":"Protein e-phoresis serum","code_information":[{"code":"84165","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8.06,"maximum":21.74,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10.74,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":21.74},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13.43},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13.43},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13.43},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":20.73,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8.06,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18.8},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10.74},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10.95,"additional_payer_notes":"APC"}]}]},{"description":"Assay of pyruvate","code_information":[{"code":"84210","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":10.86,"maximum":27.95,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14.48,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":21.96},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18.1},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18.1},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18.1},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":27.95,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10.86,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25.34},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14.48},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14.77,"additional_payer_notes":"APC"}]}]},{"description":"Assay of vitamin b-2","code_information":[{"code":"84252","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":15.18,"maximum":40.94,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20.24,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":40.94},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25.3},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25.3},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25.3},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":39.06,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15.18,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35.42},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20.24},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20.64,"additional_payer_notes":"APC"}]}]},{"description":"Assay of sweat sodium","code_information":[{"code":"84302","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3.64,"maximum":9.86,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4.86,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":9.86},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":6.08},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":6.08},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":6.08},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":9.38,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3.64,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8.51},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":4.86},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4.96,"additional_payer_notes":"APC"}]}]},{"description":"Sugars single quant","code_information":[{"code":"84378","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8.65,"maximum":23.33,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11.53,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":23.33},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14.41},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14.41},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14.41},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":22.25,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8.65,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20.18},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11.53},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11.76,"additional_payer_notes":"APC"}]}]},{"description":"Assay of vitamin b-1","code_information":[{"code":"84425","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":15.92,"maximum":42.97,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21.23,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":42.97},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26.54},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26.54},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26.54},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":40.97,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15.92,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37.15},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21.23},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21.65,"additional_payer_notes":"APC"}]}]},{"description":"Assay of thyroid activity","code_information":[{"code":"84442","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":11.08,"maximum":29.93,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14.78,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":29.93},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18.48},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18.48},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18.48},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":28.53,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11.08,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25.87},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14.78},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15.08,"additional_payer_notes":"APC"}]}]},{"description":"Assay of triglycerides","code_information":[{"code":"84478","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4.3,"maximum":11.62,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5.74,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":11.62},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7.18},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7.18},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7.18},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11.08,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4.3,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10.05},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5.74},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5.85,"additional_payer_notes":"APC"}]}]},{"description":"Assay of feces for trypsin","code_information":[{"code":"84490","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7.45,"maximum":19.16,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9.93,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":15.37},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12.41},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12.41},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12.41},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":19.16,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7.45,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17.38},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9.93},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10.13,"additional_payer_notes":"APC"}]}]},{"description":"Assay of urine/uric acid","code_information":[{"code":"84560","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3.81,"maximum":9.8,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5.08,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":9.62},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":6.35},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":6.35},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":6.35},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":9.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3.81,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8.89},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5.08},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5.18,"additional_payer_notes":"APC"}]}]},{"description":"Assay of vitamin a","code_information":[{"code":"84590","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8.71,"maximum":23.48,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11.61,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":23.48},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14.51},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14.51},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14.51},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":22.41,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8.71,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20.32},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11.61},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11.84,"additional_payer_notes":"APC"}]}]},{"description":"Chorionic gonadotropin assay","code_information":[{"code":"84703","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5.64,"maximum":15.22,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7.52,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":15.22},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":9.4},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":9.4},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":9.4},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":14.51,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5.64,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13.16},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7.52},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7.67,"additional_payer_notes":"APC"}]}]},{"description":"Spun microhematocrit","code_information":[{"code":"85013","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4.79,"maximum":13.51,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4.79},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8.75},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8.75},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8.75},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13.51,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5.25,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12.25},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7.14,"additional_payer_notes":"APC"}]}]},{"description":"Automated reticulocyte count","code_information":[{"code":"85045","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2.99,"maximum":8.1,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3.99,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":8.1},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4.99},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4.99},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4.99},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7.7,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2.99,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6.98},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3.99},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4.07,"additional_payer_notes":"APC"}]}]},{"description":"Clot factor ii prothrom spec","code_information":[{"code":"85210","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":9.74,"maximum":25.05,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.98,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":11.77},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16.23},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16.23},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16.23},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":25.05,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9.74,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22.72},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12.98},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.24,"additional_payer_notes":"APC"}]}]},{"description":"Clot factor ix ptc/chrstmas","code_information":[{"code":"85250","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":14.28,"maximum":38.54,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19.04,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":38.54},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23.8},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23.8},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23.8},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":36.75,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14.28,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33.32},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19.04},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19.42,"additional_payer_notes":"APC"}]}]},{"description":"Antithrombin iii activity","code_information":[{"code":"85300","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8.89,"maximum":24.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11.85,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":24.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14.81},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14.81},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14.81},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":22.87,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8.89,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20.74},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11.85},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.09,"additional_payer_notes":"APC"}]}]},{"description":"Thrombomodulin","code_information":[{"code":"85337","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":12.95,"maximum":33.33,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17.27,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":21.11},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21.59},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21.59},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21.59},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":33.33,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.95,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30.22},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17.27},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17.62,"additional_payer_notes":"APC"}]}]},{"description":"Fibrin degrade semiquant","code_information":[{"code":"85378","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7.29,"maximum":18.76,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9.72,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":14.44},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12.15},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12.15},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12.15},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":18.76,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7.29,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17.01},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9.72},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9.91,"additional_payer_notes":"APC"}]}]},{"description":"Fibrinolytic antiplasmin","code_information":[{"code":"85410","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5.78,"maximum":15.6,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7.71,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":15.6},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":9.64},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":9.64},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":9.64},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":14.88,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5.78,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13.49},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7.71},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7.86,"additional_payer_notes":"APC"}]}]},{"description":"Hemolysin acid","code_information":[{"code":"85475","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6.65,"maximum":17.96,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8.87,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":17.96},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11.09},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11.09},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11.09},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":17.12,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6.65,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15.52},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8.87},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9.05,"additional_payer_notes":"APC"}]}]},{"description":"RBC osmotic fragility","code_information":[{"code":"85555","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5.6,"maximum":14.42,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7.47,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":13.51},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":9.34},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":9.34},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":9.34},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":14.42,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5.6,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13.07},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7.47},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7.62,"additional_payer_notes":"APC"}]}]},{"description":"Russell viper venom diluted","code_information":[{"code":"85613","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7.18,"maximum":19.38,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9.58,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":19.38},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11.98},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11.98},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11.98},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":18.49,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7.18,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16.77},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9.58},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9.77,"additional_payer_notes":"APC"}]}]},{"description":"Thromboplastin time partial","code_information":[{"code":"85730","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4.51,"maximum":12.16,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6.01,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":12.16},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7.51},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7.51},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7.51},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11.6,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4.51,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10.52},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6.01},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6.13,"additional_payer_notes":"APC"}]}]},{"description":"Actin antibody each","code_information":[{"code":"86015","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":9.04,"maximum":23.26,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.05,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":17.12},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15.06},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15.06},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15.06},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":23.26,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9.04,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21.09},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11.53},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.29,"additional_payer_notes":"APC"}]}]},{"description":"Acetylcholn rcptr bndng antb","code_information":[{"code":"86041","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":13.8,"maximum":35.51,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18.4,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":27.55},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":35.51,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.8,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32.2},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18.4},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18.77,"additional_payer_notes":"APC"}]}]},{"description":"C-reactive protein","code_information":[{"code":"86140","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3.88,"maximum":10.48,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5.18,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":10.48},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":6.48},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":6.48},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":6.48},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":10.0,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3.88,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9.07},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5.18},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5.28,"additional_payer_notes":"APC"}]}]},{"description":"Cold agglutinin titer","code_information":[{"code":"86157","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6.04,"maximum":15.56,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8.06,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":11.77},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10.08},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10.08},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10.08},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":15.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6.04,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14.11},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8.06},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8.22,"additional_payer_notes":"APC"}]}]},{"description":"Dna antibody single strand","code_information":[{"code":"86226","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":9.08,"maximum":24.48,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.11,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":24.48},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15.14},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15.14},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15.14},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":23.37,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9.08,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21.19},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12.11},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.35,"additional_payer_notes":"APC"}]}]},{"description":"Immunoassay tumor qual","code_information":[{"code":"86294","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":19.18,"maximum":49.35,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25.57,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":32.22},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":31.96},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":31.96},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":31.96},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":49.35,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19.18,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":44.75},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25.57},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26.08,"additional_payer_notes":"APC"}]}]},{"description":"Immunoassay tumor other","code_information":[{"code":"86316","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":15.61,"maximum":42.11,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20.81,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":42.11},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26.01},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26.01},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26.01},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":40.16,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15.61,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36.42},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20.81},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21.23,"additional_payer_notes":"APC"}]}]},{"description":"Immunodiffusion ouchterlony","code_information":[{"code":"86331","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8.98,"maximum":24.25,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11.98,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":24.25},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14.98},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14.98},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14.98},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":23.12,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8.98,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20.97},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11.98},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.22,"additional_payer_notes":"APC"}]}]},{"description":"Leukocyte histamine release","code_information":[{"code":"86343","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":9.34,"maximum":25.22,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.46,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":25.22},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15.58},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15.58},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15.58},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":24.05,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9.34,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21.81},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12.46},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.71,"additional_payer_notes":"APC"}]}]},{"description":"T cell absolute count/ratio","code_information":[{"code":"86360","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":35.24,"maximum":95.09,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":46.98,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":95.09},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":58.73},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":58.73},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":58.73},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":90.67,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":35.24,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":82.22},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":46.98},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":47.92,"additional_payer_notes":"APC"}]}]},{"description":"Mitochondrial antibody each","code_information":[{"code":"86381","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":19.09,"maximum":49.12,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25.45,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":37.8},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":31.81},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":31.81},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":31.81},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":49.12,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19.09,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":44.54},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25.45},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25.96,"additional_payer_notes":"APC"}]}]},{"description":"Sars-cov-2 antb quantitative","code_information":[{"code":"86413","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":38.57,"maximum":99.26,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":51.43,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":74.06},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":64.29},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":64.29},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":64.29},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":99.26,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":38.57,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":90.0},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":42.13},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":52.46,"additional_payer_notes":"APC"}]}]},{"description":"Syphilis test non-trep quant","code_information":[{"code":"86593","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3.3,"maximum":8.9,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4.4,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":8.9},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5.5},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5.5},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5.5},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":8.49,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3.3,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7.7},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":4.4},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4.49,"additional_payer_notes":"APC"}]}]},{"description":"Bordetella antibody","code_information":[{"code":"86615","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":9.89,"maximum":25.46,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":11.77},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16.49},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16.49},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16.49},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":25.46,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9.89,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23.08},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13.19},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.45,"additional_payer_notes":"APC"}]}]},{"description":"Chlamydia igm antibody","code_information":[{"code":"86632","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":9.51,"maximum":24.47,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.68,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":11.77},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15.85},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15.85},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15.85},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":24.47,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9.51,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22.19},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12.68},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.93,"additional_payer_notes":"APC"}]}]},{"description":"Encephaltis east eqne anbdy","code_information":[{"code":"86652","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":9.89,"maximum":25.46,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":11.77},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16.49},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16.49},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16.49},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":25.46,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9.89,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23.08},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13.19},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.45,"additional_payer_notes":"APC"}]}]},{"description":"Francisella tularensis","code_information":[{"code":"86668","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":10.62,"maximum":27.33,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14.16,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":21.05},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17.7},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17.7},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17.7},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":27.33,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10.62,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24.78},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14.16},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14.44,"additional_payer_notes":"APC"}]}]},{"description":"Htlv/hiv confirmj antibody","code_information":[{"code":"86689","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":14.51,"maximum":39.17,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19.35,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":39.17},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24.19},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24.19},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24.19},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":37.35,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14.51,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33.86},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19.35},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19.74,"additional_payer_notes":"APC"}]}]},{"description":"Hiv-1/hiv-2 1 result antbdy","code_information":[{"code":"86703","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":10.28,"maximum":27.74,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.71,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":27.74},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17.14},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17.14},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17.14},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":26.46,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10.28,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23.99},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13.71},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.98,"additional_payer_notes":"APC"}]}]},{"description":"John cunningham antibody","code_information":[{"code":"86711","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":12.67,"maximum":32.6,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16.89,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":29.12},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21.11},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21.11},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21.11},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":32.6,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.67,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29.56},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16.89},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17.23,"additional_payer_notes":"APC"}]}]},{"description":"Mycoplasma antibody","code_information":[{"code":"86738","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":9.93,"maximum":26.8,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.24,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":26.8},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16.55},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16.55},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16.55},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":25.55,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9.93,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23.17},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13.24},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.5,"additional_payer_notes":"APC"}]}]},{"description":"Rotavirus antibody","code_information":[{"code":"86759","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":13.67,"maximum":35.18,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18.23,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":26.7},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22.79},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22.79},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22.79},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":35.18,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.67,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31.9},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18.23},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18.59,"additional_payer_notes":"APC"}]}]},{"description":"Toxoplasma antibody igm","code_information":[{"code":"86778","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":10.81,"maximum":27.81,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14.41,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":25.87},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18.01},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18.01},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18.01},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":27.81,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10.81,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25.22},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14.41},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14.7,"additional_payer_notes":"APC"}]}]},{"description":"Zika virus igm antibody","code_information":[{"code":"86794","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":12.64,"maximum":32.52,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16.85,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":30.9},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21.06},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21.06},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21.06},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":32.52,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.64,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29.49},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16.85},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17.19,"additional_payer_notes":"APC"}]}]},{"description":"Hla typing a b or c","code_information":[{"code":"86812","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":19.36,"maximum":52.22,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25.81,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":52.22},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":32.26},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":32.26},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":32.26},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":49.81,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19.36,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":45.17},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25.81},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26.33,"additional_payer_notes":"APC"}]}]},{"description":"Hla class i/ii antibody qual","code_information":[{"code":"86829","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":48.14,"maximum":123.89,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":64.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":60.05},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":80.24},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":80.24},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":80.24},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":123.89,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":48.14,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":112.33},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":64.19},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":65.47,"additional_payer_notes":"APC"}]}]},{"description":"Coombs test direct","code_information":[{"code":"86880","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5.39,"maximum":112.62,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":58.35,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":8.7},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":6.74},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":6.74},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":6.74},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":112.62,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":43.76,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9.43},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5.39},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":59.52,"additional_payer_notes":"APC"}]}]},{"description":"Bld typing serologic rh phnt","code_information":[{"code":"86906","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7.75,"maximum":71.3,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":36.94,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":15.67},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":9.69},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":9.69},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":9.69},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":71.3,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27.71,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13.56},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7.75},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":37.68,"additional_payer_notes":"APC"}]}]},{"description":"Culture othr specimn aerobic","code_information":[{"code":"87070","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6.46,"maximum":17.45,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8.62,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":17.45},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10.78},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10.78},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10.78},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":16.64,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6.46,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15.09},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8.62},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8.79,"additional_payer_notes":"APC"}]}]},{"description":"Urine culture/colony count","code_information":[{"code":"87086","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6.05,"maximum":16.33,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8.07,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":16.33},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10.09},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10.09},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10.09},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":15.58,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6.05,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14.12},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8.07},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8.23,"additional_payer_notes":"APC"}]}]},{"description":"Chlamydia culture","code_information":[{"code":"87110","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":14.7,"maximum":39.65,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19.6,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":39.65},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24.5},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24.5},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24.5},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":37.83,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14.7,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34.3},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19.6},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19.99,"additional_payer_notes":"APC"}]}]},{"description":"Culture Type Pulse Field Gel","code_information":[{"code":"87152","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5.8,"maximum":14.94,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7.74,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":10.6},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":9.68},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":9.68},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":9.68},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":14.94,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5.8,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13.55},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7.74},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7.89,"additional_payer_notes":"APC"}]}]},{"description":"Pinworm Exam","code_information":[{"code":"87172","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3.2,"maximum":8.64,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4.27,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":8.64},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5.34},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5.34},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5.34},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":8.24,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3.2,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7.47},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":4.27},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4.36,"additional_payer_notes":"APC"}]}]},{"description":"Microbe suscept macrobroth","code_information":[{"code":"87188","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4.98,"maximum":13.43,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6.64,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":13.43},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8.3},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8.3},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8.3},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":12.82,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4.98,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11.62},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6.64},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6.77,"additional_payer_notes":"APC"}]}]},{"description":"Tissue exam for fungi","code_information":[{"code":"87220","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3.2,"maximum":8.64,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4.27,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":8.64},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5.34},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5.34},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5.34},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":8.24,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3.2,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7.47},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":4.27},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4.36,"additional_payer_notes":"APC"}]}]},{"description":"Pertussis ag if","code_information":[{"code":"87265","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8.98,"maximum":24.26,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11.98,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":24.26},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14.98},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14.98},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14.98},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":23.12,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8.98,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20.97},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11.98},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.22,"additional_payer_notes":"APC"}]}]},{"description":"Influenza b ag if","code_information":[{"code":"87275","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":9.19,"maximum":24.26,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.25,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":24.26},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15.31},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15.31},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15.31},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":23.64,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9.19,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21.44},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12.25},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.5,"additional_payer_notes":"APC"}]}]},{"description":"Varicella zoster ag if","code_information":[{"code":"87290","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":10.06,"maximum":25.9,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.42,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":24.26},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16.78},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16.78},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16.78},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":25.9,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10.06,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23.49},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13.42},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.69,"additional_payer_notes":"APC"}]}]},{"description":"Cryptosporidium ag ia","code_information":[{"code":"87328","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":10.36,"maximum":26.67,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.82,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":24.26},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17.28},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17.28},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17.28},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":26.67,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10.36,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24.19},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13.82},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14.1,"additional_payer_notes":"APC"}]}]},{"description":"Hepatitis b surface ag ia","code_information":[{"code":"87340","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7.75,"maximum":20.9,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10.33,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":20.9},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12.91},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12.91},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12.91},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":19.94,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7.75,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18.08},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10.33},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10.54,"additional_payer_notes":"APC"}]}]},{"description":"Influenza a/b ag ia","code_information":[{"code":"87400","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":10.6,"maximum":27.27,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14.13,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":24.26},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17.66},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17.66},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17.66},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":27.27,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10.6,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24.73},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14.13},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14.41,"additional_payer_notes":"APC"}]}]},{"description":"Ag detect polyval ia mult","code_information":[{"code":"87451","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7.88,"maximum":20.28,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10.51,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":19.4},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13.14},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13.14},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13.14},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":20.28,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7.88,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18.39},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10.51},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10.72,"additional_payer_notes":"APC"}]}]},{"description":"Borrelia miyamotoi amp prb","code_information":[{"code":"87478","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":26.32,"maximum":67.72,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":35.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":51.96},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43.86},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43.86},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43.86},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":67.72,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26.32,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":61.41},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35.09},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":35.79,"additional_payer_notes":"APC"}]}]},{"description":"Chylmd pneum dna quant","code_information":[{"code":"87487","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":32.13,"maximum":86.68,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":42.84,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":86.68},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":53.55},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":53.55},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":53.55},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":82.68,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":32.13,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":74.97},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":42.84},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":43.7,"additional_payer_notes":"APC"}]}]},{"description":"Enterovirus probe&revrs trns","code_information":[{"code":"87498","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":26.32,"maximum":71.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":35.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":71.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43.86},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43.86},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43.86},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":67.72,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26.32,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":61.41},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35.09},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":35.79,"additional_payer_notes":"APC"}]}]},{"description":"Gardner vag dna dir probe","code_information":[{"code":"87510","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":15.04,"maximum":40.58,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20.05,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":40.58},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25.06},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25.06},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25.06},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":38.7,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15.04,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35.09},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20.05},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20.45,"additional_payer_notes":"APC"}]}]},{"description":"Hepatitis c revrs trnscrpj","code_information":[{"code":"87522","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":32.13,"maximum":86.68,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":42.84,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":86.68},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":53.55},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":53.55},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":53.55},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":82.68,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":32.13,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":74.97},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":42.84},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":43.7,"additional_payer_notes":"APC"}]}]},{"description":"Hhv-6 dna dir probe","code_information":[{"code":"87531","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":40.58,"maximum":111.94,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":58.0,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":40.58},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":72.5},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":72.5},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":72.5},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":111.94,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":43.5,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":101.5},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":58.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":59.16,"additional_payer_notes":"APC"}]}]},{"description":"Hiv-2 quant&revrse trnscripj","code_information":[{"code":"87539","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":43.96,"maximum":113.14,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":58.62,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":86.68},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":73.28},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":73.28},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":73.28},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":113.14,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":43.96,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":102.59},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":58.62},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":59.79,"additional_payer_notes":"APC"}]}]},{"description":"M.tuberculo dna amp probe","code_information":[{"code":"87556","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":31.26,"maximum":80.44,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":41.68,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":71.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":52.1},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":52.1},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":52.1},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":80.44,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":31.26,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":72.94},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":41.68},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":42.51,"additional_payer_notes":"APC"}]}]},{"description":"M.pneumon dna amp probe","code_information":[{"code":"87581","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":26.32,"maximum":71.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":35.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":71.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43.86},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43.86},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43.86},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":67.72,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26.32,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":61.41},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35.09},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":35.79,"additional_payer_notes":"APC"}]}]},{"description":"Hpv high-risk types","code_information":[{"code":"87624","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":26.32,"maximum":71.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":35.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":71.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43.86},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43.86},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43.86},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":67.72,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26.32,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":61.41},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35.09},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":35.79,"additional_payer_notes":"APC"}]}]},{"description":"Sarscov2 & inf a&b amp prb","code_information":[{"code":"87636","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":106.97,"maximum":275.28,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":142.63,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":211.87},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":178.29},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":178.29},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":178.29},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":275.28,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":106.97,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":249.6},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":142.6},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":145.48,"additional_payer_notes":"APC"}]}]},{"description":"Trichomonas vagin dir probe","code_information":[{"code":"87660","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":15.04,"maximum":40.58,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20.05,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":40.58},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25.06},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25.06},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25.06},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":38.7,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15.04,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35.09},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20.05},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20.45,"additional_payer_notes":"APC"}]}]},{"description":"Strep b assay w/optic","code_information":[{"code":"87802","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":9.55,"maximum":24.57,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.73,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":24.26},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15.91},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15.91},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15.91},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":24.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9.55,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22.28},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12.73},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.98,"additional_payer_notes":"APC"}]}]},{"description":"Sars-cov-2 covid19 w/optic","code_information":[{"code":"87811","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":31.04,"maximum":79.86,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":41.38,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":61.48},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":51.73},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":51.73},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":51.73},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":79.86,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":31.04,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":72.42},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":41.48},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":42.21,"additional_payer_notes":"APC"}]}]},{"description":"Phenotype dna hiv w/clt add","code_information":[{"code":"87904","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":19.55,"maximum":52.74,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26.07,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":52.74},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":32.59},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":32.59},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":32.59},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":50.32,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19.55,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":45.62},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26.07},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26.59,"additional_payer_notes":"APC"}]}]},{"description":"Cytopath c/v thin layer","code_information":[{"code":"88142","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":15.2,"maximum":40.98,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20.26,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":40.98},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25.33},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25.33},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25.33},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":39.1,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15.2,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35.46},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20.26},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20.67,"additional_payer_notes":"APC"}]}]},{"description":"Cytopath tbs c/v manual","code_information":[{"code":"88164","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":13.9,"maximum":35.78,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18.54,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":21.4},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22.74},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22.74},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22.74},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":35.78,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.9,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31.83},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15.12},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18.91,"additional_payer_notes":"APC"}]}]},{"description":"Tissue culture placenta","code_information":[{"code":"88235","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":100.79,"maximum":290.08,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":150.3,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":100.79},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":187.88},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":187.88},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":187.88},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":290.08,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":112.72,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":263.03},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":150.3},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":153.31,"additional_payer_notes":"APC"}]}]},{"description":"Chromosome analysis 5","code_information":[{"code":"88261","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":198.26,"maximum":510.18,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":264.34,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":357.65},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":330.43},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":330.43},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":330.43},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":510.18,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":198.26,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":462.6},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":264.34},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":269.63,"additional_payer_notes":"APC"}]}]},{"description":"Cytogenetics 10-30","code_information":[{"code":"88273","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":26.11,"maximum":67.18,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":34.81,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":65.02},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43.51},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43.51},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43.51},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":67.18,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26.11,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":60.92},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34.81},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":35.51,"additional_payer_notes":"APC"}]}]},{"description":"Protein analysis w/probe","code_information":[{"code":"88372","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":26.22,"maximum":46.03,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":46.03},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":32.78},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":32.78},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":32.78},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":45.89},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26.22}]}]},{"description":"Exam synovial fluid crystals","code_information":[{"code":"89060","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5.5,"maximum":14.47,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7.33,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":14.47},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":9.16},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":9.16},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":9.16},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":14.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5.5,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12.83},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7.33},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7.48,"additional_payer_notes":"APC"}]}]},{"description":"Semen anal strict criteria","code_information":[{"code":"89322","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":11.62,"maximum":31.37,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15.5,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":31.37},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19.38},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19.38},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19.38},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":29.92,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11.62,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27.13},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15.5},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15.81,"additional_payer_notes":"APC"}]}]},{"description":"Scr c/v cyto,thinlayer,rescr","code_information":[{"code":"G0143","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":20.29,"maximum":52.21,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27.05,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":40.98},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":33.81},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":33.81},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":33.81},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":52.21,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20.29,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":47.34},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27.05},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27.59,"additional_payer_notes":"APC"}]}]},{"description":"Fecal blood scrn immunoassay","code_information":[{"code":"G0328","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":13.54,"maximum":34.84,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18.05,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":32.2},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22.56},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22.56},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22.56},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":34.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.54,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31.59},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18.05},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18.41,"additional_payer_notes":"APC"}]}]},{"description":"Drug test def 1-7 classes","code_information":[{"code":"G0480","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":85.82,"maximum":220.85,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":114.43,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":118.75},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":143.04},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":143.04},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":143.04},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":220.85,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":85.82,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":200.25},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":114.43},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":116.72,"additional_payer_notes":"APC"}]}]},{"description":"Congo red blood test","code_information":[{"code":"P2029","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3.71,"maximum":9.55,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4.95,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":9.07},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":6.19},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":6.19},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":6.19},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":9.55,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3.71,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8.66},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":4.95},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5.05,"additional_payer_notes":"APC"}]}]},{"description":"Potassium hydroxide preps","code_information":[{"code":"Q0112","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4.37,"maximum":11.25,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5.83,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":8.64},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7.29},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7.29},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7.29},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11.25,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4.37,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10.2},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5.83},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5.95,"additional_payer_notes":"APC"}]}]},{"description":"Us leiomyomata ablate <200","code_information":[{"code":"0071T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2401.4,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3201.87,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6179.61,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2401.4,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3265.91,"additional_payer_notes":"APC"}]}]},{"description":"Perq sacral augmt unilat inj","code_information":[{"code":"0200T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":13851.98,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Njx paravert w/us lumb/sac","code_information":[{"code":"0217T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":2334.0,"payers_information":[{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Trluml perip athrc abd aorta","code_information":[{"code":"0236T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8563.85,"maximum":27583.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11418.47,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":22037.64,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8563.85,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":27583.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11646.84,"additional_payer_notes":"APC"}]}]},{"description":"Implt/rpl crtd sns dev lead","code_information":[{"code":"0267T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8657.0,"maximum":8770.0,"payers_information":[{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":8657.0}]}]},{"description":"Insj ocular telescope prosth","code_information":[{"code":"0308T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":12211.17,"maximum":44873.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16281.56,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":44873.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":44873.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":44873.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":31423.41,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12211.17,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":43285.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16607.19,"additional_payer_notes":"APC"}]}]},{"description":"Collagen crosslinking cornea","code_information":[{"code":"0402T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1763.69,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2351.59,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4538.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1763.69,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2398.62,"additional_payer_notes":"APC"}]}]},{"description":"Rmvl & rpl car modulj pls gn","code_information":[{"code":"0414T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":16501.0,"maximum":54996.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22001.33,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":54996.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":54996.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":54996.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":42462.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16501.0,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":51942.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22441.36,"additional_payer_notes":"APC"}]}]},{"description":"Insj/rplc nstim apnea stm ld","code_information":[{"code":"0426T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":26827.0,"maximum":26827.0,"payers_information":[{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0}]}]},{"description":"Impltj synth rnfcmt abdl wal","code_information":[{"code":"0437T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":2334.0,"payers_information":[{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Rmvl impltbl glucose sensor","code_information":[{"code":"0447T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":148.84,"maximum":2334.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":198.45,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":383.01,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":148.84,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":202.42,"additional_payer_notes":"APC"}]}]},{"description":"Insj/rplcmt iims implt mntr","code_information":[{"code":"0527T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6138.95,"maximum":27583.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8185.27,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":15797.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6138.95,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":27583.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8348.97,"additional_payer_notes":"APC"}]}]},{"description":"Insertion ss dfb electrode","code_information":[{"code":"0572T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6138.95,"maximum":27583.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8185.27,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":15797.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6138.95,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":27583.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8348.97,"additional_payer_notes":"APC"}]}]},{"description":"Temp fml iu vlv-pmp 1st insj","code_information":[{"code":"0596T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":517.28,"maximum":3030.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":689.7,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1331.13,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":517.28,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":703.5,"additional_payer_notes":"APC"}]}]},{"description":"Insj gtube perq mag gastrpxy","code_information":[{"code":"0647T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1423.51,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1898.01,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3663.16,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1423.51,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1935.97,"additional_payer_notes":"APC"}]}]},{"description":"Dx mammo incl cad uni","code_information":[{"code":"77065","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":114.41,"maximum":114.41,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":114.41}]},{"setting":"outpatient","billing_class":"facility","modifier_code":["TC"],"minimum":61.76,"maximum":158.92,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":82.34,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":158.92,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":61.76,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":83.99,"additional_payer_notes":"APC"}]}]},{"description":"General health panel","code_information":[{"code":"80050","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":47.28,"maximum":64.55,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":64.55},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":47.28}]}]},{"description":"Antidepressant tricyclic 1/2","code_information":[{"code":"80335","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":35.06,"maximum":35.06,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":35.06}]}]},{"description":"Drug screening fentanyl","code_information":[{"code":"80354","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":35.06,"maximum":35.06,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":35.06}]}]},{"description":"Opioids & opiate analogs 1/2","code_information":[{"code":"80362","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":35.06,"maximum":35.06,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":35.06}]}]},{"description":"Drug screening tramadol","code_information":[{"code":"80373","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":35.06,"maximum":35.06,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":35.06}]}]},{"description":"Insj biomechanical device","code_information":[{"code":"22854","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":2334.0,"payers_information":[{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Clsd tx pelvic ring fx","code_information":[{"code":"27198","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":182.99,"maximum":2334.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":243.98,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":470.88,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":182.99,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":248.86,"additional_payer_notes":"APC"}]}]},{"description":"Anabolic steroid 1 or 2","code_information":[{"code":"80327","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":35.06,"maximum":35.06,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":35.06}]}]},{"description":"Cannabinoids natural","code_information":[{"code":"80349","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":35.06,"maximum":35.06,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":35.06}]}]},{"description":"Methylenedioxyamphetamines","code_information":[{"code":"80359","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":35.06,"maximum":35.06,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":35.06}]}]},{"description":"Skeletal muscle relaxant 1/2","code_information":[{"code":"80369","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":35.06,"maximum":35.06,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":35.06}]}]},{"description":"Path clin consltj mod 21-40","code_information":[{"code":"80504","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":73.64,"maximum":325.23,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":168.51,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":73.64},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":325.23,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":126.39,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":152.32},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":171.88,"additional_payer_notes":"APC"}]}]},{"description":"Laryngoplasty laryngeal sten","code_information":[{"code":"31553","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4391.52,"maximum":16106.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5855.36,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11300.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4391.52,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5972.47,"additional_payer_notes":"APC"}]}]},{"description":"Largsc w/njx augmentation","code_information":[{"code":"31574","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1320.39,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1760.51,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3397.79,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1320.39,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1795.72,"additional_payer_notes":"APC"}]}]},{"description":"Vein access cutdown > 1 yr","code_information":[{"code":"36425","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":331.39,"maximum":2334.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":441.86,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":852.79,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":331.39,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":450.7,"additional_payer_notes":"APC"}]}]},{"description":"Collect blood from picc","code_information":[{"code":"36592","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":98.7,"maximum":2334.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":131.6,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":253.99,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":98.7,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":134.23,"additional_payer_notes":"APC"}]}]},{"description":"Intro cath dialysis circuit","code_information":[{"code":"36903","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8563.85,"maximum":27583.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11418.47,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":22037.64,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8563.85,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":27583.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11646.84,"additional_payer_notes":"APC"}]}]},{"description":"Trluml balo angiop 1st art","code_information":[{"code":"37246","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4222.18,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5629.58,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":10865.09,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4222.18,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5742.17,"additional_payer_notes":"APC"}]}]},{"description":"Cam cervix uteri drg colp","code_information":[{"code":"57465","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":2334.0,"payers_information":[{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Ndsc dcmprn 1 ntrspc lumbar","code_information":[{"code":"62380","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":18364.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"G-esoph reflx tst w/electrod","code_information":[{"code":"91035","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":637.04,"maximum":2334.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":849.39,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1639.32,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":637.04,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":866.38,"additional_payer_notes":"APC"}]}]},{"description":"Colon motility 6 hr study","code_information":[{"code":"91117","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":160.18,"maximum":2334.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":213.57,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":412.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":160.18,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":217.84,"additional_payer_notes":"APC"}]}]},{"description":"Ear and throat examination","code_information":[{"code":"92502","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":400.09,"maximum":2334.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":533.45,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1029.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":400.09,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":544.12,"additional_payer_notes":"APC"}]}]},{"description":"Prq card stent/ath/angio","code_information":[{"code":"92934","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":17314.0,"maximum":18364.0,"payers_information":[{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0}]}]},{"description":"Cardioversion electric ext","code_information":[{"code":"92960","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":490.31,"maximum":3030.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":653.75,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2959.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1261.73,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":490.31,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":3030.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":666.82,"additional_payer_notes":"APC"}]}]},{"description":"Revision of mitral valve","code_information":[{"code":"92987","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8563.85,"maximum":22037.64,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11418.47,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":22037.64,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8563.85,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11646.84,"additional_payer_notes":"APC"}]}]},{"description":"Drug admin & hemodynmic meas","code_information":[{"code":"93463","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":2334.0,"payers_information":[{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Inject suprvlv aortography","code_information":[{"code":"93567","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":2334.0,"payers_information":[{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Transcath closure of asd","code_information":[{"code":"93580","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":13599.0,"maximum":43643.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18131.99,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43643.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43643.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43643.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":34994.75,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13599.0,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":41120.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18494.63,"additional_payer_notes":"APC"}]}]},{"description":"Intra-atrial pacing","code_information":[{"code":"93610","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3579.0,"maximum":14889.41,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7714.72,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":14889.41,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5786.04,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7869.01,"additional_payer_notes":"APC"}]}]},{"description":"Electrophysiology evaluation","code_information":[{"code":"93621","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":2334.0,"payers_information":[{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Electrophysiology evaluation","code_information":[{"code":"93644","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":2334.0,"payers_information":[{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Intracardiac Ecg (Ice)","code_information":[{"code":"93662","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":2334.0,"payers_information":[{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Photodynamic tx addl 15 min","code_information":[{"code":"96571","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":2334.0,"payers_information":[{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Low cost skin substitute app","code_information":[{"code":"C5274","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":2334.0,"payers_information":[{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"U/s trtmt, not leiomyomata","code_information":[{"code":"C9734","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7529.0,"maximum":24508.8,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12698.86,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7529.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":24508.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9524.15,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12952.84,"additional_payer_notes":"APC"}]}]},{"description":"Transcath intraop microinf","code_information":[{"code":"C9759","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":2334.0,"payers_information":[{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Vitrec/mech pars, subret inj","code_information":[{"code":"C9770","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8770.0,"maximum":8770.0,"payers_information":[{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8770.0}]}]},{"description":"Insert cv cath inf & sup app","code_information":[{"code":"C9780","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5990.73,"maximum":27583.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7987.64,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":15416.14,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5990.73,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":27583.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8147.39,"additional_payer_notes":"APC"}]}]},{"description":"Wound closure by adhesive","code_information":[{"code":"G0168","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":2334.0,"payers_information":[{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Robot lin-radsurg com, first","code_information":[{"code":"G0339","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":15691.0,"maximum":16106.0,"payers_information":[{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16106.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15691.0}]}]},{"description":"Iiv3 vacc no prsv 0.5 ml im","code_information":[{"code":"90656","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":24.59,"maximum":60.85,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":24.59},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":42.47},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":42.47},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":42.47},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":41.35},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":60.85}]}]},{"description":"Riv3 vaccine no preserv im","code_information":[{"code":"90673","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":91.84,"maximum":227.3,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":91.84},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":158.63},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":158.63},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":158.63},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":154.46},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":227.3}]}]},{"description":"Hepb vacc 3 dose immunsup im","code_information":[{"code":"90740","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":180.86,"maximum":430.57,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":180.86},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":312.4},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":312.4},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":312.4},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":292.58},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":430.57}]}]},{"description":"Sarscv2 vac 10mcg trs-suc im","code_information":[{"code":"91319","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":96.56,"maximum":238.99,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":96.56},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":166.78},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":166.78},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":166.78},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":162.39},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":238.99}]}]},{"description":"Inj multihance multipack","code_information":[{"code":"A9578","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1.99,"maximum":4.87,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1.99},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3.25},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3.25},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3.25},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3.31},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":4.87}]}]},{"description":"Abatacept injection","code_information":[{"code":"J0129","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":34.39,"maximum":119.25,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":45.86,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":47.72},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":84.54},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":84.54},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":84.54},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":88.51,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":47.42},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":34.39,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":81.03},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":119.25},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":46.78,"additional_payer_notes":"APC"}]}]},{"description":"Adenosine inj 1mg","code_information":[{"code":"J0153","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":0.34,"maximum":0.87,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":0.43},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.87},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.87},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.87},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.34},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.59},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.87}]}]},{"description":"Inj, donanemab-azbt, 2 mg","code_information":[{"code":"J0175","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3.12,"maximum":11.14,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4.16,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4.6},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7.87},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7.87},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7.87},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":8.04,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":4.43},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3.12,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7.57},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11.14},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4.25,"additional_payer_notes":"APC"}]}]},{"description":"Inj velmanase alfa-tycv 1 mg","code_information":[{"code":"J0217","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":359.39,"maximum":1200.11,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":479.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":489.48},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":883.59},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":883.59},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":883.59},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":924.84,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":477.27},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":359.39,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":815.5},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1200.11},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":488.77,"additional_payer_notes":"APC"}]}]},{"description":"Inj, remdesivir, 1 mg?","code_information":[{"code":"J0248","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5.63,"maximum":17.29,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7.51,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6.99},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12.79},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12.79},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12.79},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":14.5,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6.88},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5.63,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11.75},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17.29},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7.66,"additional_payer_notes":"APC"}]}]},{"description":"Amphotericin B","code_information":[{"code":"J0285","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":54.21,"maximum":136.32,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":55.08},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":64.84},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":64.84},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":64.84},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":54.21},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":92.63},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":136.32}]}]},{"description":"Hydralazine hcl injection","code_information":[{"code":"J0360","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4.42,"maximum":11.1,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4.84},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":9.86},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":9.86},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":9.86},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":4.42},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7.55},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11.1}]}]},{"description":"Basiliximab","code_information":[{"code":"J0480","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3678.79,"maximum":12680.27,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4905.05,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5156.43},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8877.69},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8877.69},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8877.69},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":9466.74,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5042.88},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3678.79,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8616.52},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12680.27},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5003.15,"additional_payer_notes":"APC"}]}]},{"description":"Penicillin g benzathine inj","code_information":[{"code":"J0561","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":24.44,"maximum":73.01,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":32.59,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":29.68},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":55.67},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":55.67},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":55.67},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":62.9,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29.04},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":24.44,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":49.62},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":73.01},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":33.24,"additional_payer_notes":"APC"}]}]},{"description":"Inj, rimabotulinumtoxinb","code_information":[{"code":"J0587","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":9.97,"maximum":35.36,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.29,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":14.3},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25.35},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25.35},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25.35},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":25.64,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14.07},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9.97,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24.03},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35.36},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.55,"additional_payer_notes":"APC"}]}]},{"description":"C-1 esterase, berinert","code_information":[{"code":"J0597","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":59.45,"maximum":197.27,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":79.26,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":79.5},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":144.14},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":144.14},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":144.14},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":152.98,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":78.45},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":59.45,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":134.05},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":197.27},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":80.85,"additional_payer_notes":"APC"}]}]},{"description":"Leucovorin calcium injection","code_information":[{"code":"J0640","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3.86,"maximum":11.32,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3.86},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7.5},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7.5},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7.5},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":4.51},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7.7},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11.32}]}]},{"description":"Inj mepivacaine HCL/10 ml","code_information":[{"code":"J0670","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3.85,"maximum":9.67,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3.99},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7.26},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7.26},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7.26},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3.85},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6.57},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9.67}]}]},{"description":"Ceftriaxone sodium injection","code_information":[{"code":"J0696","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":0.48,"maximum":1.22,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":0.54},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.91},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.91},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.91},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.48},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.83},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1.22}]}]},{"description":"Ceftazidime and avibactam","code_information":[{"code":"J0714","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":82.33,"maximum":274.23,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":109.77,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":110.55},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":199.41},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":199.41},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":199.41},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":211.85,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":109.06},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":82.33,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":186.35},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":274.23},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":111.96,"additional_payer_notes":"APC"}]}]},{"description":"Inj, cabote rilpivir 2mg 3mg","code_information":[{"code":"J0741","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":18.5,"maximum":63.08,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":24.67,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":25.44},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":44.9},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":44.9},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":44.9},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":47.61,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25.09},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18.5,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":42.86},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":63.08},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25.16,"additional_payer_notes":"APC"}]}]},{"description":"Prochlorperazine injection","code_information":[{"code":"J0780","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3.2,"maximum":8.04,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3.21},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4.79},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4.79},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4.79},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3.2},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5.46},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8.04}]}]},{"description":"Injection, imetelstat, 1 mg","code_information":[{"code":"J0870","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":44.65,"maximum":151.02,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":59.53,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":61.06},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":108.34},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":108.34},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":108.34},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":114.89,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":44.65,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":151.02},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":60.72,"additional_payer_notes":"APC"}]}]},{"description":"Darbepoetin alfa, esrd use","code_information":[{"code":"J0882","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2.19,"maximum":8.09,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2.92,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3.21},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5.69},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5.69},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5.69},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5.64,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3.22},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2.19,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5.49},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8.09},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2.98,"additional_payer_notes":"APC"}]}]},{"description":"Deferoxamine mesylate inj","code_information":[{"code":"J0895","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":9.03,"maximum":24.34,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":9.03},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17.13},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17.13},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17.13},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9.68},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16.54},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24.34}]}]},{"description":"Inj, testosterone, azmiro","code_information":[{"code":"J1072","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":0.97,"maximum":2.52,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1.3,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2.52},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2.52},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2.52},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2.5,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":0.97,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1.32,"additional_payer_notes":"APC"}]}]},{"description":"Phenytoin sodium injection","code_information":[{"code":"J1165","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":0.51,"maximum":1.29,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":0.57},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1.25},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1.25},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1.25},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.51},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.87},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1.29}]}]},{"description":"Methadone injection","code_information":[{"code":"J1230","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":22.37,"maximum":56.25,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":23.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43.54},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43.54},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43.54},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22.37},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38.22},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":56.25}]}]},{"description":"Inj, eculizumab, 2 mg","code_information":[{"code":"J1299","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":33.15,"maximum":85.3,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":44.2,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":49.29},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":85.06},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":85.06},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":85.06},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":85.3,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":33.15,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":45.08,"additional_payer_notes":"APC"}]}]},{"description":"Elosulfase alfa, injection","code_information":[{"code":"J1322","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":239.64,"maximum":800.2,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":319.52,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":323.33},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":582.91},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":582.91},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":582.91},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":616.67,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":318.24},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":239.64,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":543.75},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":800.2},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":325.91,"additional_payer_notes":"APC"}]}]},{"description":"Ethanolamine oleate 100 mg","code_information":[{"code":"J1430","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":410.45,"maximum":1338.51,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":547.27,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":547.47},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":987.08},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":987.08},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":987.08},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1056.23,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":532.32},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":410.45,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":909.55},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1338.51},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":558.22,"additional_payer_notes":"APC"}]}]},{"description":"Inj eflapegrastim-xnst 0.1mg","code_information":[{"code":"J1449","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":23.97,"maximum":74.42,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":38.56,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":24.87},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":40.12},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":40.12},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":40.12},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":74.42,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23.97},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":28.92,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":40.96},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":60.27},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":39.33,"additional_payer_notes":"APC"}]}]},{"description":"Gamma globulin 1 CC inj","code_information":[{"code":"J1460","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":36.66,"maximum":134.54,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":48.87,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":53.78},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":92.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":92.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":92.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":94.33,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":53.51},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":36.66,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":91.43},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":134.54},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":49.85,"additional_payer_notes":"APC"}]}]},{"description":"Hizentra injection","code_information":[{"code":"J1559","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":11.16,"maximum":37.14,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14.88,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":15.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26.83},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26.83},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26.83},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":28.72,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14.76},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11.16,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25.23},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37.14},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15.18,"additional_payer_notes":"APC"}]}]},{"description":"Hepagam B intravenous, inj","code_information":[{"code":"J1573","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":49.21,"maximum":179.52,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":65.61,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":71.67},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":136.16},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":136.16},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":136.16},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":126.63,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":71.39},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":49.21,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":121.99},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":179.52},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":66.92,"additional_payer_notes":"APC"}]}]},{"description":"Inj glucagon hcl, fresenius","code_information":[{"code":"J1611","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":96.96,"maximum":304.67,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":129.28,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":165.48},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":275.28},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":275.28},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":275.28},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":249.51,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":121.16},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":96.96,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":207.03},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":304.67},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":131.87,"additional_payer_notes":"APC"}]}]},{"description":"Inj heparin, pfizer, 1000u","code_information":[{"code":"J1643","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3.23,"maximum":9.59,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3.23},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5.71},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5.71},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5.71},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3.81},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6.51},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9.59}]}]},{"description":"Ibuprofen injection","code_information":[{"code":"J1741","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2.44,"maximum":8.09,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3.25,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3.28},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5.78},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5.78},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5.78},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6.28,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3.21},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2.44,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5.49},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8.09},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3.32,"additional_payer_notes":"APC"}]}]},{"description":"Imuglucerase injection","code_information":[{"code":"J1786","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":32.49,"maximum":118.11,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":43.33,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":47.45},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":82.25},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":82.25},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":82.25},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":83.62,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":46.97},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":32.49,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":80.25},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":118.11},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":44.19,"additional_payer_notes":"APC"}]}]},{"description":"Inj. inebilizumab-cdon, 1 mg","code_information":[{"code":"J1823","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":382.99,"maximum":1318.78,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":510.65,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":532.84},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":939.42},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":939.42},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":939.42},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":985.56,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":524.47},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":382.99,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":896.14},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1318.78},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":520.87,"additional_payer_notes":"APC"}]}]},{"description":"Inj, furosemide, 1 mg","code_information":[{"code":"J1938","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":0.02,"maximum":0.04,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":0.02},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.04},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.04},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.04}]}]},{"description":"Leuprolide depot cipla 7.5mg","code_information":[{"code":"J1954","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":242.81,"maximum":1326.46,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":687.29,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":242.81},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":419.41},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":419.41},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":419.41},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1326.46,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":254.74},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":515.47,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":435.27},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":640.55},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":701.03,"additional_payer_notes":"APC"}]}]},{"description":"Lorazepam injection","code_information":[{"code":"J2060","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1.46,"maximum":3.68,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1.73},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2.5},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2.5},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2.5},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1.46},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2.5},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3.68}]}]},{"description":"Inj, micafungin (baxter)","code_information":[{"code":"J2246","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":0.7,"maximum":2.52,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":0.7},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.97},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.97},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.97},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2.52}]}]},{"description":"Inj, morphine (fresenius)","code_information":[{"code":"J2272","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4.4,"maximum":15.45,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7.3},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15.45},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15.45},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15.45},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":4.4},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7.51},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11.06}]}]},{"description":"Inj, nitroglycerin, 5 mg","code_information":[{"code":"J2305","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1.47,"maximum":3.84,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1.47},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2.7},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2.7},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2.7},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1.53},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2.61},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3.84}]}]},{"description":"Inj ocrelizumab 1mg hya-ocsq","code_information":[{"code":"J2351","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":36.04,"maximum":92.76,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":48.06,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":49.71},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":89.76},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":89.76},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":89.76},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":92.76,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":36.04,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":49.02,"additional_payer_notes":"APC"}]}]},{"description":"Injection, oritavancin","code_information":[{"code":"J2407","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":22.3,"maximum":77.67,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":29.73,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":31.38},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":54.19},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":54.19},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":54.19},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":57.37,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30.89},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22.3,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":52.78},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":77.67},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":30.32,"additional_payer_notes":"APC"}]}]},{"description":"Inj, pasireotide long acting","code_information":[{"code":"J2502","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":462.53,"maximum":1452.46,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":616.71,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":579.63},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1071.2},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1071.2},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1071.2},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1190.25,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":462.53,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1452.46},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":629.04,"additional_payer_notes":"APC"}]}]},{"description":"Phenobarbital sodium inj","code_information":[{"code":"J2560","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":32.38,"maximum":83.74,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":32.38},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":51.99},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":51.99},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":51.99},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33.3},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":56.91},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":83.74}]}]},{"description":"Fluphenazine decanoate 25 MG","code_information":[{"code":"J2680","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":9.71,"maximum":25.62,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":9.71},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14.31},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14.31},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14.31},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10.19},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17.41},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25.62}]}]},{"description":"Inj, faricimab-svoa, 0.1mg","code_information":[{"code":"J2777","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":24.29,"maximum":95.96,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":32.38,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":38.19},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":65.51},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":65.51},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":65.51},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":62.5,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38.16},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":24.29,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":65.21},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":95.96},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":33.03,"additional_payer_notes":"APC"}]}]},{"description":"Rho d immune globulin 50 mcg","code_information":[{"code":"J2788","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":25.98,"maximum":66.86,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":25.98},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":52.93},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":52.93},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":52.93},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26.59},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":45.44},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":66.86}]}]},{"description":"Methocarbamol injection","code_information":[{"code":"J2800","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7.0,"maximum":17.89,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":9.09},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":9.09},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":9.09},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7.11},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12.15},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17.89}]}]},{"description":"Inj, methylpred sod succ 5mg","code_information":[{"code":"J2919","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":0.28,"maximum":0.74,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":0.28},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.49},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.49},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.49},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.29},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.5},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.74}]}]},{"description":"Telavancin injection","code_information":[{"code":"J3095","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5.61,"maximum":20.15,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7.48,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7.8},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14.19},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14.19},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14.19},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":14.44,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8.01},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5.61,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13.69},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20.15},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7.63,"additional_payer_notes":"APC"}]}]},{"description":"Inj. teprotumumab-trbw 10 mg","code_information":[{"code":"J3241","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":284.92,"maximum":944.99,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":379.9,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":387.82},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":682.27},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":682.27},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":682.27},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":733.21,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":375.82},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":284.92,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":642.14},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":944.99},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":387.5,"additional_payer_notes":"APC"}]}]},{"description":"Inj, toripalimab-tpzi, 1 mg","code_information":[{"code":"J3263","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":30.67,"maximum":107.05,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":40.89,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":43.01},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":75.05},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":75.05},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":75.05},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":78.92,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":42.57},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":30.67,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":72.74},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":107.05},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":41.71,"additional_payer_notes":"APC"}]}]},{"description":"Ustekinumab, iv inject, 1 mg","code_information":[{"code":"J3358","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8.52,"maximum":34.73,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11.36,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":14.09},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25.25},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25.25},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25.25},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":21.92,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13.81},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8.52,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23.61},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34.73},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11.58,"additional_payer_notes":"APC"}]}]},{"description":"Vyjuvek 5x10^9pfu/ml, 0.1 ml","code_information":[{"code":"J3401","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":774.33,"maximum":2768.19,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1032.44,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1118.34},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1970.52},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1970.52},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1970.52},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1992.6,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1100.9},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":774.33,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1881.04},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2768.19},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1053.09,"additional_payer_notes":"APC"}]}]},{"description":"Hyaluronidase injection","code_information":[{"code":"J3470","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":32.56,"maximum":81.87,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":35.39},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":59.95},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":59.95},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":59.95},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32.56},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":55.63},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":81.87}]}]},{"description":"Normal saline solution infus","code_information":[{"code":"J7030","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2.71,"maximum":6.81,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2.72},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4.33},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4.33},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4.33},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2.71},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":4.63},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6.81}]}]},{"description":"Inj, adzynma, 10 iu","code_information":[{"code":"J7171","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":27.16,"maximum":94.12,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":36.21,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":37.97},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":67.61},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":67.61},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":67.61},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":69.89,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37.43},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27.16,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":63.95},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":94.12},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":36.94,"additional_payer_notes":"APC"}]}]},{"description":"Factor viii recomb novoeight","code_information":[{"code":"J7182","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1.08,"maximum":3.89,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1.44,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1.54},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2.88},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2.88},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2.88},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2.78,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1.54},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1.08,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2.65},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3.89},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1.47,"additional_payer_notes":"APC"}]}]},{"description":"Factor viii recombinant nos","code_information":[{"code":"J7192","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1.18,"maximum":4.19,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1.58,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1.72},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2.92},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2.92},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2.92},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3.05,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1.67},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1.18,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2.85},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":4.19},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1.61,"additional_payer_notes":"APC"}]}]},{"description":"Factor ix idelvion inj","code_information":[{"code":"J7202","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4.13,"maximum":14.19,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5.51,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5.7},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10.15},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10.15},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10.15},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":10.63,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5.64},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4.13,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9.64},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14.19},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5.62,"additional_payer_notes":"APC"}]}]},{"description":"Inj, kovaltry, 1 i.u.","code_information":[{"code":"J7211","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1.2,"maximum":4.03,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1.6,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1.64},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3.08,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1.61},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1.2,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2.74},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":4.03},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1.63,"additional_payer_notes":"APC"}]}]},{"description":"Inj., yutiq, 0.01 mg","code_information":[{"code":"J7314","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":397.42,"maximum":1431.74,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":529.89,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":577.03},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1011.91},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1011.91},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1011.91},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1022.69,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":569.4},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":397.42,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":972.9},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1431.74},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":540.49,"additional_payer_notes":"APC"}]}]},{"description":"Gel-one","code_information":[{"code":"J7326","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":400.19,"maximum":1433.07,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":533.59,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":592.33},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":995.63},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":995.63},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":995.63},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1029.83,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":569.92},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":400.19,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":973.8},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1433.07},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":544.26,"additional_payer_notes":"APC"}]}]},{"description":"Aminolevulinic acid, 10% gel","code_information":[{"code":"J7345","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1.39,"maximum":4.69,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1.85,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1.96},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3.44},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3.44},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3.44},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3.57,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1.86},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1.39,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3.18},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":4.69},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1.88,"additional_payer_notes":"APC"}]}]},{"description":"Lymphocyte immune globulin","code_information":[{"code":"J7504","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4161.72,"maximum":11858.47,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5548.96,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4813.92},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":9524.91},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":9524.91},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":9524.91},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":10709.5,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":4716.06},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4161.72,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8058.1},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11858.47},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5659.94,"additional_payer_notes":"APC"}]}]},{"description":"Cyclosporin parenteral 250mg","code_information":[{"code":"J7516","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":77.26,"maximum":194.27,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":78.54},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":138.11},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":138.11},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":138.11},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":77.26},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":132.02},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":194.27}]}]},{"description":"Ensifentrine inh 3 mg","code_information":[{"code":"J7601","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":57.33,"maximum":160.63,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":57.33},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":99.02},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":99.02},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":99.02},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":160.63}]}]},{"description":"Albuterol ipratrop non-comp","code_information":[{"code":"J7620","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":0.2,"maximum":0.51,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":0.21},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.38},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.38},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.38},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.2},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.35},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.51}]}]},{"description":"Treprostinil, non-comp unit","code_information":[{"code":"J7686","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":823.03,"maximum":2069.51,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":836.44},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1520.29},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1520.29},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1520.29},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":823.03},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1406.28},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2069.51}]}]},{"description":"Oral methotrexate (xatmep)","code_information":[{"code":"J8612","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":17.19,"maximum":56.38,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22.92,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43.05},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43.05},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43.05},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":44.23,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17.19,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":56.38},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23.37,"additional_payer_notes":"APC"}]}]},{"description":"Inj, atezolizumab,10 mg","code_information":[{"code":"J9022","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":72.41,"maximum":240.17,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":96.55,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":98.33},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":172.94},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":172.94},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":172.94},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":186.33,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":95.52},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":72.41,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":163.21},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":240.17},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":98.48,"additional_payer_notes":"APC"}]}]},{"description":"Bcg live intravesical 1mg","code_information":[{"code":"J9030","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2.53,"maximum":8.17,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3.38,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3.45},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5.93},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5.93},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5.93},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6.52,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3.25},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2.53,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5.55},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8.17},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3.44,"additional_payer_notes":"APC"}]}]},{"description":"Bortezomib injection","code_information":[{"code":"J9041","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2.4,"maximum":6.04,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2.75},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3.02},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3.02},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3.02},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2.4},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":4.11},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6.04}]}]},{"description":"Inj, bendamustine, 1 mg","code_information":[{"code":"J9056","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":22.43,"maximum":78.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":29.91,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":29.96},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":53.31},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":53.31},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":53.31},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":57.73,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31.02},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22.43,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":53.0},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":78.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":30.51,"additional_payer_notes":"APC"}]}]},{"description":"Inj, cyclophosphamd, sandoz","code_information":[{"code":"J9074","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2.58,"maximum":11.85,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3.44,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4.77},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6.64,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":4.71},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2.58,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8.05},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11.85},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3.51,"additional_payer_notes":"APC"}]}]},{"description":"Daratumumab, hyaluronidase","code_information":[{"code":"J9144","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":42.79,"maximum":139.9,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":57.05,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":58.29},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":103.87},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":103.87},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":103.87},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":110.11,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":55.63},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":42.79,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":95.07},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":139.9},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":58.19,"additional_payer_notes":"APC"}]}]},{"description":"Injection, elotuzumab, 1mg","code_information":[{"code":"J9176","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6.14,"maximum":21.02,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8.19,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":8.5},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14.97},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14.97},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14.97},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":15.8,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8.36},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6.14,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14.28},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21.02},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8.35,"additional_payer_notes":"APC"}]}]},{"description":"Floxuridine injection","code_information":[{"code":"J9200","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3297.37,"maximum":10861.8,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4396.49,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4387.16},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7838.55},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7838.55},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7838.55},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":8485.23,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":4319.69},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3297.37,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7380.83},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10861.8},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4484.42,"additional_payer_notes":"APC"}]}]},{"description":"Ifosfamide injection","code_information":[{"code":"J9208","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":27.08,"maximum":68.26,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":27.08},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":44.64},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":44.64},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":44.64},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27.14},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":46.38},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":68.26}]}]},{"description":"Ipilimumab injection","code_information":[{"code":"J9228","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":142.82,"maximum":490.18,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":190.43,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":198.24},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":348.49},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":348.49},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":348.49},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":367.53,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":194.95},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":142.82,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":333.09},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":490.18},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":194.24,"additional_payer_notes":"APC"}]}]},{"description":"Paclitaxel protein bound","code_information":[{"code":"J9264","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4.94,"maximum":36.86,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6.59,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":14.37},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23.03},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23.03},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23.03},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":12.71,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14.66},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4.94,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25.05},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36.86},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6.72,"additional_payer_notes":"APC"}]}]},{"description":"Inj, tebentafusp-tebn, 1 mcg","code_information":[{"code":"J9274","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":171.0,"maximum":584.68,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":228.01,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":236.24},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":412.47},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":412.47},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":412.47},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":440.05,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":232.52},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":171.0,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":397.31},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":584.68},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":232.57,"additional_payer_notes":"APC"}]}]},{"description":"Injection, necitumumab, 1 mg","code_information":[{"code":"J9295","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4.3,"maximum":15.59,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5.73,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6.3},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10.89},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10.89},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10.89},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11.06,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6.2},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4.3,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10.6},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15.59},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5.85,"additional_payer_notes":"APC"}]}]},{"description":"Pemetrexed injection","code_information":[{"code":"J9305","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4.15,"maximum":14.36,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6.95,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4.15},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7.09},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7.09},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7.09},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13.42,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5.71},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5.21,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9.75},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14.36},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7.09,"additional_payer_notes":"APC"}]}]},{"description":"Pertuzu, trastuzu, 10 mg","code_information":[{"code":"J9316","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":44.92,"maximum":173.91,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":59.9,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":69.29},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":120.44},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":120.44},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":120.44},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":115.6,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":69.16},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":44.92,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":118.18},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":173.91},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":61.09,"additional_payer_notes":"APC"}]}]},{"description":"Temozolomide injection","code_information":[{"code":"J9328","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7.81,"maximum":28.35,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10.41,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":11.45},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19.75},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19.75},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19.75},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":20.09,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11.27},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7.81,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19.26},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28.35},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10.62,"additional_payer_notes":"APC"}]}]},{"description":"Inj, retifanlimab-dlwr, 1 mg","code_information":[{"code":"J9345","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":23.24,"maximum":79.66,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":30.98,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":32.71},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":56.97},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":56.97},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":56.97},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":59.79,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31.68},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23.24,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":54.13},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":79.66},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":31.6,"additional_payer_notes":"APC"}]}]},{"description":"Inj, ado-trastuzumab emt 1mg","code_information":[{"code":"J9354","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":32.72,"maximum":111.54,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":43.63,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":45.22},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":79.52},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":79.52},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":79.52},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":84.2,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":44.35},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":32.72,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":75.79},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":111.54},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":44.5,"additional_payer_notes":"APC"}]}]},{"description":"Insj biomechanical device","code_information":[{"code":"22859","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":2334.0,"payers_information":[{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Insj stablj dev w/o dcmprn","code_information":[{"code":"22870","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":2334.0,"payers_information":[{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Inj teclistamab cqyv 0.5 mg","code_information":[{"code":"J9380","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":26.49,"maximum":88.62,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":35.32,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":35.66},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":63.21},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":63.21},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":63.21},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":68.17,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35.24},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26.49,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":60.22},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":88.62},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":36.03,"additional_payer_notes":"APC"}]}]},{"description":"Albumin (human), 25%, 20 ml","code_information":[{"code":"P9046","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":16.0,"maximum":57.8,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21.33,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":23.35},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":40.34},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":40.34},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":40.34},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":41.17,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16.0,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":39.28},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":57.8},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21.76,"additional_payer_notes":"APC"}]}]},{"description":"Axicabtagene ciloleucel car+","code_information":[{"code":"Q2041","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":421875.67,"maximum":1332710.45,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":562500.89,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":553124.8},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1012845.3},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1012845.3},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1012845.3},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1085626.72,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":421875.67,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":905606.73},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1332710.45},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":573750.91,"additional_payer_notes":"APC"}]}]},{"description":"Afamitresgene autoleucel","code_information":[{"code":"Q2057","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":610475.53,"maximum":1570957.03,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":813967.38,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1464178.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1464178.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1464178.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1570957.03,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":610475.53,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":830246.72,"additional_payer_notes":"APC"}]}]},{"description":"Integra matrix","code_information":[{"code":"Q4108","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":55.53,"maximum":237.56,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":123.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":55.53},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":93.32},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":93.32},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":93.32},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":237.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":92.32,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":82.95},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":122.08},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":125.55,"additional_payer_notes":"APC"}]}]},{"description":"Oasis tri-layer wound matrix","code_information":[{"code":"Q4124","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4.71,"maximum":237.56,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":123.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":10.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4.71},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4.71},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4.71},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":237.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":92.32,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18.91},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27.82},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":125.55,"additional_payer_notes":"APC"}]}]},{"description":"Biodfence 1cm","code_information":[{"code":"Q4140","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":92.32,"maximum":467.76,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":123.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":185.81},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":313.19},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":313.19},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":313.19},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":237.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":92.32,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":317.85},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":467.76},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":125.55,"additional_payer_notes":"APC"}]}]},{"description":"Dermavest, plurivest sq cm","code_information":[{"code":"Q4153","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":92.32,"maximum":633.55,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":123.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":140.89},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":206.34},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":206.34},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":206.34},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":237.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":92.32,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":430.51},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":633.55},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":125.55,"additional_payer_notes":"APC"}]}]},{"description":"Amnio bio and woundex sq cm","code_information":[{"code":"Q4163","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":92.32,"maximum":495.99,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":123.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":200.4},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":346.14},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":346.14},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":346.14},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":237.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":92.32,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":337.03},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":495.99},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":125.55,"additional_payer_notes":"APC"}]}]},{"description":"Floweramniopatch, per sq cm","code_information":[{"code":"Q4178","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":92.32,"maximum":237.56,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":123.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":101.23},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":176.91},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":176.91},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":176.91},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":237.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":92.32,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":161.28},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":237.35},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":125.55,"additional_payer_notes":"APC"}]}]},{"description":"Coll-e-derm 1 sq cm","code_information":[{"code":"Q4193","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":92.32,"maximum":6373.41,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":123.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1769.1},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3255.05},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3255.05},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3255.05},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":237.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":92.32,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6373.41},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":125.55,"additional_payer_notes":"APC"}]}]},{"description":"Xwrap 1 sq cm","code_information":[{"code":"Q4204","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":92.32,"maximum":9314.68,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":123.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3221.92},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7172.07},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7172.07},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7172.07},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":237.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":92.32,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9314.68},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":125.55,"additional_payer_notes":"APC"}]}]},{"description":"Corplex, per sq cm","code_information":[{"code":"Q4232","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":92.32,"maximum":721.84,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":123.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":227.13},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":247.21},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":247.21},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":247.21},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":237.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":92.32,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":490.51},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":721.84},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":125.55,"additional_payer_notes":"APC"}]}]},{"description":"AmnioAMP-MP per sq cm","code_information":[{"code":"Q4250","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":92.32,"maximum":7773.78,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":123.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3149.44},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5513.14},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5513.14},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5513.14},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":237.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":92.32,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7773.78},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":125.55,"additional_payer_notes":"APC"}]}]},{"description":"Surgraft tl, per sq cm","code_information":[{"code":"Q4263","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":92.32,"maximum":3254.7,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":123.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1884.3},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3254.7},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3254.7},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3254.7},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":237.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":92.32,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2492.92},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":125.55,"additional_payer_notes":"APC"}]}]},{"description":"Esano aca, per sq cm","code_information":[{"code":"Q4275","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":92.32,"maximum":7003.95,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":123.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2944.15},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5083.41},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5083.41},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5083.41},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":237.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":92.32,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7003.95},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":125.55,"additional_payer_notes":"APC"}]}]},{"description":"Revoshield+ amnio, per sq cm","code_information":[{"code":"Q4289","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":92.32,"maximum":5062.5,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":123.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1762.45},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2789.4},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2789.4},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2789.4},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":237.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":92.32,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3440.08},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5062.5},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":125.55,"additional_payer_notes":"APC"}]}]},{"description":"Amnicore pro+, per sq cm","code_information":[{"code":"Q4299","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":92.32,"maximum":5427.73,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":123.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2856.7},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5427.73},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5427.73},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5427.73},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":237.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":92.32,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":125.55,"additional_payer_notes":"APC"}]}]},{"description":"Dermabind fm, per sq cm","code_information":[{"code":"Q4313","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":92.32,"maximum":9437.24,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":123.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3670.95},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":6689.31},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":6689.31},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":6689.31},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":237.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":92.32,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9437.24},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":125.55,"additional_payer_notes":"APC"}]}]},{"description":"Axolotl dualgraft, per sq cm","code_information":[{"code":"Q4332","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":92.32,"maximum":5531.99,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":123.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1865.79},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3198.59},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3198.59},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3198.59},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":237.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":92.32,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5531.99},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":125.55,"additional_payer_notes":"APC"}]}]},{"description":"Amniocore sl, per sq cm","code_information":[{"code":"Q4367","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":92.32,"maximum":1007.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":123.09,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1007.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1007.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1007.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":237.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":92.32,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":125.55,"additional_payer_notes":"APC"}]}]},{"description":"Nivestym","code_information":[{"code":"Q5110","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":0.24,"maximum":0.79,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":0.32,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":0.32},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.54},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.54},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.54},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":0.62,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":0.24,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.54},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.79},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":0.33,"additional_payer_notes":"APC"}]}]},{"description":"Inj., zirabev, 10 mg","code_information":[{"code":"Q5118","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":19.42,"maximum":62.62,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25.89,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":29.63},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":45.47},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":45.47},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":45.47},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":49.97,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19.42,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":42.55},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":62.62},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26.41,"additional_payer_notes":"APC"}]}]},{"description":"Inj alymsys 10 mg","code_information":[{"code":"Q5126","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":50.66,"maximum":158.53,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":79.94,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":50.66},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":80.94},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":80.94},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":80.94},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":154.29,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":59.96,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":107.73},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":158.53},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":81.54,"additional_payer_notes":"APC"}]}]},{"description":"Inj, aflibercept-ayyh, 1 mg","code_information":[{"code":"Q5147","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":602.44,"maximum":1651.26,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":803.26,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":875.45},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1651.26},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1651.26},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1651.26},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1550.28,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":602.44,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":819.32,"additional_payer_notes":"APC"}]}]},{"description":"LOCM 200-299mg/ml iodine,1ml","code_information":[{"code":"Q9966","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":0.45,"maximum":1.12,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":0.45},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.85},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.85},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.85},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.76},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1.12}]}]},{"description":"RBC antibody elution","code_information":[{"code":"86860","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":43.19,"maximum":325.23,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":168.51,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":43.19},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":325.23,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":126.39,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":143.5},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":171.88,"additional_payer_notes":"APC"}]}]},{"description":"Compatibility test incubate","code_information":[{"code":"86921","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":43.19,"maximum":325.23,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":168.51,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":43.19},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":325.23,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":126.39,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":143.5},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":171.88,"additional_payer_notes":"APC"}]}]},{"description":"Rbc serum pretx incubj drugs","code_information":[{"code":"86975","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":43.19,"maximum":852.79,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":441.86,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":43.19},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":852.79,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":331.39,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":109.03},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":450.7,"additional_payer_notes":"APC"}]}]},{"description":"Blood smear interpretation","code_information":[{"code":"85060","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":25.26,"maximum":36.24,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":36.24},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25.26}]}]},{"description":"Compatibility test spin","code_information":[{"code":"86920","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":48.28,"maximum":325.23,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":168.51,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":48.28},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":325.23,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":126.39,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":143.5},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":171.88,"additional_payer_notes":"APC"}]}]},{"description":"Rbc pretx incubatj w/density","code_information":[{"code":"86972","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":55.91,"maximum":325.23,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":168.51,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":55.91},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":325.23,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":126.39,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":143.5},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":171.88,"additional_payer_notes":"APC"}]}]},{"description":"Autopsy (necropsy) gross","code_information":[{"code":"88000","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":207.15,"maximum":329.36,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":329.36},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":207.15}]}]},{"description":"Autopsy (necropsy) complete","code_information":[{"code":"88027","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":368.47,"maximum":585.52,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":585.52},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":368.47}]}]},{"description":"Cytopath fl nongyn filter","code_information":[{"code":"88106","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":21.46,"maximum":78.06,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":28.61,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":78.06},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":55.21,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21.46,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22.99},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":29.18,"additional_payer_notes":"APC"}]}]},{"description":"Cytopath c/v interpret","code_information":[{"code":"88141","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":26.35,"maximum":46.84,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":46.84},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26.35}]}]},{"description":"Cytp dx eval fna 1st ea site","code_information":[{"code":"88172","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":28.26,"maximum":325.23,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":168.51,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":28.26},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":325.23,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":126.39,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":143.5},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":171.88,"additional_payer_notes":"APC"}]}]},{"description":"Flowcytometry/read 2-8","code_information":[{"code":"88187","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":39.34,"maximum":105.5,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":105.5},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":39.34}]}]},{"description":"Tissue exam by pathologist","code_information":[{"code":"88305","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":38.66,"maximum":99.48,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":51.54,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":48.59},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":99.48,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":38.66,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":49.47},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":52.57,"additional_payer_notes":"APC"}]}]},{"description":"Microslide consultation","code_information":[{"code":"88321","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":27.71,"maximum":126.77,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":36.94,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":126.77},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":71.3,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27.71,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33.43},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":37.68,"additional_payer_notes":"APC"}]}]},{"description":"Immunohisto antb addl slide","code_information":[{"code":"88341","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":64.6,"maximum":88.96,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":88.96},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":64.6}]}]},{"description":"Analysis tumor","code_information":[{"code":"88358","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":56.2,"maximum":325.23,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":168.51,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":56.2},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":325.23,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":126.39,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":143.5},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":171.88,"additional_payer_notes":"APC"}]}]},{"description":"Insitu hybridization auto","code_information":[{"code":"88367","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":101.44,"maximum":684.27,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":354.54,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":101.44},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":684.27,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":265.91,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":283.41},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":361.63,"additional_payer_notes":"APC"}]}]},{"description":"M/phmtrc alys ishquant/semiq","code_information":[{"code":"88377","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":126.39,"maximum":490.07,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":168.51,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":490.07},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":325.23,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":126.39,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":143.5},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":171.88,"additional_payer_notes":"APC"}]}]},{"description":"Bone marrow interpretation","code_information":[{"code":"85097","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":73.38,"maximum":1538.03,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":796.91,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":73.38},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1538.03,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":597.68,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":628.2},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":812.84,"additional_payer_notes":"APC"}]}]},{"description":"Assay for phencyclidine","code_information":[{"code":"83992","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":29.72,"maximum":43.31,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":29.72},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":43.31}]}]},{"description":"Autopsy (necropsy) complete","code_information":[{"code":"88025","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":345.38,"maximum":548.93,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":548.93},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":345.38}]}]},{"description":"Cytopath fl nongyn smears","code_information":[{"code":"88104","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":27.71,"maximum":71.3,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":36.94,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":65.86},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":71.3,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27.71,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33.43},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":37.68,"additional_payer_notes":"APC"}]}]},{"description":"Flowcytometry/tc add-on","code_information":[{"code":"88185","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":22.38,"maximum":65.57,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":65.57},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22.38}]}]},{"description":"Tissue exam by pathologist","code_information":[{"code":"88304","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":38.66,"maximum":99.48,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":51.54,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":48.59},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":99.48,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":38.66,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":49.47},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":52.57,"additional_payer_notes":"APC"}]}]},{"description":"Enzyme histochemistry","code_information":[{"code":"88319","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":86.7,"maximum":1538.03,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":796.91,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":86.7},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1538.03,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":597.68,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":628.2},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":812.84,"additional_payer_notes":"APC"}]}]},{"description":"Intraop cyto path consult 2","code_information":[{"code":"88334","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":18.04,"maximum":30.8,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":30.8},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18.04}]}]},{"description":"Analysis nerve","code_information":[{"code":"88356","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":38.66,"maximum":118.33,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":51.54,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":118.33},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":99.48,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":38.66,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":49.47},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":52.57,"additional_payer_notes":"APC"}]}]},{"description":"Insitu hybridization (fish)","code_information":[{"code":"88366","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":126.39,"maximum":325.23,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":168.51,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":280.86},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":325.23,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":126.39,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":283.41},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":171.88,"additional_payer_notes":"APC"}]}]},{"description":"Optical endomicroscpy interp","code_information":[{"code":"88375","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":51.25,"maximum":72.31,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":72.31},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":51.25}]}]},{"description":"Phys blood bank serv authrj","code_information":[{"code":"86079","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":38.66,"maximum":99.48,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":51.54,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":75.42},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":99.48,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":38.66,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":49.47},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":52.57,"additional_payer_notes":"APC"}]}]},{"description":"Coccidioidomycosis skin test","code_information":[{"code":"86490","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":99.92,"maximum":99.92,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":99.92}]}]},{"description":"Plasma fresh frozen","code_information":[{"code":"86927","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":27.46,"maximum":325.23,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":168.51,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":27.46},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":325.23,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":126.39,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":143.5},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":171.88,"additional_payer_notes":"APC"}]}]},{"description":"Vol reduction of blood/prod","code_information":[{"code":"86960","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":44.72,"maximum":325.23,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":168.51,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":44.72},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":325.23,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":126.39,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":143.5},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":171.88,"additional_payer_notes":"APC"}]}]},{"description":"Rbc pretreatment serum","code_information":[{"code":"86978","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":33.43,"maximum":112.62,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":58.35,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":48.28},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":112.62,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":43.76,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33.43},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":59.52,"additional_payer_notes":"APC"}]}]},{"description":"Dis site tele svcs  RHC/FQHC","code_information":[{"code":"G2025","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":91.42,"maximum":91.42,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":91.42}]}]},{"description":"Phys blood bank serv xmatch","code_information":[{"code":"86077","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":21.46,"maximum":76.45,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":28.61,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":76.45},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":55.21,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21.46,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22.99},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":29.18,"additional_payer_notes":"APC"}]}]},{"description":"Skin test candida","code_information":[{"code":"86485","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":21.46,"maximum":55.21,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":28.61,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":27.46},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":55.21,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21.46,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22.99},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":29.18,"additional_payer_notes":"APC"}]}]},{"description":"RBC antibody identification","code_information":[{"code":"86870","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":59.47,"maximum":684.27,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":354.54,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":59.47},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":684.27,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":265.91,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":283.41},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":361.63,"additional_payer_notes":"APC"}]}]},{"description":"Compatibility test antiglob","code_information":[{"code":"86922","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":51.34,"maximum":325.23,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":168.51,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":51.34},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":325.23,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":126.39,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":143.5},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":171.88,"additional_payer_notes":"APC"}]}]},{"description":"Blood product/irradiation","code_information":[{"code":"86945","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":27.71,"maximum":71.3,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":36.94,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":40.15},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":71.3,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27.71,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33.43},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":37.68,"additional_payer_notes":"APC"}]}]},{"description":"Rbc serum pretx id dilution","code_information":[{"code":"86976","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":21.46,"maximum":55.21,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":28.61,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":48.28},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":55.21,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21.46,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22.99},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":29.18,"additional_payer_notes":"APC"}]}]},{"description":"Autopsy (necropsy) gross","code_information":[{"code":"88012","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":207.15,"maximum":329.36,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":329.36},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":207.15}]}]},{"description":"Limited autopsy","code_information":[{"code":"88036","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":103.58,"maximum":164.68,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":164.68},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":103.58}]}]},{"description":"Cytp urne 3-5 probes ea spec","code_information":[{"code":"88120","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":126.39,"maximum":821.94,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":168.51,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":821.94},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":325.23,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":126.39,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":143.5},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":171.88,"additional_payer_notes":"APC"}]}]},{"description":"Cytopath smear other source","code_information":[{"code":"88162","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":38.66,"maximum":99.48,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":51.54,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":91.08},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":99.48,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":38.66,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":49.47},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":52.57,"additional_payer_notes":"APC"}]}]},{"description":"Decalcify tissue","code_information":[{"code":"88311","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":9.02,"maximum":11.99,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":11.99},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9.02}]}]},{"description":"Path consult introp","code_information":[{"code":"88329","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":33.43,"maximum":112.62,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":58.35,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":54.65},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":112.62,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":43.76,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33.43},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":59.52,"additional_payer_notes":"APC"}]}]},{"description":"Immunofluor antb 1st stain","code_information":[{"code":"88346","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":78.58,"maximum":325.23,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":168.51,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":78.58},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":325.23,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":126.39,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":283.41},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":171.88,"additional_payer_notes":"APC"}]}]},{"description":"Nerve teasing preparations","code_information":[{"code":"88362","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":210.53,"maximum":1538.03,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":796.91,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":210.53},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1538.03,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":597.68,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":628.2},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":812.84,"additional_payer_notes":"APC"}]}]},{"description":"Tiss exam molecular study","code_information":[{"code":"88387","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7.22,"maximum":13.02,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":13.02},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7.22}]}]},{"description":"Cultr oocyte/embryo <4 days","code_information":[{"code":"89250","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":126.39,"maximum":1488.18,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":168.51,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1488.18},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":325.23,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":126.39,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":143.5},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":171.88,"additional_payer_notes":"APC"}]}]},{"description":"Histoplasmosis skin test","code_information":[{"code":"86510","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8.44,"maximum":71.3,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":36.94,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":8.44},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":71.3,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27.71,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":55.01},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":37.68,"additional_payer_notes":"APC"}]}]},{"description":"Frozen blood prep","code_information":[{"code":"86930","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":126.39,"maximum":325.23,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":168.51,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":160.1},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":325.23,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":126.39,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":283.41},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":171.88,"additional_payer_notes":"APC"}]}]},{"description":"Pooling blood platelets","code_information":[{"code":"86965","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":44.72,"maximum":325.23,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":168.51,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":44.72},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":325.23,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":126.39,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":143.5},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":171.88,"additional_payer_notes":"APC"}]}]},{"description":"Split blood or products","code_information":[{"code":"86985","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":35.06,"maximum":325.23,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":168.51,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":35.06},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":325.23,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":126.39,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":143.5},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":171.88,"additional_payer_notes":"APC"}]}]},{"description":"Beta amyl a?40&a?42 lc-ms/ms","code_information":[{"code":"0346U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":139.67,"maximum":139.67,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":139.67}]}]},{"description":"Autopsy (necropsy) gross","code_information":[{"code":"88014","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":189.83,"maximum":301.91,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":301.91},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":189.83}]}]},{"description":"Limited autopsy","code_information":[{"code":"88037","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":92.03,"maximum":146.38,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":146.38},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":92.03}]}]},{"description":"Cytp urine 3-5 probes cmptr","code_information":[{"code":"88121","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":126.39,"maximum":717.97,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":168.51,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":717.97},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":325.23,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":126.39,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":283.41},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":171.88,"additional_payer_notes":"APC"}]}]},{"description":"Cytp fna eval ea addl","code_information":[{"code":"88177","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7.22,"maximum":10.68,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":10.68},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7.22}]}]},{"description":"Cyto/molecular report","code_information":[{"code":"88291","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":34.65,"maximum":46.56,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":46.56},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34.65}]}]},{"description":"Special stains group 1","code_information":[{"code":"88312","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":38.66,"maximum":99.92,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":51.54,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":99.92},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":99.48,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":38.66,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":49.47},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":52.57,"additional_payer_notes":"APC"}]}]},{"description":"Path consult intraop 1 bloc","code_information":[{"code":"88331","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":44.53,"maximum":325.23,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":168.51,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":44.53},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":325.23,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":126.39,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":143.5},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":171.88,"additional_payer_notes":"APC"}]}]},{"description":"Electron microscopy","code_information":[{"code":"88348","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":380.68,"maximum":1538.03,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":796.91,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":380.68},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1538.03,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":597.68,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":628.2},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":812.84,"additional_payer_notes":"APC"}]}]},{"description":"Xm archive tissue molec anal","code_information":[{"code":"88363","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":21.46,"maximum":55.21,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":28.61,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":28.93},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":55.21,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21.46,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22.99},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":29.18,"additional_payer_notes":"APC"}]}]},{"description":"Tiss ex molecul study add-on","code_information":[{"code":"88388","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":14.03,"maximum":14.03,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":14.03}]}]},{"description":"Cultr oocyte/embryo <4 days","code_information":[{"code":"89251","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":126.39,"maximum":1547.65,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":168.51,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1547.65},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":325.23,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":126.39,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":143.5},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":171.88,"additional_payer_notes":"APC"}]}]},{"description":"Adrenalin epinephrine inject","code_information":[{"code":"J0171","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":0.8,"maximum":2.06,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":0.8},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.83},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1.41},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2.06}]}]},{"description":"Inj, acetaminophen (b braun)","code_information":[{"code":"J0136","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":0.06,"maximum":0.13,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":0.06},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.09},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.09},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.09},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.06},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.09},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.13}]}]},{"description":"Clotting assay whole blood","code_information":[{"code":"85396","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":20.93,"maximum":30.47,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":30.47},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20.93}]}]},{"description":"Autologous blood op salvage","code_information":[{"code":"86891","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":192.13,"maximum":1538.03,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":796.91,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":192.13},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1538.03,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":597.68,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":628.2},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":812.84,"additional_payer_notes":"APC"}]}]},{"description":"Blood typing antigen system","code_information":[{"code":"86911","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":23.1,"maximum":30.49,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":30.49},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23.1}]}]},{"description":"Frozen blood freeze/thaw","code_information":[{"code":"86932","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":27.71,"maximum":136.22,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":36.94,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":136.22},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":71.3,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27.71,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33.43},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":37.68,"additional_payer_notes":"APC"}]}]},{"description":"Rbc pretx incubatj w/enzymes","code_information":[{"code":"86971","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":32.03,"maximum":325.23,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":168.51,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":32.03},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":325.23,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":126.39,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":283.41},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":171.88,"additional_payer_notes":"APC"}]}]},{"description":"Autopsy (necropsy) gross","code_information":[{"code":"88005","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":241.8,"maximum":384.25,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":384.25},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":241.8}]}]},{"description":"Autopsy (necropsy) complete","code_information":[{"code":"88028","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":207.15,"maximum":329.36,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":329.36},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":207.15}]}]},{"description":"Cytopath concentrate tech","code_information":[{"code":"88108","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":27.71,"maximum":71.3,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":36.94,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":69.94},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":71.3,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27.71,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33.43},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":37.68,"additional_payer_notes":"APC"}]}]},{"description":"Cytopath smear other source","code_information":[{"code":"88160","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":21.46,"maximum":64.87,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":28.61,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":64.87},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":55.21,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21.46,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22.99},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":29.18,"additional_payer_notes":"APC"}]}]},{"description":"Cytopath eval fna report","code_information":[{"code":"88173","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":38.66,"maximum":114.96,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":51.54,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":114.96},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":99.48,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":38.66,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":49.47},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":52.57,"additional_payer_notes":"APC"}]}]},{"description":"Flowcytometry/read 9-15","code_information":[{"code":"88188","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":66.04,"maximum":133.82,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":133.82},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":66.04}]}]},{"description":"Tissue exam by pathologist","code_information":[{"code":"88307","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":265.91,"maximum":684.27,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":354.54,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":318.25},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":684.27,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":265.91,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":283.41},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":361.63,"additional_payer_notes":"APC"}]}]},{"description":"Microslide consultation","code_information":[{"code":"88323","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":38.66,"maximum":99.48,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":51.54,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":71.99},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":99.48,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":38.66,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":49.47},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":52.57,"additional_payer_notes":"APC"}]}]},{"description":"Immunohisto antb 1st stain","code_information":[{"code":"88342","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":99.41,"maximum":325.23,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":168.51,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":99.41},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":325.23,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":126.39,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":143.5},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":171.88,"additional_payer_notes":"APC"}]}]},{"description":"Tumor immunohistochem/manual","code_information":[{"code":"88360","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":92.3,"maximum":325.23,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":168.51,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":92.3},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":325.23,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":126.39,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":143.5},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":171.88,"additional_payer_notes":"APC"}]}]},{"description":"Insitu hybridization manual","code_information":[{"code":"88368","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":104.48,"maximum":684.27,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":354.54,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":104.48},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":684.27,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":265.91,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":283.41},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":361.63,"additional_payer_notes":"APC"}]}]},{"description":"Microdissection laser","code_information":[{"code":"88380","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":80.12,"maximum":122.58,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":122.58},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":80.12}]}]},{"description":"Chct for mal hyperthermia","code_information":[{"code":"89049","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":96.64,"maximum":325.23,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":168.51,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":96.64},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":325.23,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":126.39,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":143.5},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":171.88,"additional_payer_notes":"APC"}]}]},{"description":"Sputum specimen collection","code_information":[{"code":"89220","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":23.16,"maximum":325.23,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":168.51,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":23.16},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":325.23,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":126.39,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":143.5},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":171.88,"additional_payer_notes":"APC"}]}]},{"description":"Autopsy (necropsy) complete","code_information":[{"code":"88020","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":356.93,"maximum":567.22,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":567.22},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":356.93}]}]},{"description":"Coroners autopsy (necropsy)","code_information":[{"code":"88045","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":57.74,"maximum":91.48,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":91.48},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":57.74}]}]},{"description":"Flowcytometry/ tc 1 marker","code_information":[{"code":"88184","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":108.05,"maximum":684.27,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":354.54,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":108.05},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":684.27,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":265.91,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":283.41},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":361.63,"additional_payer_notes":"APC"}]}]},{"description":"Tissue exam by pathologist","code_information":[{"code":"88302","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":22.99,"maximum":71.3,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":36.94,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":35.88},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":71.3,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27.71,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22.99},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":37.68,"additional_payer_notes":"APC"}]}]},{"description":"Histochemical stains add-on","code_information":[{"code":"88314","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":75.43,"maximum":77.57,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":77.57},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":75.43}]}]},{"description":"Intraop cyto path consult 1","code_information":[{"code":"88333","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":50.62,"maximum":1538.03,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":796.91,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":50.62},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1538.03,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":597.68,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":628.2},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":812.84,"additional_payer_notes":"APC"}]}]},{"description":"Analysis skeletal muscle","code_information":[{"code":"88355","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":105.02,"maximum":325.23,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":168.51,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":105.02},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":325.23,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":126.39,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":143.5},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":171.88,"additional_payer_notes":"APC"}]}]},{"description":"Insitu hybridization (fish)","code_information":[{"code":"88365","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":126.39,"maximum":325.23,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":168.51,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":187.86},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":325.23,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":126.39,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":143.5},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":171.88,"additional_payer_notes":"APC"}]}]},{"description":"M/phmtrc alys ishquant/semiq","code_information":[{"code":"88374","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":126.39,"maximum":425.21,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":168.51,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":425.21},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":325.23,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":126.39,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":143.5},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":171.88,"additional_payer_notes":"APC"}]}]},{"description":"Nfct ds bv&vaginitis amp prb","code_information":[{"code":"0352U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":211.2,"maximum":211.2,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":211.2}]}]},{"description":"Pt spec alg rx-onc tx option","code_information":[{"code":"0794T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":43.76,"maximum":2334.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":58.35,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":183.94},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":112.62,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":43.76,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":59.52,"additional_payer_notes":"APC"}]}]},{"description":"Ccm/bhi by rhc/fqhc 20min mo","code_information":[{"code":"G0511","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":77.48,"maximum":77.48,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":77.48}]}]},{"description":"Inj risankizumab-rzaa 1 mg","code_information":[{"code":"J2327","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":10.9,"maximum":41.05,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14.53,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":16.35},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28.2},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28.2},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28.2},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":28.04,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16.33},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10.9,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27.9},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":41.05},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14.82,"additional_payer_notes":"APC"}]}]},{"description":"Olanzapine long-acting inj","code_information":[{"code":"J2358","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3.15,"maximum":7.95,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3.21},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5.54},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5.54},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5.54},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3.15},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5.4},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7.95}]}]},{"description":"Inj, nicardipine 0.1 mg","code_information":[{"code":"J2404","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":0.08,"maximum":0.21,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":0.1},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.16},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.16},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.16},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.08},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.15},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.21}]}]},{"description":"Inj, palonosetron (avyxa)","code_information":[{"code":"J2468","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":41.42,"maximum":162.64,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":55.23,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":65.9},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":111.79},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":111.79},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":111.79},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":106.59,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":41.42,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":162.64},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":56.33,"additional_payer_notes":"APC"}]}]},{"description":"Piperacillin/tazobactam","code_information":[{"code":"J2543","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1.23,"maximum":3.1,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1.23},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2.11},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2.11},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2.11},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1.23},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2.11},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3.1}]}]},{"description":"Inj, vasopressin (baxter)","code_information":[{"code":"J2601","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1.31,"maximum":9.88,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1.75,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3.85},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5.58},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5.58},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5.58},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3.38,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3.94},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1.31,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6.72},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9.88},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1.79,"additional_payer_notes":"APC"}]}]},{"description":"Protein C concentrate","code_information":[{"code":"J2724","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2.86,"maximum":40.92,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15.07,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":16.52},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2.86},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2.86},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2.86},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":29.09,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16.28},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11.3,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27.81},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":40.92},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15.37,"additional_payer_notes":"APC"}]}]},{"description":"Rasburicase","code_information":[{"code":"J2783","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":290.59,"maximum":1007.24,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":387.45,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":407.51},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":715.31},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":715.31},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":715.31},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":747.78,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":400.57},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":290.59,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":684.44},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1007.24},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":395.2,"additional_payer_notes":"APC"}]}]},{"description":"Ropivacaine HCl injection","code_information":[{"code":"J2795","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":0.07,"maximum":0.2,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":0.07},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.12},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.12},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.12},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.08},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.13},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.2}]}]},{"description":"Injection, siltuximab","code_information":[{"code":"J2860","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":130.55,"maximum":424.63,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":174.07,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":179.71},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":307.71},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":307.71},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":307.71},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":335.95,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":168.87},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":130.55,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":288.54},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":424.63},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":177.55,"additional_payer_notes":"APC"}]}]},{"description":"Inj talquetamab-tgvs 0.25 mg","code_information":[{"code":"J3055","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":57.54,"maximum":190.49,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":76.72,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":77.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":137.55},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":137.55},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":137.55},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":148.07,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":75.76},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":57.54,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":129.44},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":190.49},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":78.26,"additional_payer_notes":"APC"}]}]},{"description":"Testosterone undecanoate 1mg","code_information":[{"code":"J3145","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1.61,"maximum":5.23,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2.15,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2.22},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3.79},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3.79},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3.79},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4.15,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2.08},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1.61,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3.55},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5.23},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2.19,"additional_payer_notes":"APC"}]}]},{"description":"Trimethobenzamide hcl inj","code_information":[{"code":"J3250","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":55.04,"maximum":138.72,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":55.04},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":101.46},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":101.46},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":101.46},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":55.16},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":94.26},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":138.72}]}]},{"description":"Inj triamcinolone ace xr 1mg","code_information":[{"code":"J3304","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":14.46,"maximum":49.01,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19.28,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":19.81},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":34.6},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":34.6},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":34.6},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":37.21,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19.49},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14.46,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33.3},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":49.01},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19.67,"additional_payer_notes":"APC"}]}]},{"description":"Injection, vedolizumab","code_information":[{"code":"J3380","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":16.22,"maximum":59.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21.62,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":23.28},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":41.92},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":41.92},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":41.92},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":41.73,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23.46},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16.22,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":40.09},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":59.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22.05,"additional_payer_notes":"APC"}]}]},{"description":"Inj, hydroxocobalamin","code_information":[{"code":"J3425","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":0.01,"maximum":0.03,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":0.01},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.02},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.02},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.02},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.01},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.02},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.03}]}]},{"description":"Zidovudine","code_information":[{"code":"J3485","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1.13,"maximum":4.11,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1.51,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1.66},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2.88},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2.88},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2.88},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2.92,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1.64},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1.13,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2.79},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":4.11},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1.54,"additional_payer_notes":"APC"}]}]},{"description":"D5w infusion","code_information":[{"code":"J7070","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3.9,"maximum":9.8,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":4.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5.78},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5.78},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5.78},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3.9},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6.66},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9.8}]}]},{"description":"Inj, levothyroxine, hikma","code_information":[{"code":"J0652","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5.56,"maximum":13.99,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5.65},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":9.76},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":9.76},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":9.76},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5.56},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9.51},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13.99}]}]},{"description":"Cefepime hcl for injection","code_information":[{"code":"J0692","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1.32,"maximum":3.38,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1.32},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2.34},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2.34},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2.34},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1.34},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2.29},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3.38}]}]},{"description":"Inj, cefepime hcl (b braun)","code_information":[{"code":"J0703","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5.33,"maximum":13.4,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5.54},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":9.64},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":9.64},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":9.64},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5.33},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9.1},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13.4}]}]},{"description":"Inj, clindamycin (baxter)","code_information":[{"code":"J0737","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2.78,"maximum":7.11,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2.78},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3.26},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3.26},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3.26},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2.82},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":4.83},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7.11}]}]},{"description":"Hiv prep, ftc/taf 200/25mg","code_information":[{"code":"J0751","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":53.57,"maximum":194.09,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":71.43,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":78.4},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":135.42},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":135.42},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":135.42},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":137.85,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":77.18},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":53.57,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":131.89},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":194.09},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":72.86,"additional_payer_notes":"APC"}]}]},{"description":"Crotalidae poly immune fab","code_information":[{"code":"J0840","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1430.18,"maximum":4845.08,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1906.91,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1931.39},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3536.15},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3536.15},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3536.15},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3680.33,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1926.86},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1430.18,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3292.33},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":4845.08},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1945.04,"additional_payer_notes":"APC"}]}]},{"description":"Inj, daptomycin (hospira)","code_information":[{"code":"J0877","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":0.05,"maximum":0.12,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":0.07},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.11},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.11},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.11},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.05},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.07},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.12}]}]},{"description":"Epoetin beta non esrd","code_information":[{"code":"J0888","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1.31,"maximum":3.3,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1.39},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2.69},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2.69},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2.69},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1.31},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2.24},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3.3}]}]},{"description":"Depo-estradiol cypionate inj","code_information":[{"code":"J1000","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":41.85,"maximum":105.22,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":46.55},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":89.13},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":89.13},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":89.13},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":41.85},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":71.5},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":105.22}]}]},{"description":"Digoxin injection","code_information":[{"code":"J1160","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5.37,"maximum":24.01,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5.37},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7.6},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7.6},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7.6},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9.55},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16.32},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24.01}]}]},{"description":"Inj ronzanolixizum-noli 1 mg","code_information":[{"code":"J9333","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":17.69,"maximum":62.12,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23.59,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":25.12},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":44.01},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":44.01},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":44.01},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":45.52,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24.7},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17.69,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":42.22},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":62.12},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":24.06,"additional_payer_notes":"APC"}]}]},{"description":"Topotecan injection","code_information":[{"code":"J9351","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1.4,"maximum":4.85,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1.4},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2.55},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2.55},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2.55},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1.93},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3.29},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":4.85}]}]},{"description":"Inj lon tesirin-lpyl 0.075mg","code_information":[{"code":"J9359","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":169.96,"maximum":577.5,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":226.61,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":233.2},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":411.81},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":411.81},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":411.81},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":437.35,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":229.67},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":169.96,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":392.42},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":577.5},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":231.14,"additional_payer_notes":"APC"}]}]},{"description":"Inj, ziv-aflibercept, 1mg","code_information":[{"code":"J9400","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6.51,"maximum":21.73,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8.67,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":9.13},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15.16},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15.16},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15.16},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":16.74,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8.64},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6.51,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14.76},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21.73},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8.85,"additional_payer_notes":"APC"}]}]},{"description":"Dronabinol 2.5mg oral","code_information":[{"code":"Q0167","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1.63,"maximum":5.03,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1.63},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3.18},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3.18},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3.18},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3.42},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5.03}]}]},{"description":"Lisocabtagene mara car pos t","code_information":[{"code":"Q2054","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":434677.96,"maximum":1406133.05,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":579570.61,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":568086.52},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1029107.75},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1029107.75},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1029107.75},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1118571.29,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":434677.96,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":955499.04},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1406133.05},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":591162.03,"additional_payer_notes":"APC"}]}]},{"description":"Inj phenylephrine hcl 20 mcg","code_information":[{"code":"J2371","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":0.01,"maximum":0.03,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":0.01},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.03}]}]},{"description":"Inj naloxone hydrochloride","code_information":[{"code":"J2310","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":9.42,"maximum":23.69,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":10.13},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9.42},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16.1},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23.69}]}]},{"description":"TB intradermal test","code_information":[{"code":"86580","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":10.98,"maximum":55.21,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":28.61,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":10.98},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":55.21,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21.46,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22.99},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":29.18,"additional_payer_notes":"APC"}]}]},{"description":"Inj., cemiplimab-rwlc, 1 mg","code_information":[{"code":"J9119","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":22.25,"maximum":76.81,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":29.67,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":31.81},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":54.52},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":54.52},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":54.52},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":57.26,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30.54},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22.25,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":52.19},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":76.81},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":30.26,"additional_payer_notes":"APC"}]}]},{"description":"Docetaxel injection","code_information":[{"code":"J9171","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":0.67,"maximum":1.98,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":0.67},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.72},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.72},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.72},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.79},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1.35},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1.98}]}]},{"description":"Fludarabine phosphate inj","code_information":[{"code":"J9185","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":65.48,"maximum":458.21,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":65.48},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":136.13},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":136.13},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":136.13},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":182.23},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":311.36},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":458.21}]}]},{"description":"Inj irinotecan liposome 1 mg","code_information":[{"code":"J9205","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":49.4,"maximum":174.83,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":65.86,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":71.81},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":123.98},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":123.98},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":123.98},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":127.11,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":69.53},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":49.4,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":118.81},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":174.83},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":67.18,"additional_payer_notes":"APC"}]}]},{"description":"Inj. lurbinectedin, 0.1 mg","code_information":[{"code":"J9223","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":161.96,"maximum":557.85,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":215.95,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":225.54},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":391.64},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":391.64},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":391.64},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":416.78,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":221.85},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":161.96,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":379.07},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":557.85},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":220.27,"additional_payer_notes":"APC"}]}]},{"description":"Methotrexate sodium inj","code_information":[{"code":"J9260","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2.84,"maximum":9.17,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2.84},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4.3},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4.3},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4.3},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3.65},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6.23},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9.17}]}]},{"description":"Inj pembrolizumab","code_information":[{"code":"J9271","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":45.48,"maximum":156.82,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":60.64,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":65.29},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":111.27},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":111.27},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":111.27},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":117.04,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":62.36},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":45.48,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":106.56},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":156.82},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":61.86,"additional_payer_notes":"APC"}]}]},{"description":"Enverse, per sq cm","code_information":[{"code":"Q4258","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":79.0,"maximum":237.56,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":123.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":79.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":156.58},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":156.58},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":156.58},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":237.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":92.32,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":135.83},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":199.88},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":125.55,"additional_payer_notes":"APC"}]}]},{"description":"HOCM 250-299mg/ml iodine,1ml","code_information":[{"code":"Q9961","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":0.32,"maximum":0.79,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":0.32},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.54},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.54},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.54},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.54},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.79}]}]},{"description":"Surgraft xt per sq cm","code_information":[{"code":"Q4269","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":92.32,"maximum":3148.2,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":123.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3148.2},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":237.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":92.32,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2453.14},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":125.55,"additional_payer_notes":"APC"}]}]},{"description":"Inj Retacrit non-esrd use","code_information":[{"code":"Q5106","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5.98,"maximum":20.34,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7.97,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7.78},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14.38},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14.38},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14.38},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":15.38,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5.98,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13.82},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20.34},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8.13,"additional_payer_notes":"APC"}]}]},{"description":"Inj truxima 10 mg","code_information":[{"code":"Q5115","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":25.92,"maximum":86.66,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":34.56,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":38.24},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":59.24},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":59.24},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":59.24},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":66.71,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25.92,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":58.89},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":86.66},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":35.25,"additional_payer_notes":"APC"}]}]},{"description":"Inj. riabni, 10 mg","code_information":[{"code":"Q5123","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":13.9,"maximum":100.14,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18.53,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":36.4},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":56.84},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":56.84},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":56.84},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":35.77,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.9,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":68.04},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":100.14},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18.9,"additional_payer_notes":"APC"}]}]},{"description":"Inj, tofidence, 1 mg","code_information":[{"code":"Q5133","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3.76,"maximum":16.34,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5.01,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6.57},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11.01},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11.01},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11.01},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":9.68,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3.76,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11.1},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16.34},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5.11,"additional_payer_notes":"APC"}]}]},{"description":"Autologous blood process","code_information":[{"code":"86890","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":126.39,"maximum":325.23,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":168.51,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":136.22},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":325.23,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":126.39,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":143.5},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":171.88,"additional_payer_notes":"APC"}]}]},{"description":"Blood typing paternity test","code_information":[{"code":"86910","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":26.71,"maximum":35.06,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":35.06},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26.71}]}]},{"description":"Frozen blood thaw","code_information":[{"code":"86931","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":119.95,"maximum":325.23,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":168.51,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":119.95},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":325.23,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":126.39,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":283.41},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":171.88,"additional_payer_notes":"APC"}]}]},{"description":"Rbc pretx incubatj w/chemicl","code_information":[{"code":"86970","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":33.43,"maximum":112.62,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":58.35,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":40.15},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":112.62,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":43.76,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33.43},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":59.52,"additional_payer_notes":"APC"}]}]},{"description":"Autopsy (necropsy) gross","code_information":[{"code":"88016","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":264.9,"maximum":420.85,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":420.85},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":264.9}]}]},{"description":"Forensic autopsy (necropsy)","code_information":[{"code":"88040","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":575.63,"maximum":914.88,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":914.88},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":575.63}]}]},{"description":"Forensic cytopathology","code_information":[{"code":"88125","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":13.51,"maximum":99.48,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":51.54,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":13.51},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":99.48,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":38.66,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":49.47},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":52.57,"additional_payer_notes":"APC"}]}]},{"description":"Cell marker study","code_information":[{"code":"88182","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":38.66,"maximum":107.12,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":51.54,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":107.12},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":99.48,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":38.66,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":49.47},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":52.57,"additional_payer_notes":"APC"}]}]},{"description":"Surgical path gross","code_information":[{"code":"88300","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":15.05,"maximum":55.21,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":28.61,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":15.05},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":55.21,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21.46,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22.99},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":29.18,"additional_payer_notes":"APC"}]}]},{"description":"Special stains group 2","code_information":[{"code":"88313","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":33.43,"maximum":253.99,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":131.6,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":80.11},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":253.99,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":98.7,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33.43},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":134.23,"additional_payer_notes":"APC"}]}]},{"description":"Path consult intraop addl","code_information":[{"code":"88332","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":23.1,"maximum":26.72,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":26.72},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23.1}]}]},{"description":"Immunofluor antb addl stain","code_information":[{"code":"88350","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":62.03,"maximum":63.88,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":62.03},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":63.88}]}]},{"description":"Insitu hybridization (fish)","code_information":[{"code":"88364","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":104.3,"maximum":141.59,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":141.59},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":104.3}]}]},{"description":"M/phmtrc alys ishquant/semiq","code_information":[{"code":"88373","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":47.28,"maximum":76.22,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":76.22},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":47.28}]}]},{"description":"Onc chemo rx cytotox csc 14","code_information":[{"code":"0564T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":50.6,"maximum":50.6,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":50.6}]}]},{"description":"Bcg vaccine intravesical","code_information":[{"code":"90586","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":172.66,"maximum":408.24,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":172.66},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":296.71},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":296.71},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":296.71},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":277.41},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":408.24}]}]},{"description":"Iiv no prsv increased ag im","code_information":[{"code":"90662","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":91.84,"maximum":227.3,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":91.84},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":158.63},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":158.63},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":158.63},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":154.46},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":227.3}]}]},{"description":"Tdap vaccine 7 yrs/> im","code_information":[{"code":"90715","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":42.98,"maximum":105.17,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":42.98},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":75.45},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":75.45},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":75.45},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":71.47},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":105.17}]}]},{"description":"Hep b vac 3ag 10mcg 3 dos im","code_information":[{"code":"90759","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":81.2,"maximum":200.97,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":81.2},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":140.25},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":140.25},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":140.25},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":136.57},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":200.97}]}]},{"description":"Inj gadoterate meglumi 0.1ml","code_information":[{"code":"A9575","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":0.13,"maximum":0.33,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":0.13},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.22},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.22},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.22},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.22},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.33}]}]},{"description":"Erythro lactobionate /500 MG","code_information":[{"code":"J1364","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":67.28,"maximum":169.17,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":72.56},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":142.6},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":142.6},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":142.6},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":67.28},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":114.96},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":169.17}]}]},{"description":"Inj filgrastim excl biosimil","code_information":[{"code":"J1442","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":0.75,"maximum":2.67,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1.01,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1.08},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1.87},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1.87},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1.87},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1.94,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1.06},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":0.75,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1.81},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2.67},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1.03,"additional_payer_notes":"APC"}]}]},{"description":"Inj, fosaprepitant (teva)","code_information":[{"code":"J1456","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":0.03,"maximum":2.15,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":0.04,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1.33},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2.15},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2.15},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2.15},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":0.07,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.48},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":0.03,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.81},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1.2},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":0.04,"additional_payer_notes":"APC"}]}]},{"description":"Inj, imm glob bivigam, 500mg","code_information":[{"code":"J1556","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":60.93,"maximum":208.63,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":81.24,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":85.03},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":146.81},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":146.81},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":146.81},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":156.8,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":82.97},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":60.93,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":141.77},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":208.63},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":82.87,"additional_payer_notes":"APC"}]}]},{"description":"Gammagard liquid injection","code_information":[{"code":"J1569","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":36.98,"maximum":126.49,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":49.3,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":49.64},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":90.81},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":90.81},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":90.81},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":95.15,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":50.3},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":36.98,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":85.95},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":126.49},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":50.29,"additional_payer_notes":"APC"}]}]},{"description":"Inj glycopyrrolate fres kabi","code_information":[{"code":"J1598","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1.83,"maximum":5.49,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1.83},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3.52},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3.52},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3.52},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2.18},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3.74},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5.49}]}]},{"description":"Haloperidol decanoate inj","code_information":[{"code":"J1631","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5.07,"maximum":15.11,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":5.07},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8.9},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8.9},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8.9},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6.01},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10.27},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15.11}]}]},{"description":"Tetanus immune globulin inj","code_information":[{"code":"J1670","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":446.26,"maximum":1557.47,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":595.02,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":633.34},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1096.39},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1096.39},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1096.39},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1148.38,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":619.39},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":446.26,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1058.33},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1557.47},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":606.92,"additional_payer_notes":"APC"}]}]},{"description":"Fiasp for insulin pump use","code_information":[{"code":"J1811","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7.34,"maximum":21.52,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7.34},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14.75},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14.75},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14.75},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8.56},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14.62},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21.52}]}]},{"description":"Lanreotide injection","code_information":[{"code":"J1930","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":28.07,"maximum":122.46,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":37.43,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":43.51},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":69.65},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":69.65},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":69.65},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":72.24,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":48.7},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":28.07,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":83.21},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":122.46},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":38.18,"additional_payer_notes":"APC"}]}]},{"description":"Inj fensolvi 0.25 mg","code_information":[{"code":"J1951","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":108.98,"maximum":371.56,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":145.31,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":147.69},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":266.81},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":266.81},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":266.81},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":280.45,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":147.77},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":108.98,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":252.49},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":371.56},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":148.22,"additional_payer_notes":"APC"}]}]},{"description":"Lincomycin injection","code_information":[{"code":"J2010","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6.86,"maximum":18.32,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6.86},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10.66},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10.66},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10.66},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7.29},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12.45},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18.32}]}]},{"description":"Inj, epinephrine (belcher)","code_information":[{"code":"J0173","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2.48,"maximum":6.48,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2.48},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2.58},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":4.4},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6.48}]}]},{"description":"Inj., aprepitant, 1 mg","code_information":[{"code":"J0185","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1.19,"maximum":4.64,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1.59,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1.88},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3.37},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3.37},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3.37},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3.07,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1.85},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1.19,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3.15},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":4.64},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1.62,"additional_payer_notes":"APC"}]}]},{"description":"Icatibant injection","code_information":[{"code":"J1744","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":137.85,"maximum":367.7,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":137.85},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":367.7}]}]},{"description":"Inj, meropenem (b. braun)","code_information":[{"code":"J2184","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2.25,"maximum":5.64,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2.3},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3.94},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3.94},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3.94},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2.25},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3.83},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5.64}]}]},{"description":"Inj milrinone lactate / 5 mg","code_information":[{"code":"J2260","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1.42,"maximum":3.56,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1.73},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2.67},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2.67},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2.67},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1.42},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2.42},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3.56}]}]},{"description":"Inj moxifloxacin (fres kabi)","code_information":[{"code":"J2281","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6.68,"maximum":16.8,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7.81},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14.75},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14.75},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14.75},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6.68},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11.41},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16.8}]}]},{"description":"Inj pemetrexed ditromethamin","code_information":[{"code":"J9323","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":11.37,"maximum":28.73,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":11.37},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19.65},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19.65},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19.65},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28.73}]}]},{"description":"Inj givosiran 0.5 mg","code_information":[{"code":"J0223","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":90.69,"maximum":314.37,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":120.92,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":128.12},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":222.66},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":222.66},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":222.66},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":233.37,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":125.02},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":90.69,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":213.62},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":314.37},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":123.33,"additional_payer_notes":"APC"}]}]},{"description":"Inj aminocaproic acid 1 gram","code_information":[{"code":"J0281","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1.43,"maximum":2.84,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1.43},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2.84},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2.84},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2.84}]}]},{"description":"Ampicillin sodium per 1.5 gm","code_information":[{"code":"J0295","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1.73,"maximum":4.47,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1.73},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2.84},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2.84},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2.84},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1.78},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3.03},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":4.47}]}]},{"description":"Atropine sulfate injection","code_information":[{"code":"J0461","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":0.11,"maximum":0.3,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":0.12},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.13},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.13},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.13},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.11},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.2},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.3}]}]},{"description":"Inj benztropine mesylate","code_information":[{"code":"J0515","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":18.28,"maximum":45.99,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":18.45},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":32.81},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":32.81},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":32.81},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18.28},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31.25},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":45.99}]}]},{"description":"Injection, burosumab-twza 1m","code_information":[{"code":"J0584","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":385.03,"maximum":1278.83,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":513.37,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":516.71},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":914.98},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":914.98},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":914.98},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":990.81,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":508.58},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":385.03,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":869.0},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1278.83},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":523.64,"additional_payer_notes":"APC"}]}]},{"description":"Busulfan injection","code_information":[{"code":"J0594","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":0.77,"maximum":3.86,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1.03,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1.61},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3.49},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3.49},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3.49},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1.99,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1.53},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":0.77,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2.63},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3.86},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1.05,"additional_payer_notes":"APC"}]}]},{"description":"Inj, vancomycin hcl (mylan)","code_information":[{"code":"J3371","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6.94,"maximum":17.51,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6.94},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6.97},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11.9},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17.51}]}]},{"description":"Allowrap ds or dry 1 sq cm","code_information":[{"code":"Q4150","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":91.04,"maximum":237.56,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":123.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":91.04},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":161.23},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":161.23},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":161.23},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":237.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":92.32,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":160.4},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":236.05},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":125.55,"additional_payer_notes":"APC"}]}]},{"description":"Affinity1 square cm","code_information":[{"code":"Q4159","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":92.32,"maximum":716.97,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":123.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":289.22},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":446.83},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":446.83},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":446.83},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":237.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":92.32,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":487.2},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":716.97},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":125.55,"additional_payer_notes":"APC"}]}]},{"description":"Inj, naloxone hcl (zimhi)","code_information":[{"code":"J2311","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1.62,"maximum":4.09,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1.65},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1.62},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2.78},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":4.09}]}]},{"description":"Vancomycin hcl injection","code_information":[{"code":"J3370","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2.01,"maximum":5.07,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2.15},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2.01},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3.44},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5.07}]}]},{"description":"Doxorubicin hcl injection","code_information":[{"code":"J9000","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3.47,"maximum":9.04,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3.47},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5.17},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5.17},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5.17},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3.6},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6.14},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9.04}]}]},{"description":"Clofarabine injection","code_information":[{"code":"J9027","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":9.15,"maximum":31.35,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16.24,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":17.61},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27.96},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27.96},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27.96},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":31.35,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9.15},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.18,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15.65},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23.03},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16.57,"additional_payer_notes":"APC"}]}]},{"description":"Inj. belrapzo/bendamustine","code_information":[{"code":"J9036","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8.7,"maximum":46.63,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11.6,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":15.62},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22.79},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22.79},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22.79},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":22.39,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18.54},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8.7,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31.69},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":46.63},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11.83,"additional_payer_notes":"APC"}]}]},{"description":"Inj, bortezomib, hospira","code_information":[{"code":"J9049","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1.56,"maximum":3.93,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1.57},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2.94},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2.94},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2.94},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1.56},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2.66},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3.93}]}]},{"description":"Inj cyclophosphamd auromedic","code_information":[{"code":"J9071","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":0.37,"maximum":1.91,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":0.49,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":0.96},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1.49},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1.49},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1.49},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":0.95,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.75},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":0.37,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1.3},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1.91},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":0.5,"additional_payer_notes":"APC"}]}]},{"description":"Interfyl, 1 mg","code_information":[{"code":"Q4171","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":13.34,"maximum":32.42,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":13.34},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20.16},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20.16},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20.16},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22.03},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32.42}]}]},{"description":"Amnioarmor 1 sq cm","code_information":[{"code":"Q4188","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":92.32,"maximum":943.73,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":123.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":542.63},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":926.41},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":926.41},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":926.41},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":237.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":92.32,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":641.28},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":943.73},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":125.55,"additional_payer_notes":"APC"}]}]},{"description":"Cygnus matrix, per sq cm","code_information":[{"code":"Q4199","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":92.32,"maximum":990.41,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":123.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":365.66},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":247.48},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":247.48},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":247.48},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":237.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":92.32,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":673.01},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":990.41},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":125.55,"additional_payer_notes":"APC"}]}]},{"description":"Amniobind, per sq cm","code_information":[{"code":"Q4225","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":92.32,"maximum":3973.63,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":123.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1525.8},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2604.39},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2604.39},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2604.39},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":237.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":92.32,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2700.17},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3973.63},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":125.55,"additional_payer_notes":"APC"}]}]},{"description":"Amnio-maxx or lite per sq cm","code_information":[{"code":"Q4239","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":92.32,"maximum":6876.24,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":123.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2584.91},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3873.16},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3873.16},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3873.16},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":237.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":92.32,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6876.24},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":125.55,"additional_payer_notes":"APC"}]}]},{"description":"Sanograft, per sq cm","code_information":[{"code":"Q4319","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":92.32,"maximum":2915.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":123.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2915.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":237.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":92.32,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2044.98},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":125.55,"additional_payer_notes":"APC"}]}]},{"description":"Complete sl per sq cm","code_information":[{"code":"Q4270","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":92.32,"maximum":6404.52,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":123.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3707.88},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":6404.52},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":6404.52},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":6404.52},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":237.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":92.32,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":125.55,"additional_payer_notes":"APC"}]}]},{"description":"Barrera slor dl per sq cm","code_information":[{"code":"Q4281","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":92.32,"maximum":2417.88,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":123.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":616.33},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1033.69},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1033.69},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1033.69},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":237.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":92.32,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1643.0},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2417.88},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":125.55,"additional_payer_notes":"APC"}]}]},{"description":"Rebound matrix, per sq cm","code_information":[{"code":"Q4296","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":92.32,"maximum":7357.07,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":123.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1623.74},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2764.77},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2764.77},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2764.77},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":237.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":92.32,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7357.07},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":125.55,"additional_payer_notes":"APC"}]}]},{"description":"Grafix plus, per sq cm","code_information":[{"code":"Q4304","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":92.32,"maximum":2504.67,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":123.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":828.81},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1165.99},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1165.99},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1165.99},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":237.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":92.32,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1701.98},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2504.67},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":125.55,"additional_payer_notes":"APC"}]}]},{"description":"Inj, cipaglucosidase, 5 mg","code_information":[{"code":"J1203","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":72.23,"maximum":243.34,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":96.3,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":98.84},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":170.61},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":170.61},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":170.61},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":185.86,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":96.77},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":72.23,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":165.35},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":243.34},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":98.23,"additional_payer_notes":"APC"}]}]},{"description":"Injection, doxercalciferol","code_information":[{"code":"J1270","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":0.41,"maximum":1.04,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":0.42},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.71},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.71},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.71},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.41},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.7},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1.04}]}]},{"description":"Inj, evinacumab-dgnb, 5mg","code_information":[{"code":"J1305","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":148.22,"maximum":507.23,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":197.63,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":204.94},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":360.53},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":360.53},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":360.53},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":381.43,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":201.72},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":148.22,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":344.67},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":507.23},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":201.59,"additional_payer_notes":"APC"}]}]},{"description":"Prtl exchange transfuse nb","code_information":[{"code":"36456","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":327.28,"maximum":2334.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":436.37,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":842.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":327.28,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":445.1,"additional_payer_notes":"APC"}]}]},{"description":"Endovenous mchnchem add-on","code_information":[{"code":"36474","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":2334.0,"payers_information":[{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Stent plmt ctr dialysis seg","code_information":[{"code":"36908","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":2334.0,"payers_information":[{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Obinutuzumab inj","code_information":[{"code":"J9301","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":63.35,"maximum":203.73,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":84.46,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":82.73},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":149.08},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":149.08},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":149.08},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":163.01,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":81.02},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":63.35,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":138.44},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":203.73},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":86.15,"additional_payer_notes":"APC"}]}]},{"description":"Inj rituximab, hyaluronidase","code_information":[{"code":"J9311","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":27.29,"maximum":99.59,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":36.39,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":41.28},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":70.23},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":70.23},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":70.23},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":70.23,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":39.6},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27.29,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":67.67},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":99.59},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":37.12,"additional_payer_notes":"APC"}]}]},{"description":"Thiotepa injection","code_information":[{"code":"J9340","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":240.1,"maximum":603.72,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":269.56},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":240.1},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":410.24},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":603.72}]}]},{"description":"Duodenal motility study","code_information":[{"code":"91022","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":276.82,"maximum":2334.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":369.09,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":712.35,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":276.82,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":376.48,"additional_payer_notes":"APC"}]}]},{"description":"Gi tract capsule endoscopy","code_information":[{"code":"91110","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":672.83,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":897.11,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1731.42,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":672.83,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":915.05,"additional_payer_notes":"APC"}]}]},{"description":"Gastroenterology procedure","code_information":[{"code":"91299","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":95.45,"maximum":2334.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":127.27,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":245.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":95.45,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":129.82,"additional_payer_notes":"APC"}]}]},{"description":"Prq card stent w/angio 1 vsl","code_information":[{"code":"92928","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8563.85,"maximum":22037.64,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11418.47,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":22037.64,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8563.85,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11646.84,"additional_payer_notes":"APC"}]}]},{"description":"Prq card revasc chronic addl","code_information":[{"code":"92944","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":17314.0,"maximum":18364.0,"payers_information":[{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18364.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17314.0}]}]},{"description":"Endoluminl ivus oct c 1st","code_information":[{"code":"92978","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":2334.0,"payers_information":[{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Inject hrt congntl art/grft","code_information":[{"code":"93564","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":2334.0,"payers_information":[{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Njx cath slct p-art angrp bi","code_information":[{"code":"93573","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":2334.0,"payers_information":[{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Perq transcath closure each","code_information":[{"code":"93592","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":2334.0,"payers_information":[{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Intra-atrial recording","code_information":[{"code":"93602","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3579.0,"maximum":14889.41,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7714.72,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":14889.41,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5786.04,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7869.01,"additional_payer_notes":"APC"}]}]},{"description":"Heart rhythm pacing","code_information":[{"code":"93618","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":903.21,"maximum":4761.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1204.28,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3579.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2324.26,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":903.21,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4761.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1228.36,"additional_payer_notes":"APC"}]}]},{"description":"Evaluation heart device","code_information":[{"code":"93640","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":2334.0,"payers_information":[{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Tx atrial fib pulm vein isol","code_information":[{"code":"93656","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":19389.9,"maximum":49896.68,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25853.2,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43643.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43643.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43643.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":49896.68,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19389.9,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":41120.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26370.26,"additional_payer_notes":"APC"}]}]},{"description":"Spin/brain pump refil & main","code_information":[{"code":"95991","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":227.71,"maximum":2334.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":303.61,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":585.96,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":227.71,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":309.68,"additional_payer_notes":"APC"}]}]},{"description":"Low cost skin substitute app","code_information":[{"code":"C5271","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":2334.0,"payers_information":[{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Fluorescence lymph map w/ICG","code_information":[{"code":"C9756","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.0,"maximum":2334.0,"payers_information":[{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1887.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Revasc lith-sten-ath tib/per","code_information":[{"code":"C9775","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":13599.0,"maximum":34994.75,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18131.99,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26827.0},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":34994.75,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13599.0,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":27583.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18494.63,"additional_payer_notes":"APC"}]}]},{"description":"Inj epinephrine (adrenalin)","code_information":[{"code":"J0169","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2.51,"maximum":2.51,"payers_information":[{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2.51},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2.51},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2.51}]}]},{"description":"Inj metoprolol tartrate 1 mg","code_information":[{"code":"J0616","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":0.25,"maximum":0.25,"payers_information":[{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.25},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.25},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.25}]}]},{"description":"Inj, iloprost, 0.1 mcg","code_information":[{"code":"J1749","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":10.85,"maximum":17.97,"payers_information":[{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10.85},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10.85},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10.85},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17.97}]}]},{"description":"Vonvendi inj 1 iu vwf:rco","code_information":[{"code":"J7179","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1.36,"maximum":5.03,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1.81,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2.01},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3.51},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3.51},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3.51},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3.5,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2.01},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1.36,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3.42},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5.03},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1.85,"additional_payer_notes":"APC"}]}]},{"description":"Factor viii recomb obizur","code_information":[{"code":"J7188","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2.43,"maximum":8.79,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3.24,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3.55},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":6.14},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":6.14},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":6.14},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6.25,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3.49},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2.43,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5.98},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8.79},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3.3,"additional_payer_notes":"APC"}]}]},{"description":"Anti-inhibitor","code_information":[{"code":"J7198","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1.84,"maximum":6.42,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2.45,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2.64},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4.66},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4.66},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4.66},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4.72,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2.56},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1.84,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":4.37},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6.42},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2.5,"additional_payer_notes":"APC"}]}]},{"description":"Inj. jivi 1 iu","code_information":[{"code":"J7208","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2.07,"maximum":6.67,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2.76,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2.7},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5.04},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5.04},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5.04},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5.32,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2.65},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2.07,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":4.53},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6.67},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2.81,"additional_payer_notes":"APC"}]}]},{"description":"Fluocinolone acetonide implt","code_information":[{"code":"J7311","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":254.1,"maximum":907.22,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":338.8,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":374.04},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":645.55},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":645.55},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":645.55},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":653.89,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":360.8},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":254.1,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":616.48},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":907.22},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":345.58,"additional_payer_notes":"APC"}]}]},{"description":"Euflexxa inj per dose","code_information":[{"code":"J7323","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":73.6,"maximum":328.55,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":98.14,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":141.58},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":217.52},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":217.52},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":217.52},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":189.4,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":130.66},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":73.6,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":223.26},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":328.55},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":100.1,"additional_payer_notes":"APC"}]}]},{"description":"Inj., triluron, 1 mg","code_information":[{"code":"J7332","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7.82,"maximum":27.47,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10.43,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":11.31},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19.31},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19.31},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19.31},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":20.13,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10.93},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7.82,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18.67},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27.47},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10.64,"additional_payer_notes":"APC"}]}]},{"description":"Azathioprine oral 50mg","code_information":[{"code":"J7500","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1.11,"maximum":4.07,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1.11},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4.07},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4.07},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4.07},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1.29},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2.2},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3.23}]}]},{"description":"Antithymocyte globuln rabbit","code_information":[{"code":"J7511","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":793.34,"maximum":2587.08,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1057.79,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1033.29},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1893.14},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1893.14},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":1893.14},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2041.54,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1028.87},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":793.34,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1757.98},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2587.08},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1078.95,"additional_payer_notes":"APC"}]}]},{"description":"Tacrolim granules oral susp","code_information":[{"code":"J7521","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1.46,"maximum":2.38,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1.46},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2.38},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2.38},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2.38}]}]},{"description":"Levalbuterol non-comp con","code_information":[{"code":"J7612","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":0.31,"maximum":0.79,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":0.31},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.57},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.57},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":0.57},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.32},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.54},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.79}]}]},{"description":"Methacholine chloride, neb","code_information":[{"code":"J7674","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1.74,"maximum":4.39,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":1.79},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3.28},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3.28},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3.28},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1.74},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2.98},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":4.39}]}]},{"description":"Etoposide oral 50 mg","code_information":[{"code":"J8560","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":66.04,"maximum":208.33,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":88.06,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":84.11},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":143.95},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":143.95},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":143.95},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":169.95,"additional_payer_notes":"APC"},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":82.85},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":66.04,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":141.56},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":208.33},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":89.82,"additional_payer_notes":"APC"}]}]},{"description":"Inj, pemetrexed (avyxa) 10mg","code_information":[{"code":"J9292","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":55.25,"maximum":258.09,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":73.67,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":158.24},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":158.24},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":158.24},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":142.18,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":55.25,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":258.09},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":75.14,"additional_payer_notes":"APC"}]}]},{"description":"Oasis burn matrix","code_information":[{"code":"Q4103","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":13.78,"maximum":237.56,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":123.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":13.78},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23.52},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23.52},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23.52},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":237.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":92.32,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23.09},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33.97},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":125.55,"additional_payer_notes":"APC"}]}]},{"description":"Matristem micromatrix","code_information":[{"code":"Q4118","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2.81,"maximum":6.91,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":2.81},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4.85},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4.85},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":4.85},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":4.7},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6.91}]}]},{"description":"Grafix prime","code_information":[{"code":"Q4133","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":92.32,"maximum":377.75,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":123.09,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":150.01},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":258.74},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":258.74},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":258.74},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":237.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":92.32,"additional_payer_notes":"APC"},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":256.69},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":377.75},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":125.55,"additional_payer_notes":"APC"}]}]},{"description":"Woundplus, per sq cm","code_information":[{"code":"Q4326","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":92.32,"maximum":5114.03,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":123.09,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2057.61},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2057.61},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":2057.61},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":237.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":92.32,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5114.03},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":125.55,"additional_payer_notes":"APC"}]}]},{"description":"Tri membrane wrap, per sq cm","code_information":[{"code":"Q4344","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":92.32,"maximum":8328.67,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":123.09,"additional_payer_notes":"APC"},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5110.01},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5110.01},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":5110.01},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":237.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":92.32,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8328.67},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":125.55,"additional_payer_notes":"APC"}]}]},{"description":"Phys blood bank serv reactj","code_information":[{"code":"86078","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":76.45,"maximum":325.23,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":168.51,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":76.45},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":325.23,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":126.39,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":143.5},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":171.88,"additional_payer_notes":"APC"}]}]},{"description":"Skin test nos antigen","code_information":[{"code":"86486","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6.91,"maximum":55.21,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":28.61,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":6.91},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":55.21,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21.46,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22.99},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":29.18,"additional_payer_notes":"APC"}]}]},{"description":"Compatibility test electric","code_information":[{"code":"86923","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":38.62,"maximum":325.23,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":168.51,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":38.62},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":325.23,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":126.39,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":143.5},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":171.88,"additional_payer_notes":"APC"}]}]},{"description":"Leukacyte transfusion","code_information":[{"code":"86950","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":104.21,"maximum":325.23,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":168.51,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":104.21},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":325.23,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":126.39,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":143.5},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":171.88,"additional_payer_notes":"APC"}]}]},{"description":"Rbc serum pretx incubj/inhib","code_information":[{"code":"86977","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":48.28,"maximum":325.23,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":168.51,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":48.28},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":325.23,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":126.39,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":143.5},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":171.88,"additional_payer_notes":"APC"}]}]},{"description":"Autopsy (necropsy) gross","code_information":[{"code":"88007","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":253.35,"maximum":402.54,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":402.54},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":253.35}]}]},{"description":"Autopsy (necropsy) complete","code_information":[{"code":"88029","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":207.15,"maximum":329.36,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":329.36},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":207.15}]}]},{"description":"Cytopath cell enhance tech","code_information":[{"code":"88112","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":38.66,"maximum":99.48,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":51.54,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":61.28},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":99.48,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":38.66,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":49.47},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":52.57,"additional_payer_notes":"APC"}]}]},{"description":"Cytopath smear other source","code_information":[{"code":"88161","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":21.46,"maximum":55.72,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":28.61,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":55.72},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":55.21,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21.46,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22.99},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":29.18,"additional_payer_notes":"APC"}]}]},{"description":"Flowcytometry/read 16 & >","code_information":[{"code":"88189","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":88.78,"maximum":165.4,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":165.4},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":88.78}]}]},{"description":"Tissue exam by pathologist","code_information":[{"code":"88309","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":451.73,"maximum":1538.03,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":796.91,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":451.73},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1538.03,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":597.68,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":628.2},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":812.84,"additional_payer_notes":"APC"}]}]},{"description":"Comprehensive review of data","code_information":[{"code":"88325","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":49.47,"maximum":325.23,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":168.51,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":199.69},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":325.23,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":126.39,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":49.47},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":171.88,"additional_payer_notes":"APC"}]}]},{"description":"Immunohisto antibody slide","code_information":[{"code":"88344","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":188.36,"maximum":684.27,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":354.54,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":188.36},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":684.27,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":265.91,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":283.41},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":361.63,"additional_payer_notes":"APC"}]}]},{"description":"Tumor immunohistochem/comput","code_information":[{"code":"88361","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":125.33,"maximum":684.27,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":354.54,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":125.33},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":684.27,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":265.91,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":283.41},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":361.63,"additional_payer_notes":"APC"}]}]},{"description":"M/phmtrc alysishquant/semiq","code_information":[{"code":"88369","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":82.65,"maximum":108.55,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":108.55},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":82.65}]}]},{"description":"Microdissection manual","code_information":[{"code":"88381","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":130.22,"maximum":156.99,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":130.22},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":156.99}]}]},{"description":"Collect sweat for test","code_information":[{"code":"89230","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7.42,"maximum":99.48,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":51.54,"additional_payer_notes":"APC"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7.42},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":99.48,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":38.66,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":49.47},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":52.57,"additional_payer_notes":"APC"}]}]},{"description":"Rx metb advrs trgt sq aly 20","code_information":[{"code":"0380U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":624.18,"maximum":624.18,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":624.18}]}]},{"description":"Inject spine l/s (cd)","code_information":[{"code":"62311","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1221.0,"maximum":1221.0,"payers_information":[{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1221.0}]}]},{"description":"Eculizumab injection","code_information":[{"code":"J1300","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":242.7,"maximum":610.27,"payers_information":[{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":242.7},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":414.7},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":610.27}]}]},{"description":"Inj, vancomycin hcl (xellia)","code_information":[{"code":"J3372","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6.91,"maximum":17.37,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7.19},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6.91},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11.8},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17.37}]}]},{"description":"Calcitonin salmon injection","code_information":[{"code":"J0630","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1236.91,"maximum":3110.22,"payers_information":[{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1236.91},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2113.46},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3110.22}]}]},{"description":"Abltj mal brst tum perq crtx","code_information":[{"code":"0581T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2904.59,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3872.79,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7474.49,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2904.59,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3950.25,"additional_payer_notes":"APC"}]}]},{"description":"Inject spine c/t","code_information":[{"code":"62310","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1221.0,"maximum":1221.0,"payers_information":[{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1221.0}]}]},{"description":"Intraop hipec px 1st 60 min","code_information":[{"code":"96547","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2334.0,"maximum":2334.0,"payers_information":[{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Esophag mucosal integ add-on","code_information":[{"code":"C9777","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2860.11,"maximum":7791.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3813.48,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7360.02,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2860.11,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":7791.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3889.75,"additional_payer_notes":"APC"}]}]},{"description":"Hernia repair w/mesh","code_information":[{"code":"49568","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5415.0,"maximum":5415.0,"payers_information":[{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5415.0}]}]},{"description":"Corplex p, per cc","code_information":[{"code":"Q4231","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1874.25,"maximum":2758.19,"payers_information":[{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1874.25},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2758.19}]}]},{"description":"Rpr ventral hern init reduc","code_information":[{"code":"49560","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5415.0,"maximum":5415.0,"payers_information":[{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5415.0}]}]},{"description":"Inj, zymfentra, 10 mg","code_information":[{"code":"J1748","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":282.84,"maximum":711.2,"payers_information":[{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":282.84},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":483.28},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":711.2}]}]},{"description":"Rpr umbil hern reduc > 5 yr","code_information":[{"code":"49585","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5415.0,"maximum":5415.0,"payers_information":[{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5415.0}]}]},{"description":"Sperm identification","code_information":[{"code":"89257","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":38.66,"maximum":99.48,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":51.54,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":99.48,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":38.66,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":49.47},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":52.57,"additional_payer_notes":"APC"}]}]},{"description":"Assist oocyte fertilization","code_information":[{"code":"89280","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":597.68,"maximum":1538.03,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":796.91,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1538.03,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":597.68,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":628.2},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":812.84,"additional_payer_notes":"APC"}]}]},{"description":"Storage/year sperm/semen","code_information":[{"code":"89343","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":126.39,"maximum":325.23,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":168.51,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":325.23,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":126.39,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":143.5},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":171.88,"additional_payer_notes":"APC"}]}]},{"description":"Specimen handling office-lab","code_information":[{"code":"99000","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5.77,"maximum":5.77,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5.77}]}]},{"description":"Prostate biopsy, any mthd","code_information":[{"code":"G0416","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":265.91,"maximum":684.27,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":354.54,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":684.27,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":265.91,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":283.41},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":361.63,"additional_payer_notes":"APC"}]}]},{"description":"Human ig im","code_information":[{"code":"90281","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":162.64,"maximum":162.64,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":162.64}]}]},{"description":"Rh ig iv","code_information":[{"code":"90386","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1804.28,"maximum":1804.28,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1804.28}]}]},{"description":"Menb rp w/omv vaccine im","code_information":[{"code":"90620","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":678.32,"maximum":678.32,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":678.32}]}]},{"description":"Hib prp-t vaccine 4 dose im","code_information":[{"code":"90648","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":42.42,"maximum":42.42,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":42.42}]}]},{"description":"Rsv vacc pref bivalent im","code_information":[{"code":"90678","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":963.77,"maximum":963.77,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":963.77}]}]},{"description":"Dtap-ipv vaccine 4-6 yrs im","code_information":[{"code":"90696","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":415.37,"maximum":415.37,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":415.37}]}]},{"description":"Hzv vaccine live subq","code_information":[{"code":"90736","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":361.93,"maximum":361.93,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":361.93}]}]},{"description":"Hib-hepb vaccine im","code_information":[{"code":"90748","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":125.94,"maximum":125.94,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":125.94}]}]},{"description":"Miscellaneous M <46.50 and A >=77.50","code_information":[{"code":"A2004","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":42.47,"maximum":42.47,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":42.47}]}]},{"description":"Iodine I-123 sod iodide mil","code_information":[{"code":"A9509","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":419.18,"maximum":419.18,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":419.18}]}]},{"description":"Tc99m exametazime","code_information":[{"code":"A9521","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2184.37,"maximum":2184.37,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2184.37}]}]},{"description":"I125 serum albumin, dx","code_information":[{"code":"A9532","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":351.8,"maximum":905.29,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":469.06,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":905.29,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":351.8,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":558.33},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":478.44,"additional_payer_notes":"APC"}]}]},{"description":"Y90 ibritumomab, rx","code_information":[{"code":"A9543","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":42618.41,"maximum":154704.84,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":56824.55,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":109671.38,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":42618.41,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":154704.84},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":57961.04,"additional_payer_notes":"APC"}]}]},{"description":"I125 iothalamate, dx","code_information":[{"code":"A9554","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":105.68,"maximum":1253.81,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":649.64,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1253.81,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":487.23,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":105.68},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":662.63,"additional_payer_notes":"APC"}]}]},{"description":"Tc99m mertiatide","code_information":[{"code":"A9562","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2091.51,"maximum":2091.51,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2091.51}]}]},{"description":"Indium IN-111 auto platelet","code_information":[{"code":"A9571","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":11632.29,"maximum":11632.29,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11632.29}]}]},{"description":"Sodium fluoride F-18","code_information":[{"code":"A9580","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":713.33,"maximum":713.33,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":713.33}]}]},{"description":"Fluciclovine f-18","code_information":[{"code":"A9588","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":241.7,"maximum":730.77,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":322.27,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":621.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":241.7,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":730.77},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":328.72,"additional_payer_notes":"APC"}]}]},{"description":"Gallium illuccix 1 millicure","code_information":[{"code":"A9596","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":358.89,"maximum":2824.35,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":478.52,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":923.54,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":358.89,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2824.35},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":488.09,"additional_payer_notes":"APC"}]}]},{"description":"Radium ra223 dichloride ther","code_information":[{"code":"A9606","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":136.16,"maximum":459.31,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":181.55,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":350.39,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":136.16,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":459.31},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":185.18,"additional_payer_notes":"APC"}]}]},{"description":"Inj, bupivacaine (posimir)","code_information":[{"code":"C9144","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1.37,"maximum":1.37,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1.37}]}]},{"description":"Injection, cangrelor","code_information":[{"code":"C9460","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":15.21,"maximum":51.23,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20.28,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":39.13,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15.21,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":51.23},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20.68,"additional_payer_notes":"APC"}]}]},{"description":"Alefacept","code_information":[{"code":"J0215","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":68.69,"maximum":68.69,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":68.69}]}]},{"description":"Bupren/nal over 10mg bupreno","code_information":[{"code":"J0575","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":50.37,"maximum":50.37,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":50.37}]}]},{"description":"Cytogenetic study","code_information":[{"code":"88299","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":38.66,"maximum":99.48,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":51.54,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":99.48,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":38.66,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":49.47},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":52.57,"additional_payer_notes":"APC"}]}]},{"description":"Ustekinumab sub cu inj, 1 mg","code_information":[{"code":"J3357","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":168.78,"maximum":424.38,"payers_information":[{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":168.78},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":288.38},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":424.38}]}]},{"description":"Sucroferric oxyhydroxide 5mg","code_information":[{"code":"J0605","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":0.58,"maximum":0.58,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.58}]}]},{"description":"Calcium glycer & lact/10 ML","code_information":[{"code":"J0620","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":29.95,"maximum":29.95,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29.95}]}]},{"description":"Cefotaxime sodium injection","code_information":[{"code":"J0698","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":16.45,"maximum":16.45,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16.45}]}]},{"description":"Propranolol injection","code_information":[{"code":"J1800","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":27.51,"maximum":27.51,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27.51}]}]},{"description":"Insulin injection","code_information":[{"code":"J1815","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1.52,"maximum":1.52,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1.52}]}]},{"description":"Pegademase bovine, 25 iu","code_information":[{"code":"J2504","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":420.95,"maximum":420.95,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":420.95}]}]},{"description":"Loxapine for inhalation 1 mg","code_information":[{"code":"J2062","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":49.01,"maximum":49.01,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":49.01}]}]},{"description":"Chlordiazepoxide injection","code_information":[{"code":"J1990","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":54.58,"maximum":54.58,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":54.58}]}]},{"description":"Makena, 10 mg","code_information":[{"code":"J1726","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":37.62,"maximum":37.62,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37.62}]}]},{"description":"Gold sodium thiomaleate inj","code_information":[{"code":"J1600","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":36.1,"maximum":36.1,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36.1}]}]},{"description":"Etanercept injection","code_information":[{"code":"J1438","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2152.9,"maximum":2152.9,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2152.9}]}]},{"description":"Inj. viltolarsen","code_information":[{"code":"J1427","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":184.26,"maximum":184.26,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":184.26}]}]},{"description":"Medroxyprogesterone acetate","code_information":[{"code":"J1050","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1.37,"maximum":1.37,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1.37}]}]},{"description":"Difelikefalin, esrd on dialy","code_information":[{"code":"J0879","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":0.35,"maximum":0.35,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.35}]}]},{"description":"Inj sebelipase alfa 1 mg","code_information":[{"code":"J2840","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":404.7,"maximum":1468.85,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":539.6,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1041.43,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":404.7,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1468.85},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":550.39,"additional_payer_notes":"APC"}]}]},{"description":"Inj., fremanezumab-vfrm 1 mg","code_information":[{"code":"J3031","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":11.02,"maximum":11.02,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11.02}]}]},{"description":"Triamcinolone hexacetonl inj","code_information":[{"code":"J3303","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":26.55,"maximum":26.55,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26.55}]}]},{"description":"Urofollitropin, 75 iu","code_information":[{"code":"J3355","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":161.14,"maximum":161.14,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":161.14}]}]},{"description":"Inj luxturna 1 billion vec g","code_information":[{"code":"J3398","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2302.23,"maximum":8639.12,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3069.64,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5924.4,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2302.23,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8639.12},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3131.03,"additional_payer_notes":"APC"}]}]},{"description":"Inj hydroxocobalamin iv 25mg","code_information":[{"code":"J3424","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4.08,"maximum":14.11,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5.44,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":10.51,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4.08,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14.11},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5.55,"additional_payer_notes":"APC"}]}]},{"description":"Surgical pathology procedure","code_information":[{"code":"88399","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":38.66,"maximum":99.48,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":51.54,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":99.48,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":38.66,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":49.47},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":52.57,"additional_payer_notes":"APC"}]}]},{"description":"Pathology lab procedure","code_information":[{"code":"89240","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":38.66,"maximum":99.48,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":51.54,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":99.48,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":38.66,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":49.47},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":52.57,"additional_payer_notes":"APC"}]}]},{"description":"Cryopreservation sperm","code_information":[{"code":"89259","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":126.39,"maximum":325.23,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":168.51,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":325.23,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":126.39,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":143.5},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":171.88,"additional_payer_notes":"APC"}]}]},{"description":"Biopsy oocyte polar body","code_information":[{"code":"89290","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":126.39,"maximum":325.23,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":168.51,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":325.23,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":126.39,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":143.5},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":171.88,"additional_payer_notes":"APC"}]}]},{"description":"Storage/year oocyte(s)","code_information":[{"code":"89346","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":126.39,"maximum":325.23,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":168.51,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":325.23,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":126.39,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":283.41},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":171.88,"additional_payer_notes":"APC"}]}]},{"description":"Obtaining screen pap smear","code_information":[{"code":"Q0091","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":21.46,"maximum":55.21,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":28.61,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":55.21,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21.46,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22.99},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":29.18,"additional_payer_notes":"APC"}]}]},{"description":"Human ig sc","code_information":[{"code":"90284","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":62.62,"maximum":62.62,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":62.62}]}]},{"description":"Hepa vacc ped/adol 3 dose","code_information":[{"code":"90634","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":79.25,"maximum":79.25,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":79.25}]}]},{"description":"Laiv4 vaccine intranasal","code_information":[{"code":"90672","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":82.73,"maximum":82.73,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":82.73}]}]},{"description":"Rv5 vacc 3 dose live oral","code_information":[{"code":"90680","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":322.43,"maximum":322.43,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":322.43}]}]},{"description":"Dtap-ipv/hib vaccine im","code_information":[{"code":"90698","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":367.5,"maximum":367.5,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":367.5}]}]},{"description":"Var vaccine live subq","code_information":[{"code":"90716","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":597.45,"maximum":597.45,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":597.45}]}]},{"description":"Prothrombin complex kcentra","code_information":[{"code":"J7168","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1.51,"maximum":6.02,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2.01,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3.88,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1.51,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6.02},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2.05,"additional_payer_notes":"APC"}]}]},{"description":"Anacaulase-bcdb 8.8% gel 1 g","code_information":[{"code":"J7353","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":155.15,"maximum":155.15,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":155.15}]}]},{"description":"Daclizumab, parenteral","code_information":[{"code":"J7513","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1020.67,"maximum":1020.67,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1020.67}]}]},{"description":"Cromolyn sodium comp unit","code_information":[{"code":"J7632","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":0.87,"maximum":0.87,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.87}]}]},{"description":"Oral, hemady, 0.25 mg","code_information":[{"code":"J8541","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1.12,"maximum":1.12,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1.12}]}]},{"description":"Aldesleukin injection","code_information":[{"code":"J9015","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2504.15,"maximum":14432.68,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3338.87,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6444.02,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2504.15,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14432.68},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3405.65,"additional_payer_notes":"APC"}]}]},{"description":"Interferon gamma 1-b inj","code_information":[{"code":"J9216","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":26600.24,"maximum":26600.24,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26600.24}]}]},{"description":"Perphenazine 4mg oral","code_information":[{"code":"Q0175","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1.77,"maximum":1.77,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1.77}]}]},{"description":"Casirivi and imdevi 600 mg","code_information":[{"code":"Q0240","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":0.03,"maximum":0.03,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.03}]}]},{"description":"Fosphenytoin inj pe","code_information":[{"code":"Q2009","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":0.5,"maximum":22.74,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":0.66,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1.28,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":0.5,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22.74},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":0.68,"additional_payer_notes":"APC"}]}]},{"description":"Fluzone vacc, 3 yrs & >, im","code_information":[{"code":"Q2038","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":135.09,"maximum":135.09,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":135.09}]}]},{"description":"Graftjacket","code_information":[{"code":"Q4107","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":92.32,"maximum":371.55,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":123.09,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":237.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":92.32,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":371.55},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":125.55,"additional_payer_notes":"APC"}]}]},{"description":"Omeza collag per 100 mg","code_information":[{"code":"A2014","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":193.97,"maximum":193.97,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":193.97}]}]},{"description":"Innovabrn/innovamatx xl sqcm","code_information":[{"code":"A2022","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":92.32,"maximum":3522.54,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":123.09,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":237.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":92.32,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3522.54},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":125.55,"additional_payer_notes":"APC"}]}]},{"description":"Tc99m medronate","code_information":[{"code":"A9503","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":161.14,"maximum":161.14,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":161.14}]}]},{"description":"Tc99m pertechnetate","code_information":[{"code":"A9512","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":33.46,"maximum":33.46,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33.46}]}]},{"description":"Nitrogen n-13 ammonia","code_information":[{"code":"A9526","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2002.56,"maximum":2002.56,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2002.56}]}]},{"description":"Tc99m mebrofenin","code_information":[{"code":"A9537","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":308.9,"maximum":308.9,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":308.9}]}]},{"description":"In111 oxyquinoline","code_information":[{"code":"A9547","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":623.6,"maximum":2103.52,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":831.46,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1604.72,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":623.6,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2103.52},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":848.09,"additional_payer_notes":"APC"}]}]},{"description":"Ga67 gallium","code_information":[{"code":"A9556","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":59.9,"maximum":59.9,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":59.9}]}]},{"description":"P32 chromic phosphate","code_information":[{"code":"A9564","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":412.14,"maximum":412.14,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":412.14}]}]},{"description":"Iodine I-123 iobenguane","code_information":[{"code":"A9582","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1738.12,"maximum":5648.68,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2317.5,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4472.78,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1738.12,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5648.68},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2363.85,"additional_payer_notes":"APC"}]}]},{"description":"Flotufolastat f18 diag 1 mci","code_information":[{"code":"A9608","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":545.67,"maximum":1774.18,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":727.56,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1404.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":545.67,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1774.18},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":742.11,"additional_payer_notes":"APC"}]}]},{"description":"Inj, nypozi, 1 mcg","code_information":[{"code":"C9173","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1.47,"maximum":1.47,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1.47}]}]},{"description":"Sotalol hydrochloride IV","code_information":[{"code":"C9482","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":62.02,"maximum":62.02,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":62.02}]}]},{"description":"Aprotonin, 10,000 kiu","code_information":[{"code":"J0365","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7.05,"maximum":7.05,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7.05}]}]},{"description":"Esano a, per sq cm","code_information":[{"code":"Q4272","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":92.32,"maximum":953.16,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":123.09,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":237.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":92.32,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":953.16},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":125.55,"additional_payer_notes":"APC"}]}]},{"description":"Xceed tl matrix per sq cm","code_information":[{"code":"Q4353","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":92.32,"maximum":9660.63,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":123.09,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":237.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":92.32,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9660.63},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":125.55,"additional_payer_notes":"APC"}]}]},{"description":"Inj adalimumab-adbm, 1 mg","code_information":[{"code":"Q5143","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":28.4,"maximum":28.4,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28.4}]}]},{"description":"florbetaben f18 diagnostic","code_information":[{"code":"Q9983","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1188.5,"maximum":3467.81,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1584.67,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3058.41,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1188.5,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3467.81},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1616.36,"additional_payer_notes":"APC"}]}]},{"description":"Inj., haegarda 10 units","code_information":[{"code":"J0599","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":39.34,"maximum":39.34,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":39.34}]}]},{"description":"Lanthanum carbonate oral 5mg","code_information":[{"code":"J0607","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":0.25,"maximum":0.25,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.25}]}]},{"description":"Inj calcitriol per 0.1 mcg","code_information":[{"code":"J0636","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2.92,"maximum":2.92,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2.92}]}]},{"description":"Inj lefamulin 1 mg","code_information":[{"code":"J0691","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2.23,"maximum":2.23,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2.23}]}]},{"description":"Inj pantoprazole sodium 40mg","code_information":[{"code":"J2470","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":26.63,"maximum":26.63,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26.63}]}]},{"description":"Injection, peramivir","code_information":[{"code":"J2547","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1.26,"maximum":4.57,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1.68,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3.24,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1.26,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":4.57},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1.71,"additional_payer_notes":"APC"}]}]},{"description":"Nesiritide injection","code_information":[{"code":"J2325","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":79.25,"maximum":79.25,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":79.25}]}]},{"description":"Ibutilide fumarate injection","code_information":[{"code":"J1742","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":131.92,"maximum":509.03,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":175.89,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":339.47,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":131.92,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":509.03},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":179.41,"additional_payer_notes":"APC"}]}]},{"description":"Cytopathology procedure","code_information":[{"code":"88199","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":38.66,"maximum":99.48,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":51.54,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":99.48,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":38.66,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":49.47},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":52.57,"additional_payer_notes":"APC"}]}]},{"description":"Tcat impltj c sins rdctj dev","code_information":[{"code":"0645T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":13599.0,"maximum":34994.75,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18131.99,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":34994.75,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13599.0,"additional_payer_notes":"APC"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":27583.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18494.63,"additional_payer_notes":"APC"}]}]},{"description":"Inj, beqvez, per tx dose","code_information":[{"code":"J1414","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":10100475.0,"maximum":10100475.0,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10100475.0}]}]},{"description":"Inj streptokinase /250000 IU","code_information":[{"code":"J2995","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":193.73,"maximum":193.73,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":193.73}]}]},{"description":"Thiethylperazine maleate inj","code_information":[{"code":"J3280","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":12.33,"maximum":12.33,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12.33}]}]},{"description":"Prepare embryo for transfer","code_information":[{"code":"89255","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":38.66,"maximum":99.48,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":51.54,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":99.48,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":38.66,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":49.47},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":52.57,"additional_payer_notes":"APC"}]}]},{"description":"Extended culture of oocytes","code_information":[{"code":"89272","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":597.68,"maximum":1538.03,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":796.91,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1538.03,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":597.68,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":628.2},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":812.84,"additional_payer_notes":"APC"}]}]},{"description":"Storage/year embryo(s)","code_information":[{"code":"89342","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":126.39,"maximum":325.23,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":168.51,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":325.23,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":126.39,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":143.5},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":171.88,"additional_payer_notes":"APC"}]}]},{"description":"Unlisted reprod med lab proc","code_information":[{"code":"89398","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":38.66,"maximum":99.48,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":51.54,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":99.48,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":38.66,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":49.47},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":52.57,"additional_payer_notes":"APC"}]}]},{"description":"Pathogen test for platelets","code_information":[{"code":"P9100","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":35.5,"maximum":112.62,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":58.35,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":112.62,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":43.76,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35.5},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":59.52,"additional_payer_notes":"APC"}]}]},{"description":"Rh ig minidose im","code_information":[{"code":"90385","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":60.0,"maximum":164.06,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":80.0,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":154.4,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":60.0,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":164.06},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":81.6,"additional_payer_notes":"APC"}]}]},{"description":"Anthrax vaccine sc or im","code_information":[{"code":"90581","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":315.98,"maximum":315.98,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":315.98}]}]},{"description":"Menacwy-tt vaccine im","code_information":[{"code":"90619","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":561.41,"maximum":561.41,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":561.41}]}]},{"description":"Hib prp-omp vacc 3 dose im","code_information":[{"code":"90647","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":99.48,"maximum":99.48,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":99.48}]}]},{"description":"Poliovirus ipv sc/im","code_information":[{"code":"90713","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":145.73,"maximum":145.73,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":145.73}]}]},{"description":"Mcv4 menacwy vaccine im","code_information":[{"code":"90734","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":494.92,"maximum":494.92,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":494.92}]}]},{"description":"Dextran 40 infusion","code_information":[{"code":"J7100","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":140.28,"maximum":140.28,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":140.28}]}]},{"description":"Eth estr and eton monthly","code_information":[{"code":"J7295","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":508.98,"maximum":508.98,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":508.98}]}]},{"description":"Etonogestrel implant system","code_information":[{"code":"J7307","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3968.2,"maximum":3968.2,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3968.2}]}]},{"description":"Erwinaze injection","code_information":[{"code":"J9019","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1316.88,"maximum":1316.88,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1316.88}]}]},{"description":"Inj belantamab mafodont blmf","code_information":[{"code":"J9037","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":113.6,"maximum":113.6,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":113.6}]}]},{"description":"Inj., copanlisib, 1 mg","code_information":[{"code":"J9057","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":242.73,"maximum":242.73,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":242.73}]}]},{"description":"Leuprolide acetate injeciton","code_information":[{"code":"J9218","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":9.65,"maximum":24.26,"payers_information":[{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9.65},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16.48},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24.26}]}]},{"description":"Mechlorethamine hcl inj","code_information":[{"code":"J9230","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":345.21,"maximum":345.21,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":345.21}]}]},{"description":"Prochlorperazine maleate 5mg","code_information":[{"code":"Q0164","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2.15,"maximum":2.15,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2.15}]}]},{"description":"Dolasetron mesylate oral","code_information":[{"code":"Q0180","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":391.41,"maximum":391.41,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":391.41}]}]},{"description":"Casirivi and imdevi 1200 mg","code_information":[{"code":"Q0244","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":0.03,"maximum":0.03,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.03}]}]},{"description":"Radiesse injection","code_information":[{"code":"Q2026","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":261.89,"maximum":907.73,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":349.19,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":673.94,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":261.89,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":907.73},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":356.17,"additional_payer_notes":"APC"}]}]},{"description":"Architect ecm px fx 1 sq cm","code_information":[{"code":"Q4147","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":92.32,"maximum":4291.42,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":123.09,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":237.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":92.32,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":4291.42},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":125.55,"additional_payer_notes":"APC"}]}]},{"description":"Miscellaneous M >=55.50 and M <66.50","code_information":[{"code":"A2002","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":92.32,"maximum":473.76,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":123.09,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":237.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":92.32,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":473.76},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":125.55,"additional_payer_notes":"APC"}]}]},{"description":"Kerecis marigen shld sq cm","code_information":[{"code":"A2019","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":92.32,"maximum":1860.23,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":123.09,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":237.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":92.32,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1860.23},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":125.55,"additional_payer_notes":"APC"}]}]},{"description":"Tc99m sestamibi","code_information":[{"code":"A9500","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1226.71,"maximum":1226.71,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1226.71}]}]},{"description":"I131 iodobenguate, dx","code_information":[{"code":"A9508","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":714.76,"maximum":2805.69,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":953.01,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1839.31,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":714.76,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2805.69},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":972.07,"additional_payer_notes":"APC"}]}]},{"description":"I131 max 100uci","code_information":[{"code":"A9531","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":11.47,"maximum":11.47,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11.47}]}]},{"description":"In111 ibritumomab, dx","code_information":[{"code":"A9542","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2172.6,"maximum":2172.6,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2172.6}]}]},{"description":"Cr51 chromate","code_information":[{"code":"A9553","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":885.03,"maximum":3701.66,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1917.96,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3701.66,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1438.47,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":885.03},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1956.32,"additional_payer_notes":"APC"}]}]},{"description":"Tc99m oxidronate","code_information":[{"code":"A9561","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":137.38,"maximum":137.38,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":137.38}]}]},{"description":"Indium In-111 auto WBC","code_information":[{"code":"A9570","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":827.39,"maximum":2807.95,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1103.19,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2129.16,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":827.39,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2807.95},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1125.25,"additional_payer_notes":"APC"}]}]},{"description":"Gallium ga-68","code_information":[{"code":"A9587","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":37.22,"maximum":139.1,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":49.63,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":95.79,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":37.22,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":139.1},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":50.62,"additional_payer_notes":"APC"}]}]},{"description":"Piflu f-18, dia 1 millicurie","code_information":[{"code":"A9595","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":259.87,"maximum":905.07,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":346.49,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":668.73,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":259.87,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":905.07},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":353.42,"additional_payer_notes":"APC"}]}]},{"description":"Sm 153 lexidronam","code_information":[{"code":"A9604","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2369.85,"maximum":11747.34,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3159.8,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6098.41,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2369.85,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11747.34},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3223.0,"additional_payer_notes":"APC"}]}]},{"description":"Radiopharm rx agent noc","code_information":[{"code":"A9699","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":123114.3,"maximum":123114.3,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":123114.3}]}]},{"description":"Inj, nithiodote, 3mg / 125mg","code_information":[{"code":"J0211","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1.62,"maximum":5.91,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2.17,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4.18,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1.62,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5.91},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2.21,"additional_payer_notes":"APC"}]}]},{"description":"Aripiprazole injection","code_information":[{"code":"J0400","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":0.87,"maximum":0.87,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.87}]}]},{"description":"Bupren/nal 6.1 to 10mg bupre","code_information":[{"code":"J0574","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":31.47,"maximum":31.47,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31.47}]}]},{"description":"Cinacalcet, esrd on dialysis","code_information":[{"code":"J0604","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2.69,"maximum":2.69,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2.69}]}]},{"description":"Calcium acetate, oral, 23 mg","code_information":[{"code":"J0615","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":0.08,"maximum":0.08,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.08}]}]},{"description":"Inj. insulin (lyumjev)","code_information":[{"code":"J1814","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5.45,"maximum":5.45,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5.45}]}]},{"description":"Pegaptanib sodium injection","code_information":[{"code":"J2503","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2471.06,"maximum":2471.06,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2471.06}]}]},{"description":"Oxytocin injection","code_information":[{"code":"J2590","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5.48,"maximum":5.48,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5.48}]}]},{"description":"Inj., meropenem, vaborbactam","code_information":[{"code":"J2186","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1.67,"maximum":5.73,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2.22,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4.29,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1.67,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5.73},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2.27,"additional_payer_notes":"APC"}]}]},{"description":"Furosemide injection","code_information":[{"code":"J1940","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":0.41,"maximum":1.06,"payers_information":[{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.41},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.72},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1.06}]}]},{"description":"Inj hydroxyprogst capoat nos","code_information":[{"code":"J1729","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":92.91,"maximum":92.91,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":92.91}]}]},{"description":"Gallium nitrate injection","code_information":[{"code":"J1457","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3.51,"maximum":3.51,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3.51}]}]},{"description":"Inj, eteplirsen, 10 mg","code_information":[{"code":"J1428","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":125.57,"maximum":522.72,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":167.42,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":323.13,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":125.57,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":522.72},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":170.77,"additional_payer_notes":"APC"}]}]},{"description":"Corticorelin ovine triflutal","code_information":[{"code":"J0795","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":11.47,"maximum":11.47,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11.47}]}]},{"description":"Neostigmine methylslfte inj","code_information":[{"code":"J2710","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4.52,"maximum":4.52,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":4.52}]}]},{"description":"Riboflavin 5?phos opth<=3ml","code_information":[{"code":"J2787","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7448.76,"maximum":7448.76,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7448.76}]}]},{"description":"Somatropin injection","code_information":[{"code":"J2941","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":133.19,"maximum":133.19,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":133.19}]}]},{"description":"Sumatriptan succinate / 6 MG","code_information":[{"code":"J3030","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":440.85,"maximum":440.85,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":440.85}]}]},{"description":"Triamcinolone diacetate inj","code_information":[{"code":"J3302","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":0.87,"maximum":0.87,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.87}]}]},{"description":"Inj., vestronidase alfa-vjbk","code_information":[{"code":"J3397","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":218.65,"maximum":861.51,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":291.54,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":562.66,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":218.65,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":861.51},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":297.37,"additional_payer_notes":"APC"}]}]},{"description":"Lamellas xt, per sq cm","code_information":[{"code":"Q4291","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":92.32,"maximum":9493.24,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":123.09,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":237.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":92.32,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9493.24},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":125.55,"additional_payer_notes":"APC"}]}]},{"description":"Inj, wezlana, sub cu, 1 mg","code_information":[{"code":"Q5137","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":600.78,"maximum":600.78,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":600.78}]}]},{"description":"Inj, abrilada, 1 mg","code_information":[{"code":"Q5145","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":348.68,"maximum":348.68,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":348.68}]}]},{"description":"Inj, human-lans, per i.u","code_information":[{"code":"J7165","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1.3,"maximum":4.9,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1.73,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3.34,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1.3,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":4.9},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1.77,"additional_payer_notes":"APC"}]}]},{"description":"Skyla, 13.5 mg","code_information":[{"code":"J7301","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3146.83,"maximum":3146.83,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3146.83}]}]},{"description":"Cultured chondrocytes implnt","code_information":[{"code":"J7330","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":198192.56,"maximum":198192.56,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":198192.56}]}]},{"description":"Afamelanotide implant, 1 mg","code_information":[{"code":"J7352","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2207.57,"maximum":7822.63,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2943.42,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5680.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2207.57,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7822.63},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3002.29,"additional_payer_notes":"APC"}]}]},{"description":"Levalbuterol comp unit","code_information":[{"code":"J7615","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5.28,"maximum":5.28,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5.28}]}]},{"description":"Terbutaline sulf comp unit","code_information":[{"code":"J7681","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":34.35,"maximum":34.35,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34.35}]}]},{"description":"Inj, carmustine (accord)","code_information":[{"code":"J9052","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":0.13,"maximum":0.13,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.13}]}]},{"description":"Daunorubicin citrate inj","code_information":[{"code":"J9151","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":140.89,"maximum":140.89,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":140.89}]}]},{"description":"Interferon alfa-n3 inj","code_information":[{"code":"J9215","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":98.39,"maximum":98.39,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":98.39}]}]},{"description":"Inj, fulvestrant (teva)","code_information":[{"code":"J9393","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":31.25,"maximum":80.42,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":41.67,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":80.42,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":31.25,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":57.72},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":42.5,"additional_payer_notes":"APC"}]}]},{"description":"Thiethylperazine maleate10mg","code_information":[{"code":"Q0174","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1.77,"maximum":1.77,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1.77}]}]},{"description":"Bladder calculi irrig sol","code_information":[{"code":"Q2004","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":37.87,"maximum":37.87,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37.87}]}]},{"description":"Fluvirin vacc, 3 yrs & >, im","code_information":[{"code":"Q2037","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":32.59,"maximum":32.59,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32.59}]}]},{"description":"Dermagraft","code_information":[{"code":"Q4106","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":138.68,"maximum":138.68,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":138.68}]}]},{"description":"Floweramnioflo, 0.1 cc","code_information":[{"code":"Q4177","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":490.05,"maximum":490.05,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":490.05}]}]},{"description":"Surgigraft dual per sq cm","code_information":[{"code":"Q4219","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":92.32,"maximum":2148.02,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":123.09,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":237.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":92.32,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2148.02},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":125.55,"additional_payer_notes":"APC"}]}]},{"description":"cryo-cord, per sq cm","code_information":[{"code":"Q4237","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":92.32,"maximum":1359.67,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":123.09,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":237.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":92.32,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1359.67},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":125.55,"additional_payer_notes":"APC"}]}]},{"description":"Amniotext patch, per sq cm","code_information":[{"code":"Q4247","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":92.32,"maximum":6199.43,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":123.09,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":237.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":92.32,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6199.43},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":125.55,"additional_payer_notes":"APC"}]}]},{"description":"Pellograft, per sq cm","code_information":[{"code":"Q4320","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":92.32,"maximum":2451.31,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":123.09,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":237.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":92.32,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2451.31},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":125.55,"additional_payer_notes":"APC"}]}]},{"description":"Overlay sl matrix, per sq cm","code_information":[{"code":"Q4352","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":92.32,"maximum":6376.13,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":123.09,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":237.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":92.32,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6376.13},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":125.55,"additional_payer_notes":"APC"}]}]},{"description":"Inj adalimumab-ryvk, 1 mg","code_information":[{"code":"Q5142","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":28.69,"maximum":28.69,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28.69}]}]},{"description":"flutemetamol f18 diagnostic","code_information":[{"code":"Q9982","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1458.01,"maximum":3751.94,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1944.01,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3751.94,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1458.01,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2380.55},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1982.89,"additional_payer_notes":"APC"}]}]},{"description":"Ntraop hipec px ea add 30min","code_information":[{"code":"96548","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2334.0,"maximum":2334.0,"payers_information":[{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":2334.0}]}]},{"description":"Inj beta interferon im 1 mcg","code_information":[{"code":"Q3027","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":102.9,"maximum":151.42,"payers_information":[{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":102.9},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":151.42}]}]},{"description":"Cryopreservation embryo(s)","code_information":[{"code":"89258","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":597.68,"maximum":1538.03,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":796.91,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1538.03,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":597.68,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":628.2},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":812.84,"additional_payer_notes":"APC"}]}]},{"description":"Assist oocyte fertilization","code_information":[{"code":"89281","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":126.39,"maximum":325.23,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":168.51,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":325.23,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":126.39,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":143.5},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":171.88,"additional_payer_notes":"APC"}]}]},{"description":"Storage/year reprod tissue","code_information":[{"code":"89344","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":126.39,"maximum":325.23,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":168.51,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":325.23,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":126.39,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":143.5},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":171.88,"additional_payer_notes":"APC"}]}]},{"description":"Specimen handling pt-lab","code_information":[{"code":"99001","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6.14,"maximum":6.14,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6.14}]}]},{"description":"Human ig iv","code_information":[{"code":"90283","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":249.05,"maximum":249.05,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":249.05}]}]},{"description":"Rabies ig heat treated","code_information":[{"code":"90376","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":264.33,"maximum":945.58,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":352.44,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":680.21,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":264.33,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":945.58},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":359.49,"additional_payer_notes":"APC"}]}]},{"description":"Tetanus ig im","code_information":[{"code":"90389","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2120.83,"maximum":2120.83,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2120.83}]}]},{"description":"Bcg vaccine percut","code_information":[{"code":"90585","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":555.01,"maximum":555.01,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":555.01}]}]},{"description":"Menb rlp vaccine im","code_information":[{"code":"90621","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":621.16,"maximum":621.16,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":621.16}]}]},{"description":"Hepa vacc ped/adol 2 dose im","code_information":[{"code":"90633","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":114.3,"maximum":114.3,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":114.3}]}]},{"description":"4vhpv vaccine 3 dose im","code_information":[{"code":"90649","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":286.21,"maximum":286.21,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":286.21}]}]},{"description":"Rsv vacc pref recomb adjt im","code_information":[{"code":"90679","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":960.5,"maximum":960.5,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":960.5}]}]},{"description":"Dtap-ipv-hib-hepb vaccine im","code_information":[{"code":"90697","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1018.73,"maximum":1018.73,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1018.73}]}]},{"description":"Inactivated je vacc im","code_information":[{"code":"90738","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":832.29,"maximum":832.29,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":832.29}]}]},{"description":"Miscellaneous M <46.50 and A <77.50","code_information":[{"code":"A2005","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":92.32,"maximum":693.07,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":123.09,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":237.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":92.32,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":693.07},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":125.55,"additional_payer_notes":"APC"}]}]},{"description":"Innovamatrix fs, per sq cm","code_information":[{"code":"A2013","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":92.32,"maximum":3344.65,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":123.09,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":237.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":92.32,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3344.65},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":125.55,"additional_payer_notes":"APC"}]}]},{"description":"Neomatrix per sq cm","code_information":[{"code":"A2021","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":92.32,"maximum":3651.12,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":123.09,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":237.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":92.32,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3651.12},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":125.55,"additional_payer_notes":"APC"}]}]},{"description":"Tc99m tetrofosmin","code_information":[{"code":"A9502","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":429.74,"maximum":429.74,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":429.74}]}]},{"description":"Tc99m disofenin","code_information":[{"code":"A9510","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":162.92,"maximum":162.92,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":162.92}]}]},{"description":"I131 serum albumin, dx","code_information":[{"code":"A9524","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":981.02,"maximum":981.02,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":981.02}]}]},{"description":"Tc99m depreotide","code_information":[{"code":"A9536","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2110.89,"maximum":2110.89,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2110.89}]}]},{"description":"Co57/58","code_information":[{"code":"A9546","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3.51,"maximum":3.51,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3.51}]}]},{"description":"Rb82 rubidium","code_information":[{"code":"A9555","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1231.11,"maximum":1231.11,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1231.11}]}]},{"description":"P32 na phosphate","code_information":[{"code":"A9563","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":208.68,"maximum":537.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":278.24,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":537.0,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":208.68,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":487.66},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":283.8,"additional_payer_notes":"APC"}]}]},{"description":"Indium In-111 pentetreotide","code_information":[{"code":"A9572","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1500.7,"maximum":5212.53,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2000.94,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3861.81,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1500.7,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5212.53},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2040.96,"additional_payer_notes":"APC"}]}]},{"description":"Lutetium lu 177 vipivotide","code_information":[{"code":"A9607","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":200.49,"maximum":656.7,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":267.32,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":515.92,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":200.49,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":656.7},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":272.66,"additional_payer_notes":"APC"}]}]},{"description":"Gallium locametz 1 millicuri","code_information":[{"code":"A9800","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":271.88,"maximum":2377.95,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":362.5,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":699.62,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":271.88,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2377.95},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":369.75,"additional_payer_notes":"APC"}]}]},{"description":"Inj, aponvie, 1 mg","code_information":[{"code":"C9145","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5.07,"maximum":5.07,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5.07}]}]},{"description":"Abciximab injection","code_information":[{"code":"J0130","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1520.84,"maximum":1520.84,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1520.84}]}]},{"description":"Inj, adalimumab, 1 mg","code_information":[{"code":"J0139","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":249.73,"maximum":249.73,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":249.73}]}]},{"description":"Alglucerase injection","code_information":[{"code":"J0205","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":81.89,"maximum":81.89,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":81.89}]}]},{"description":"Inj, alfentanil hcl, 500mcg","code_information":[{"code":"J0216","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":12.31,"maximum":12.31,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12.31}]}]},{"description":"Apomorphine hydrochloride","code_information":[{"code":"J0364","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":144.38,"maximum":144.38,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":144.38}]}]},{"description":"Inj, etelcalcetide, 0.1 mg","code_information":[{"code":"J0606","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1.85,"maximum":12.85,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2.47,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4.76,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1.85,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12.85},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2.52,"additional_payer_notes":"APC"}]}]},{"description":"Chloroprocaine (clorotekal)","code_information":[{"code":"J2402","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1.01,"maximum":1.01,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1.01}]}]},{"description":"Inj, nusinersen, 0.1mg","code_information":[{"code":"J2326","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1000.09,"maximum":3394.92,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1333.45,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2573.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1000.09,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3394.92},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1360.12,"additional_payer_notes":"APC"}]}]},{"description":"Inj, remimazolam, 1 mg","code_information":[{"code":"J2249","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6.86,"maximum":6.86,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6.86}]}]},{"description":"Hyoscyamine sulfate inj","code_information":[{"code":"J1980","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":24.67,"maximum":24.67,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24.67}]}]},{"description":"Itraconazole injection","code_information":[{"code":"J1835","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2476.34,"maximum":2476.34,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2476.34}]}]},{"description":"Inj, ganciclovir (exela)","code_information":[{"code":"J1574","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":163.35,"maximum":163.35,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":163.35}]}]},{"description":"Vivaglobin, inj","code_information":[{"code":"J1562","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":24.67,"maximum":24.67,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24.67}]}]},{"description":"Injection, casimersen, 10 mg","code_information":[{"code":"J1426","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":124.63,"maximum":522.72,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":166.17,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":320.71,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":124.63,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":522.72},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":169.49,"additional_payer_notes":"APC"}]}]},{"description":"Inj, crovalimab-akkz, 10 mg","code_information":[{"code":"J1307","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":413.63,"maximum":1459.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":551.51,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1064.42,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":413.63,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1459.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":562.54,"additional_payer_notes":"APC"}]}]},{"description":"Dexmedetomidine film, 1 mcg","code_information":[{"code":"J1105","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1.77,"maximum":1.77,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1.77}]}]},{"description":"Chloramphenicol sodium injec","code_information":[{"code":"J0720","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":158.94,"maximum":158.94,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":158.94}]}]},{"description":"Inj secretin synthetic human","code_information":[{"code":"J2850","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":32.25,"maximum":115.9,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":43.0,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":82.99,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":32.25,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":115.9},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":43.86,"additional_payer_notes":"APC"}]}]},{"description":"Reteplase injection","code_information":[{"code":"J2993","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7560.76,"maximum":7560.76,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7560.76}]}]},{"description":"Teriparatide injection","code_information":[{"code":"J3110","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":190.53,"maximum":190.53,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":190.53}]}]},{"description":"Inj. tigecycline (accord)","code_information":[{"code":"J3244","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":9.21,"maximum":9.21,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9.21}]}]},{"description":"Inj onase abepar-xioi treat","code_information":[{"code":"J3399","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2010028.04,"maximum":6543416.45,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2680037.38,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5172472.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2010028.04,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6543416.45},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2733638.13,"additional_payer_notes":"APC"}]}]},{"description":"Inj andexxa, 10 mg","code_information":[{"code":"J7169","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":98.37,"maximum":358.83,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":131.16,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":253.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":98.37,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":358.83},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":133.79,"additional_payer_notes":"APC"}]}]},{"description":"Seg acet and eth estr yearly","code_information":[{"code":"J7294","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7907.94,"maximum":7907.94,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7907.94}]}]},{"description":"Levonorgestrel implant sys","code_information":[{"code":"J7306","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1023.31,"maximum":1023.31,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1023.31}]}]},{"description":"Monoclonal antibodies","code_information":[{"code":"J7505","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2364.5,"maximum":2364.5,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2364.5}]}]},{"description":"Mycophenol (myhibbin) 100 mg","code_information":[{"code":"J7514","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7.13,"maximum":7.13,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7.13}]}]},{"description":"Flunisolide comp unit","code_information":[{"code":"J7641","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":27.31,"maximum":27.31,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27.31}]}]},{"description":"Triamcinolone comp con","code_information":[{"code":"J7683","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":12.33,"maximum":12.33,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12.33}]}]},{"description":"Nabilone oral","code_information":[{"code":"J8650","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":41.38,"maximum":41.38,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":41.38}]}]},{"description":"Inj, bortezomib, dr. reddy's","code_information":[{"code":"J9046","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2.6,"maximum":13.37,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3.46,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6.68,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2.6,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13.37},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3.53,"additional_payer_notes":"APC"}]}]},{"description":"Inj, olaratumab, 10 mg","code_information":[{"code":"J9285","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":160.46,"maximum":160.46,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":160.46}]}]},{"description":"Diphenhydramine HCl 50mg","code_information":[{"code":"Q0163","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3.55,"maximum":3.55,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3.55}]}]},{"description":"Hydroxyzine pamoate 25mg","code_information":[{"code":"Q0177","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5.28,"maximum":5.28,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5.28}]}]},{"description":"Casirivimab and imdevimab","code_information":[{"code":"Q0243","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":0.03,"maximum":0.03,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.03}]}]},{"description":"Teniposide, 50 mg","code_information":[{"code":"Q2017","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8154.27,"maximum":8154.27,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8154.27}]}]},{"description":"Hyalomatrix","code_information":[{"code":"Q4117","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":81.48,"maximum":237.56,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":123.09,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":237.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":92.32,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":81.48},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":125.55,"additional_payer_notes":"APC"}]}]},{"description":"Amnio bio and woundex flow","code_information":[{"code":"Q4162","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6987.77,"maximum":6987.77,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6987.77}]}]},{"description":"Ascent, 0.5 mg","code_information":[{"code":"Q4213","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":187.8,"maximum":187.8,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":187.8}]}]},{"description":"Shelter dm matrix per sq cm","code_information":[{"code":"Q4346","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":92.32,"maximum":11444.33,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":123.09,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":237.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":92.32,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11444.33},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":125.55,"additional_payer_notes":"APC"}]}]},{"description":"Inj, idacio, 1 mg","code_information":[{"code":"Q5144","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":40.89,"maximum":40.89,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":40.89}]}]},{"description":"Sperm isolation complex","code_information":[{"code":"89261","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":38.66,"maximum":99.48,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":51.54,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":99.48,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":38.66,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":49.47},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":52.57,"additional_payer_notes":"APC"}]}]},{"description":"Thawing cryopresrved sperm","code_information":[{"code":"89353","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":38.66,"maximum":99.48,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":51.54,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":99.48,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":38.66,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":49.47},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":52.57,"additional_payer_notes":"APC"}]}]},{"description":"Molecular pathology interpr","code_information":[{"code":"G0452","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2.92,"maximum":2.92,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2.92}]}]},{"description":"Rsv monoc antb seasn .5ml im","code_information":[{"code":"90380","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3396.05,"maximum":3396.05,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3396.05}]}]},{"description":"Immune globulin","code_information":[{"code":"90399","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1164.93,"maximum":1164.93,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1164.93}]}]},{"description":"Typhoid vaccine oral","code_information":[{"code":"90690","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":245.7,"maximum":245.7,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":245.7}]}]},{"description":"Dt vaccine under 7 yrs im","code_information":[{"code":"90702","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":45.79,"maximum":45.79,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":45.79}]}]},{"description":"Dtap-hep b-ipv vaccine im","code_information":[{"code":"90723","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":309.85,"maximum":309.85,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":309.85}]}]},{"description":"Sperm isolation simple","code_information":[{"code":"89260","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":38.66,"maximum":99.48,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":51.54,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":99.48,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":38.66,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":49.47},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":52.57,"additional_payer_notes":"APC"}]}]},{"description":"Biopsy oocyte polar body","code_information":[{"code":"89291","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":126.39,"maximum":325.23,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":168.51,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":325.23,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":126.39,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":143.5},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":171.88,"additional_payer_notes":"APC"}]}]},{"description":"Thawing cryopresrved embryo","code_information":[{"code":"89352","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":126.39,"maximum":325.23,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":168.51,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":325.23,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":126.39,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":143.5},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":171.88,"additional_payer_notes":"APC"}]}]},{"description":"Rsv mab im 50mg","code_information":[{"code":"90378","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":327.56,"maximum":1959.85,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":436.75,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":842.93,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":327.56,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1959.85},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":445.48,"additional_payer_notes":"APC"}]}]},{"description":"Varicella-zoster ig im","code_information":[{"code":"90396","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1873.3,"maximum":6131.83,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2497.73,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4820.62,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1873.3,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6131.83},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2547.69,"additional_payer_notes":"APC"}]}]},{"description":"Dengue vacc quad 3 dose subq","code_information":[{"code":"90587","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":215.62,"maximum":215.62,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":215.62}]}]},{"description":"Menacwy-tt menb-fhbp vacc im","code_information":[{"code":"90623","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":751.41,"maximum":751.41,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":751.41}]}]},{"description":"Hep a/hep b vacc adult im","code_information":[{"code":"90636","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":352.09,"maximum":352.09,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":352.09}]}]},{"description":"9vhpv vaccine 3 dose im","code_information":[{"code":"90651","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1004.55,"maximum":1004.55,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1004.55}]}]},{"description":"Rv1 vacc 2 dose live oral","code_information":[{"code":"90681","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":301.9,"maximum":301.9,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":301.9}]}]},{"description":"Dtap vaccine < 7 yrs im","code_information":[{"code":"90700","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":96.33,"maximum":96.33,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":96.33}]}]},{"description":"Yellow fever vaccine subq","code_information":[{"code":"90717","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":480.74,"maximum":480.74,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":480.74}]}]},{"description":"Hydration iv infusion init","code_information":[{"code":"96360","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":157.79,"maximum":573.61,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":210.39,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":406.05,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":157.79,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":573.61},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":214.59,"additional_payer_notes":"APC"}]}]},{"description":"Theragenesis, per sq cm","code_information":[{"code":"A2008","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":92.32,"maximum":244.81,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":123.09,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":237.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":92.32,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":244.81},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":125.55,"additional_payer_notes":"APC"}]}]},{"description":"Resolve matrix per sq cm","code_information":[{"code":"A2024","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":92.32,"maximum":5283.8,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":123.09,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":237.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":92.32,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5283.8},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":125.55,"additional_payer_notes":"APC"}]}]},{"description":"Tl201 thallium","code_information":[{"code":"A9505","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":117.12,"maximum":117.12,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":117.12}]}]},{"description":"Choline c-11","code_information":[{"code":"A9515","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1887.32,"maximum":5616.35,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2516.43,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4856.71,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1887.32,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5616.35},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2566.76,"additional_payer_notes":"APC"}]}]},{"description":"Iodine i-131 iodide cap, dx","code_information":[{"code":"A9528","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":257.14,"maximum":257.14,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":257.14}]}]},{"description":"Tc99m pentetate","code_information":[{"code":"A9539","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":68.69,"maximum":68.69,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":68.69}]}]},{"description":"Xe133 xenon 10mci","code_information":[{"code":"A9558","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":706.27,"maximum":706.27,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":706.27}]}]},{"description":"Technetium tc-99m aerosol","code_information":[{"code":"A9567","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":55.49,"maximum":55.49,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":55.49}]}]},{"description":"Iodine i-123 ioflupane","code_information":[{"code":"A9584","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1040.8,"maximum":3778.88,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1387.74,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2678.34,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1040.8,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3778.88},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1415.49,"additional_payer_notes":"APC"}]}]},{"description":"Copper cu 64 dotatate diag","code_information":[{"code":"A9592","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":445.71,"maximum":1620.17,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":594.28,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1146.96,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":445.71,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1620.17},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":606.17,"additional_payer_notes":"APC"}]}]},{"description":"Flortaucipir inj 1 millicuri","code_information":[{"code":"A9601","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":278.25,"maximum":10100.48,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":371.0,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":716.03,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":278.25,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10100.48},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":378.42,"additional_payer_notes":"APC"}]}]},{"description":"Inj, pegulicianine, 1 mg","code_information":[{"code":"A9615","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":28.13,"maximum":102.12,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":37.51,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":72.39,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":28.13,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":102.12},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":38.26,"additional_payer_notes":"APC"}]}]},{"description":"Gallium ga-68 dotatoc","code_information":[{"code":"C9067","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2.71,"maximum":11.02,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3.61,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6.97,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2.71,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11.02},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3.68,"additional_payer_notes":"APC"}]}]},{"description":"Artiss fibrin sealant","code_information":[{"code":"C9250","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":109.26,"maximum":366.18,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":145.67,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":281.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":109.26,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":366.18},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":148.59,"additional_payer_notes":"APC"}]}]},{"description":"Inj, amisulpride, 1 mg","code_information":[{"code":"J0184","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7.18,"maximum":24.72,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9.57,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":18.47,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7.18,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24.72},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9.76,"additional_payer_notes":"APC"}]}]},{"description":"Inj sodium thiosulfate 100mg","code_information":[{"code":"J0208","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":72.58,"maximum":261.36,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":96.78,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":186.78,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":72.58,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":261.36},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":98.71,"additional_payer_notes":"APC"}]}]},{"description":"Succinycholine chloride inj","code_information":[{"code":"J0330","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4.31,"maximum":4.31,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":4.31}]}]},{"description":"Buprenorphine oral 1mg","code_information":[{"code":"J0571","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3.81,"maximum":3.81,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3.81}]}]},{"description":"Restrata, per sq cm","code_information":[{"code":"A2007","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":92.32,"maximum":237.56,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":123.09,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":237.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":92.32,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":219.27},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":125.55,"additional_payer_notes":"APC"}]}]},{"description":"Phoenix wnd mtrx, per sq cm","code_information":[{"code":"A2015","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":92.32,"maximum":3916.75,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":123.09,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":237.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":92.32,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3916.75},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":125.55,"additional_payer_notes":"APC"}]}]},{"description":"Innovamatrix pd, 1 mg","code_information":[{"code":"A2023","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":40.51,"maximum":40.51,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":40.51}]}]},{"description":"Ces system monthly supp","code_information":[{"code":"A4596","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":131.44,"maximum":131.44,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":131.44}]}]},{"description":"Tc99m apcitide","code_information":[{"code":"A9504","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1386.1,"maximum":1386.1,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1386.1}]}]},{"description":"Lutetium lu 177 dotatat ther","code_information":[{"code":"A9513","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":262.66,"maximum":806.54,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":350.21,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":675.9,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":262.66,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":806.54},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":357.21,"additional_payer_notes":"APC"}]}]},{"description":"Iodine I-125 sodium iodide","code_information":[{"code":"A9527","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":297.24,"maximum":764.9,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":396.32,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":764.9,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":297.24,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":567.86},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":404.25,"additional_payer_notes":"APC"}]}]},{"description":"Tc99m pyrophosphate","code_information":[{"code":"A9538","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":104.79,"maximum":104.79,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":104.79}]}]},{"description":"In111 pentetate","code_information":[{"code":"A9548","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":559.22,"maximum":1947.38,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":745.62,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1439.05,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":559.22,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1947.38},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":760.53,"additional_payer_notes":"APC"}]}]},{"description":"Tc99m bicisate","code_information":[{"code":"A9557","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":581.64,"maximum":1861.65,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":775.52,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1496.75,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":581.64,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1861.65},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":791.03,"additional_payer_notes":"APC"}]}]},{"description":"Fluoroestradiol f 18","code_information":[{"code":"A9591","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":345.32,"maximum":1357.64,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":460.42,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":888.61,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":345.32,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1357.64},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":469.63,"additional_payer_notes":"APC"}]}]},{"description":"Sr89 strontium","code_information":[{"code":"A9600","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3109.75,"maximum":11288.41,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4146.34,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":8002.43,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3109.75,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11288.41},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4229.26,"additional_payer_notes":"APC"}]}]},{"description":"Inj, clevidipine butyrate","code_information":[{"code":"C9248","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7.62,"maximum":7.62,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7.62}]}]},{"description":"Amifostine","code_information":[{"code":"J0207","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2216.41,"maximum":2216.41,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2216.41}]}]},{"description":"Amobarbital 125 MG inj","code_information":[{"code":"J0300","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":30.82,"maximum":30.82,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30.82}]}]},{"description":"Inj metaraminol bitartrate","code_information":[{"code":"J0380","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2.64,"maximum":2.64,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2.64}]}]},{"description":"Inj., cerliponase alfa 1 mg","code_information":[{"code":"J0567","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":92.53,"maximum":358.56,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":123.38,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":238.12,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":92.53,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":358.56},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":125.85,"additional_payer_notes":"APC"}]}]},{"description":"Sevelamer carbonate 20 mg","code_information":[{"code":"J0601","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":0.3,"maximum":0.3,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.3}]}]},{"description":"Ferric citrate orl 3 mg iron","code_information":[{"code":"J0609","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":0.08,"maximum":0.08,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.08}]}]},{"description":"Interferon beta-1b / .25 MG","code_information":[{"code":"J1830","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1333.45,"maximum":1333.45,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1333.45}]}]},{"description":"Inj, pantoprazole sodium chl","code_information":[{"code":"J2472","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":26.09,"maximum":26.09,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26.09}]}]},{"description":"Penicillin g procaine inj","code_information":[{"code":"J2510","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":128.47,"maximum":128.47,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":128.47}]}]},{"description":"Nandrolone decanoate 50 MG","code_information":[{"code":"J2320","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":10.56,"maximum":10.56,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10.56}]}]},{"description":"Meperidine/promethazine inj","code_information":[{"code":"J2180","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":20.26,"maximum":20.26,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20.26}]}]},{"description":"Histrelin acetate","code_information":[{"code":"J1675","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2.64,"maximum":2.64,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2.64}]}]},{"description":"Inj roctavian ml 2x10^13vc g","code_information":[{"code":"J1412","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":9415.28,"maximum":31766.05,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12553.71,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":24228.67,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9415.28,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31766.05},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12804.79,"additional_payer_notes":"APC"}]}]},{"description":"Inst tauro 1.35mg/hep 100u","code_information":[{"code":"J0911","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3.16,"maximum":23.58,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4.21,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":8.12,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3.16,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23.58},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4.29,"additional_payer_notes":"APC"}]}]},{"description":"Rilonacept injection","code_information":[{"code":"J2793","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":73.51,"maximum":73.51,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":73.51}]}]},{"description":"Inj plasminogen tvmh 1mg","code_information":[{"code":"J2998","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":28.82,"maximum":88.54,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":38.42,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":74.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":28.82,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":88.54},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":39.19,"additional_payer_notes":"APC"}]}]},{"description":"Pentazocine injection","code_information":[{"code":"J3070","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":72.2,"maximum":72.2,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":72.2}]}]},{"description":"Inj, betibeglogene autotemce","code_information":[{"code":"J3393","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2197695.26,"maximum":8080380.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2930260.34,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5655402.47,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2197695.26,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8080380.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2988865.55,"additional_payer_notes":"APC"}]}]},{"description":"Lanthanum carbonate pwdr 5mg","code_information":[{"code":"J0608","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":0.21,"maximum":0.21,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.21}]}]},{"description":"Centruroides immune f(ab)","code_information":[{"code":"J0716","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":13065.56,"maximum":13065.56,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13065.56}]}]},{"description":"Interferon Beta-1A inj","code_information":[{"code":"J1826","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5998.05,"maximum":5998.05,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5998.05}]}]},{"description":"Inj pantoprazole(hikma) 40mg","code_information":[{"code":"J2471","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":21.24,"maximum":21.24,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21.24}]}]},{"description":"Oxymorphone hcl injection","code_information":[{"code":"J2410","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6.15,"maximum":6.15,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6.15}]}]},{"description":"Oprelvekin injection","code_information":[{"code":"J2355","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":651.65,"maximum":651.65,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":651.65}]}]},{"description":"Minocycline hydrochloride","code_information":[{"code":"J2265","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2.05,"maximum":7.05,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2.74,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5.28,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2.05,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7.05},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2.79,"additional_payer_notes":"APC"}]}]},{"description":"Levorphanol tartrate inj","code_information":[{"code":"J1960","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7.92,"maximum":7.92,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7.92}]}]},{"description":"Lepirudin","code_information":[{"code":"J1945","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":395.42,"maximum":395.42,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":395.42}]}]},{"description":"Inj glycopyrrolate, glyrx-pf","code_information":[{"code":"J1597","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5.33,"maximum":5.33,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5.33}]}]},{"description":"Flebogamma injection","code_information":[{"code":"J1572","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":68.06,"maximum":175.13,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":90.74,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":175.13,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":68.06,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":121.26},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":92.55,"additional_payer_notes":"APC"}]}]},{"description":"Liletta, 52 mg","code_information":[{"code":"J7297","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2899.0,"maximum":2899.0,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2899.0}]}]},{"description":"Ciprofloxacin otic susp 6 mg","code_information":[{"code":"J7342","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":92.52,"maximum":92.52,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":92.52}]}]},{"description":"Budesonide comp unit","code_information":[{"code":"J7627","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":12.33,"maximum":12.33,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12.33}]}]},{"description":"Cabergoline, oral 0.25mg","code_information":[{"code":"J8515","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":49.9,"maximum":49.9,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":49.9}]}]},{"description":"Injection estrone per 1 MG","code_information":[{"code":"J1435","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":0.87,"maximum":0.87,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.87}]}]},{"description":"Inj delandistrogene mox rokl","code_information":[{"code":"J1413","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2487672.84,"maximum":9043550.16,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3316897.12,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6401611.45,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2487672.84,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9043550.16},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3383235.07,"additional_payer_notes":"APC"}]}]},{"description":"Eptifibatide injection","code_information":[{"code":"J1327","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2.9,"maximum":68.99,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3.87,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7.47,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2.9,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":68.99},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3.95,"additional_payer_notes":"APC"}]}]},{"description":"Doripenem injection","code_information":[{"code":"J1267","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1.77,"maximum":1.77,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1.77}]}]},{"description":"Phenylep ketorolac opth soln","code_information":[{"code":"J1097","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":72.23,"maximum":263.65,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":96.31,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":185.87,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":72.23,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":263.65},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":98.23,"additional_payer_notes":"APC"}]}]},{"description":"Brompheniramine maleate inj","code_information":[{"code":"J0945","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":0.87,"maximum":0.87,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.87}]}]},{"description":"Pralidoxime chloride inj","code_information":[{"code":"J2730","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":283.26,"maximum":283.26,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":283.26}]}]},{"description":"Inj, rykindo, 0.5 mg","code_information":[{"code":"J2801","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":9.77,"maximum":35.48,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.03,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":25.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9.77,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35.48},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.29,"additional_payer_notes":"APC"}]}]},{"description":"Inj, exagamglogene autotem","code_information":[{"code":"J3392","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1725680.0,"maximum":6348870.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2300906.67,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4440749.87,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1725680.0,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6348870.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2346924.8,"additional_payer_notes":"APC"}]}]},{"description":"Interferon alfacon-1 inj","code_information":[{"code":"J9212","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":16.75,"maximum":16.75,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16.75}]}]},{"description":"Ofatumumab injection","code_information":[{"code":"J9302","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":46.68,"maximum":169.42,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":62.23,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":120.11,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":46.68,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":169.42},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":63.48,"additional_payer_notes":"APC"}]}]},{"description":"Streptozocin injection","code_information":[{"code":"J9320","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1140.94,"maximum":1140.94,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1140.94}]}]},{"description":"Tixagev and cilgav, 300mg","code_information":[{"code":"Q0220","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":0.03,"maximum":0.03,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.03}]}]},{"description":"Sotrovimab","code_information":[{"code":"Q0247","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6860.7,"maximum":6860.7,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6860.7}]}]},{"description":"Dermacell","code_information":[{"code":"Q4122","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":92.32,"maximum":329.51,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":123.09,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":237.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":92.32,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":329.51},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":125.55,"additional_payer_notes":"APC"}]}]},{"description":"Excellagen, 0.1 cc","code_information":[{"code":"Q4149","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":473.72,"maximum":473.72,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":473.72}]}]},{"description":"Revitalon 1 square cm","code_information":[{"code":"Q4157","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":92.32,"maximum":552.4,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":123.09,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":237.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":92.32,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":552.4},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":125.55,"additional_payer_notes":"APC"}]}]},{"description":"Keramatrix, per square cm","code_information":[{"code":"Q4165","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":92.32,"maximum":237.56,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":123.09,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":237.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":92.32,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":121.46},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":125.55,"additional_payer_notes":"APC"}]}]},{"description":"Palingen or promatrx","code_information":[{"code":"Q4174","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3924.49,"maximum":3924.49,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3924.49}]}]},{"description":"Kyleena, 19.5 mg","code_information":[{"code":"J7296","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3779.24,"maximum":3779.24,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3779.24}]}]},{"description":"Tobramycin comp unit","code_information":[{"code":"J7685","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":157.64,"maximum":157.64,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":157.64}]}]},{"description":"Oral busulfan","code_information":[{"code":"J8510","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7.59,"maximum":229.27,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10.12,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":19.53,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7.59,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":229.27},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10.32,"additional_payer_notes":"APC"}]}]},{"description":"Gefitinib oral","code_information":[{"code":"J8565","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":792.25,"maximum":792.25,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":792.25}]}]},{"description":"Asparaginase, nos","code_information":[{"code":"J9020","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":139.14,"maximum":139.14,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":139.14}]}]},{"description":"Inj, bortezomib freseniuskab","code_information":[{"code":"J9048","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5.23,"maximum":44.93,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6.97,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13.45,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5.23,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":44.93},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7.11,"additional_payer_notes":"APC"}]}]},{"description":"Embryo hatching","code_information":[{"code":"89253","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":126.39,"maximum":325.23,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":168.51,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":325.23,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":126.39,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":143.5},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":171.88,"additional_payer_notes":"APC"}]}]},{"description":"Identify sperm tissue","code_information":[{"code":"89264","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":38.66,"maximum":99.48,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":51.54,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":99.48,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":38.66,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":49.47},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":52.57,"additional_payer_notes":"APC"}]}]},{"description":"Cryopreserve testicular tiss","code_information":[{"code":"89335","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":38.66,"maximum":99.48,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":51.54,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":99.48,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":38.66,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":49.47},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":52.57,"additional_payer_notes":"APC"}]}]},{"description":"Thaw cryoprsvrd reprod tiss","code_information":[{"code":"89354","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":126.39,"maximum":325.23,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":168.51,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":325.23,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":126.39,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":143.5},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":171.88,"additional_payer_notes":"APC"}]}]},{"description":"Screen c/v thin layer by MD","code_information":[{"code":"G0124","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":26.35,"maximum":26.35,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26.35}]}]},{"description":"Screening pap smear by phys","code_information":[{"code":"P3001","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":26.35,"maximum":26.35,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26.35}]}]},{"description":"Cmv ig iv","code_information":[{"code":"90291","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5739.62,"maximum":5739.62,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5739.62}]}]},{"description":"Rsv monoc antb seasnl 1ml im","code_information":[{"code":"90381","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1698.03,"maximum":1698.03,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1698.03}]}]},{"description":"Iiv3 vacc no prsv 0.25 ml im","code_information":[{"code":"90655","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":35.06,"maximum":35.06,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35.06}]}]},{"description":"Rsv vacc mrna lipid nano im","code_information":[{"code":"90683","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":947.43,"maximum":947.43,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":947.43}]}]},{"description":"Typhoid vaccine im","code_information":[{"code":"90691","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":321.67,"maximum":321.67,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":321.67}]}]},{"description":"Mmr vaccine sc","code_information":[{"code":"90707","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":305.38,"maximum":305.38,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":305.38}]}]},{"description":"Surgraft ft per sq cm","code_information":[{"code":"Q4268","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":92.32,"maximum":3577.96,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":123.09,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":237.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":92.32,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3577.96},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":125.55,"additional_payer_notes":"APC"}]}]},{"description":"Nudyn dl or dl mesh pr sq cm","code_information":[{"code":"Q4285","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":92.32,"maximum":523.4,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":123.09,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":237.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":92.32,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":523.4},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":125.55,"additional_payer_notes":"APC"}]}]},{"description":"Ardeograft, per sq cm","code_information":[{"code":"Q4333","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":92.32,"maximum":2331.6,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":123.09,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":237.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":92.32,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2331.6},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":125.55,"additional_payer_notes":"APC"}]}]},{"description":"Mantle dl matrix per sq cm","code_information":[{"code":"Q4349","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":92.32,"maximum":11444.33,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":123.09,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":237.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":92.32,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11444.33},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":125.55,"additional_payer_notes":"APC"}]}]},{"description":"Inj, omacetaxine mep, 0.01mg","code_information":[{"code":"J9262","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":10.76,"maximum":10.76,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10.76}]}]},{"description":"Inj pozelimab-bbfg, 1 mg","code_information":[{"code":"J9376","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":68.8,"maximum":282.73,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":91.73,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":177.04,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":68.8,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":282.73},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":93.56,"additional_payer_notes":"APC"}]}]},{"description":"Porfimer sodium injection","code_information":[{"code":"J9600","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":65961.87,"maximum":65961.87,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":65961.87}]}]},{"description":"Granisetron HCl 1 mg oral","code_information":[{"code":"Q0166","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":140.48,"maximum":140.48,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":140.48}]}]},{"description":"Bamlanivimab and etesevima","code_information":[{"code":"Q0245","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":0.03,"maximum":0.03,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.03}]}]},{"description":"Inj, sculptra, 0.5mg","code_information":[{"code":"Q2028","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1.62,"maximum":4.17,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2.16,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4.17,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1.62,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2.72},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2.2,"additional_payer_notes":"APC"}]}]},{"description":"Brachytherapy radioelements","code_information":[{"code":"Q3001","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":162.92,"maximum":162.92,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":162.92}]}]},{"description":"Amnio wound, per square cm","code_information":[{"code":"Q4181","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":92.32,"maximum":443.88,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":123.09,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":237.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":92.32,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":443.88},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":125.55,"additional_payer_notes":"APC"}]}]},{"description":"Hydrate iv infusion add-on","code_information":[{"code":"96361","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":34.74,"maximum":125.61,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":46.32,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":89.39,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":34.74,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":125.61},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":47.24,"additional_payer_notes":"APC"}]}]},{"description":"Symphony, per sq cm","code_information":[{"code":"A2009","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":92.32,"maximum":340.77,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":123.09,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":237.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":92.32,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":340.77},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":125.55,"additional_payer_notes":"APC"}]}]},{"description":"Miro3d per cubic cm","code_information":[{"code":"A2025","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":92.32,"maximum":677.19,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":123.09,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":237.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":92.32,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":677.19},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":125.55,"additional_payer_notes":"APC"}]}]},{"description":"In111 satumomab","code_information":[{"code":"A4642","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4419.9,"maximum":4419.9,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":4419.9}]}]},{"description":"Tc-99m graphite crucible","code_information":[{"code":"A9506","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":246.45,"maximum":894.61,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":328.6,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":634.2,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":246.45,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":894.61},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":335.17,"additional_payer_notes":"APC"}]}]},{"description":"Iodine I-123 sod iodide mic","code_information":[{"code":"A9516","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":303.83,"maximum":303.83,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":303.83}]}]},{"description":"Tc99m maa","code_information":[{"code":"A9540","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":80.16,"maximum":80.16,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":80.16}]}]},{"description":"Tc99m succimer","code_information":[{"code":"A9551","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":494.95,"maximum":1601.87,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":659.93,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1273.66,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":494.95,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1601.87},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":673.13,"additional_payer_notes":"APC"}]}]},{"description":"Co57 cyano","code_information":[{"code":"A9559","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":686.02,"maximum":686.02,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":686.02}]}]},{"description":"Technetium tc99m arcitumomab","code_information":[{"code":"A9568","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2203.89,"maximum":2203.89,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2203.89}]}]},{"description":"Gallium ga-68 psma-11 ucsf","code_information":[{"code":"A9593","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":412.6,"maximum":1456.29,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":550.13,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1061.75,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":412.6,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1456.29},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":561.13,"additional_payer_notes":"APC"}]}]},{"description":"Fluorodopa f-18 diag per mci","code_information":[{"code":"A9602","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":641.66,"maximum":1651.21,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":855.55,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1651.21,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":641.66,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1357.49},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":872.66,"additional_payer_notes":"APC"}]}]},{"description":"Inj, magtrace per study dose","code_information":[{"code":"A9697","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":940.5,"maximum":3098.09,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1254.0,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2420.22,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":940.5,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3098.09},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1279.08,"additional_payer_notes":"APC"}]}]},{"description":"Instill, bupivac and meloxic","code_information":[{"code":"C9088","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2.1,"maximum":2.1,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2.1}]}]},{"description":"Inj, sod thiosulfate (hope)","code_information":[{"code":"J0209","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":0.63,"maximum":2.52,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":0.84,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1.62,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":0.63,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2.52},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":0.86,"additional_payer_notes":"APC"}]}]},{"description":"Inj, artesunate, 1mg","code_information":[{"code":"J0391","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":38.87,"maximum":141.11,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":51.83,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":100.03,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":38.87,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":141.11},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":52.87,"additional_payer_notes":"APC"}]}]},{"description":"Dimecaprol injection","code_information":[{"code":"J0470","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":174.74,"maximum":174.74,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":174.74}]}]},{"description":"Bupren/nal up to 3mg bupreno","code_information":[{"code":"J0572","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":19.44,"maximum":19.44,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19.44}]}]},{"description":"Vim, per square centimeter","code_information":[{"code":"Q4251","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":92.32,"maximum":490.05,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":123.09,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":237.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":92.32,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":490.05},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":125.55,"additional_payer_notes":"APC"}]}]},{"description":"Lamellas, per sq cm","code_information":[{"code":"Q4292","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":92.32,"maximum":4004.14,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":123.09,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":237.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":92.32,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":4004.14},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":125.55,"additional_payer_notes":"APC"}]}]},{"description":"Amniotx, per sq cm","code_information":[{"code":"Q4324","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":92.32,"maximum":5280.61,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":123.09,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":237.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":92.32,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5280.61},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":125.55,"additional_payer_notes":"APC"}]}]},{"description":"Sentry sl matrix per sq cm","code_information":[{"code":"Q4348","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":92.32,"maximum":6376.13,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":123.09,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":237.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":92.32,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6376.13},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":125.55,"additional_payer_notes":"APC"}]}]},{"description":"Inj, wezlana, iv, 1 mg","code_information":[{"code":"Q5138","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1.77,"maximum":925.98,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2.35,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4.54,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1.77,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":925.98},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2.4,"additional_payer_notes":"APC"}]}]},{"description":"Sevelamer carbonate pdr 20mg","code_information":[{"code":"J0602","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":0.83,"maximum":0.83,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.83}]}]},{"description":"Caffeine citrate injection","code_information":[{"code":"J0706","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5.48,"maximum":5.48,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5.48}]}]},{"description":"Inj. Insulin (fiasp)","code_information":[{"code":"J1812","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5.23,"maximum":5.23,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5.23}]}]},{"description":"Injection, isavuconazonium","code_information":[{"code":"J1833","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":0.77,"maximum":2.69,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1.03,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":0.77,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2.69},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1.05,"additional_payer_notes":"APC"}]}]},{"description":"Inj, sezaby, 1 mg","code_information":[{"code":"J2561","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":0.84,"maximum":2.16,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1.12,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2.16,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":0.84,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1.77},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1.14,"additional_payer_notes":"APC"}]}]},{"description":"Methylnaltrexone injection","code_information":[{"code":"J2212","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4.9,"maximum":4.9,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":4.9}]}]},{"description":"Inj, lidocaine w epinephrine","code_information":[{"code":"J2004","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":0.08,"maximum":0.08,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.08}]}]},{"description":"Inj. meloxicam 1 mg","code_information":[{"code":"J1738","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":10.23,"maximum":10.23,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10.23}]}]},{"description":"Injection glatiramer acetate","code_information":[{"code":"J1595","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":467.1,"maximum":467.1,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":467.1}]}]},{"description":"Fomepizole, 15 mg","code_information":[{"code":"J1451","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4.64,"maximum":16.76,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6.18,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11.94,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4.64,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16.76},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6.31,"additional_payer_notes":"APC"}]}]},{"description":"Inj, hemgenix, per tx dose","code_information":[{"code":"J1411","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2768587.5,"maximum":10100475.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3691450.0,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7124498.5,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2768587.5,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10100475.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3765279.0,"additional_payer_notes":"APC"}]}]},{"description":"Enfuvirtide injection","code_information":[{"code":"J1324","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2.18,"maximum":2.18,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2.18}]}]},{"description":"Dolasetron mesylate","code_information":[{"code":"J1260","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":9.69,"maximum":9.69,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9.69}]}]},{"description":"Miglustat oral 65 mg","code_information":[{"code":"J1202","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":107.81,"maximum":107.81,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":107.81}]}]},{"description":"Injection, dexamethasone 9%","code_information":[{"code":"J1095","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7.38,"maximum":7.38,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7.38}]}]},{"description":"Vadadustat oral 1mg for esrd","code_information":[{"code":"J0901","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":0.46,"maximum":0.46,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.46}]}]},{"description":"Argatroban dialysis (accord)","code_information":[{"code":"J0892","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":12.94,"maximum":12.94,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12.94}]}]},{"description":"Inj, lovotibeglogene autotem","code_information":[{"code":"J3394","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2426477.99,"maximum":8692942.5,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3235303.98,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6244136.69,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2426477.99,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8692942.5},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3300010.06,"additional_payer_notes":"APC"}]}]},{"description":"5% dextrose in lac ringers","code_information":[{"code":"J7121","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":16.47,"maximum":16.47,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16.47}]}]},{"description":"Mirena, 52 mg","code_information":[{"code":"J7298","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3779.24,"maximum":3779.24,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3779.24}]}]},{"description":"Ganciclovir long act implant","code_information":[{"code":"J7310","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":11175.24,"maximum":11175.24,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11175.24}]}]},{"description":"Azathioprine parenteral","code_information":[{"code":"J7501","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":191.07,"maximum":623.37,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":254.76,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":491.68,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":191.07,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":623.37},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":259.85,"additional_payer_notes":"APC"}]}]},{"description":"Melphalan oral 2 MG","code_information":[{"code":"J8600","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":35.13,"maximum":35.13,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35.13}]}]},{"description":"Interferon alfa-2a inj","code_information":[{"code":"J9213","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":92.45,"maximum":92.45,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":92.45}]}]},{"description":"Vantas implant","code_information":[{"code":"J9225","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":12416.94,"maximum":12416.94,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12416.94}]}]},{"description":"Inj bulking agent anal canal","code_information":[{"code":"L8605","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2804.55,"maximum":2804.55,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2804.55}]}]},{"description":"Azithromycin dihydrate, oral","code_information":[{"code":"Q0144","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":34.35,"maximum":34.35,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34.35}]}]},{"description":"Promethazine HCl 12.5mg oral","code_information":[{"code":"Q0169","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":0.76,"maximum":0.76,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.76}]}]},{"description":"Tixagev and cilgav, 600mg","code_information":[{"code":"Q0221","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":0.03,"maximum":0.03,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.03}]}]},{"description":"Afluria vacc, 3 yrs & >, im","code_information":[{"code":"Q2035","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":67.47,"maximum":67.47,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":67.47}]}]},{"description":"Imported Lipodox inj","code_information":[{"code":"Q2049","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":224.06,"maximum":1439.82,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":298.74,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":576.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":224.06,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1439.82},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":304.71,"additional_payer_notes":"APC"}]}]},{"description":"Inj beta interferon sq 1 mcg","code_information":[{"code":"Q3028","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":127.58,"maximum":127.58,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":127.58}]}]},{"description":"Graftjacket xpress","code_information":[{"code":"Q4113","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5438.2,"maximum":5438.2,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5438.2}]}]},{"description":"Surgigraft, 1 sq cm","code_information":[{"code":"Q4183","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":92.32,"maximum":438.11,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":123.09,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":237.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":92.32,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":438.11},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":125.55,"additional_payer_notes":"APC"}]}]},{"description":"Tag, per square centimeter","code_information":[{"code":"Q4261","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":92.32,"maximum":1971.68,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":123.09,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":237.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":92.32,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1971.68},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":125.55,"additional_payer_notes":"APC"}]}]},{"description":"Nudyn sl or slw, per sq cm","code_information":[{"code":"Q4286","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":92.32,"maximum":689.88,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":123.09,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":237.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":92.32,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":689.88},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":125.55,"additional_payer_notes":"APC"}]}]},{"description":"Palisade dm matrix per sq cm","code_information":[{"code":"Q4350","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":92.32,"maximum":11444.33,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":123.09,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":237.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":92.32,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11444.33},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":125.55,"additional_payer_notes":"APC"}]}]},{"description":"Inj adalimumab-fkjp, 1 mg","code_information":[{"code":"Q5140","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":237.24,"maximum":237.24,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":237.24}]}]},{"description":"Visualization adjunct","code_information":[{"code":"Q9968","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8.15,"maximum":24.24,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10.87,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":20.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8.15,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24.24},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11.09,"additional_payer_notes":"APC"}]}]},{"description":"Transfusion procedure","code_information":[{"code":"86999","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":21.46,"maximum":55.21,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":28.61,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":55.21,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21.46,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22.99},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":29.18,"additional_payer_notes":"APC"}]}]},{"description":"Oocyte identification","code_information":[{"code":"89254","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":126.39,"maximum":325.23,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":168.51,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":325.23,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":126.39,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":143.5},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":171.88,"additional_payer_notes":"APC"}]}]},{"description":"Insemination of oocytes","code_information":[{"code":"89268","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":126.39,"maximum":325.23,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":168.51,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":325.23,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":126.39,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":143.5},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":171.88,"additional_payer_notes":"APC"}]}]},{"description":"Cryopreservation oocyte(s)","code_information":[{"code":"89337","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":126.39,"maximum":325.23,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":168.51,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":325.23,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":126.39,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":143.5},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":171.88,"additional_payer_notes":"APC"}]}]},{"description":"Thawing cryopresrved oocyte","code_information":[{"code":"89356","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":126.39,"maximum":325.23,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":168.51,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":325.23,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":126.39,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":143.5},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":171.88,"additional_payer_notes":"APC"}]}]},{"description":"Scr c/v cyto,autosys and md","code_information":[{"code":"G0141","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":26.35,"maximum":26.35,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26.35}]}]},{"description":"Culture bacterial urine","code_information":[{"code":"P7001","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":19.49,"maximum":19.49,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19.49}]}]},{"description":"Rh ig full-dose im","code_information":[{"code":"90384","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":326.16,"maximum":326.16,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":326.16}]}]},{"description":"Hib-mency vacc 6wk-18m0 im","code_information":[{"code":"90644","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":59.9,"maximum":59.9,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":59.9}]}]},{"description":"Rabies vaccine id","code_information":[{"code":"90676","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":177.64,"maximum":720.03,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":236.86,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":457.14,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":177.64,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":720.03},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":241.6,"additional_payer_notes":"APC"}]}]},{"description":"Mmrv vaccine sc","code_information":[{"code":"90710","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":907.1,"maximum":907.1,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":907.1}]}]},{"description":"Mpsv4 vaccine subq","code_information":[{"code":"90733","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":226.31,"maximum":226.31,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":226.31}]}]},{"description":"Miscellaneous M >=66.50","code_information":[{"code":"A2001","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":92.32,"maximum":2998.56,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":123.09,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":237.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":92.32,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2998.56},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":125.55,"additional_payer_notes":"APC"}]}]},{"description":"In111 capromab","code_information":[{"code":"A9507","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1297.72,"maximum":3576.24,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1730.29,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3339.46,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1297.72,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3576.24},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1764.9,"additional_payer_notes":"APC"}]}]},{"description":"I131 iodide cap, rx","code_information":[{"code":"A9517","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":18.05,"maximum":62.96,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":24.07,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":46.46,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18.05,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":62.96},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":24.55,"additional_payer_notes":"APC"}]}]},{"description":"I131 iodide sol, rx","code_information":[{"code":"A9530","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":15.58,"maximum":56.84,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20.77,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":40.09,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15.58,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":56.84},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21.19,"additional_payer_notes":"APC"}]}]},{"description":"Tc99m sulfur colloid","code_information":[{"code":"A9541","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2045.69,"maximum":2045.69,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2045.69}]}]},{"description":"F18 fdg","code_information":[{"code":"A9552","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1136.88,"maximum":1136.88,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1136.88}]}]},{"description":"Tc99m labeled rbc","code_information":[{"code":"A9560","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":287.08,"maximum":287.08,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":287.08}]}]},{"description":"Technetium TC-99m auto WBC","code_information":[{"code":"A9569","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":700.6,"maximum":2832.27,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":934.13,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1802.87,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":700.6,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2832.27},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":952.81,"additional_payer_notes":"APC"}]}]},{"description":"Florbetapir F18","code_information":[{"code":"A9586","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1369.23,"maximum":5974.85,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1825.64,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3523.49,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1369.23,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5974.85},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1862.15,"additional_payer_notes":"APC"}]}]},{"description":"Gallium ga-68 psma-11, ucla","code_information":[{"code":"A9594","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":272.62,"maximum":1013.23,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":363.5,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":701.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":272.62,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1013.23},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":370.77,"additional_payer_notes":"APC"}]}]},{"description":"Inj, oliceridine 0.1 mg","code_information":[{"code":"C9101","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3.6,"maximum":3.6,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3.6}]}]},{"description":"Bevacizumab injection","code_information":[{"code":"C9257","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1.4,"maximum":4.98,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1.87,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3.61,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1.4,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":4.98},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1.91,"additional_payer_notes":"APC"}]}]},{"description":"Methyldopate hcl injection","code_information":[{"code":"J0210","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":136.13,"maximum":136.13,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":136.13}]}]},{"description":"Alprostadil for injection","code_information":[{"code":"J0270","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1.29,"maximum":1.29,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1.29}]}]},{"description":"Ampho b cholesteryl sulfate","code_information":[{"code":"J0288","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":192.87,"maximum":192.87,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":192.87}]}]},{"description":"Bupren/nal 3.1 to 6mg bupren","code_information":[{"code":"J0573","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":30.74,"maximum":30.74,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30.74}]}]},{"description":"Sevelamer hydrochloride 20mg","code_information":[{"code":"J0603","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":0.54,"maximum":0.54,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.54}]}]},{"description":"Papaverin hcl injection","code_information":[{"code":"J2440","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":125.07,"maximum":125.07,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":125.07}]}]},{"description":"Pentobarbital sodium inj","code_information":[{"code":"J2515","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":14.47,"maximum":183.83,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19.3,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":37.25,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14.47,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":183.83},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19.68,"additional_payer_notes":"APC"}]}]},{"description":"Inj midazolam in 0.8% nacl","code_information":[{"code":"J2252","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":0.21,"maximum":0.21,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.21}]}]},{"description":"Mecasermin injection","code_information":[{"code":"J2170","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":459.76,"maximum":459.76,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":459.76}]}]},{"description":"Inj, lidocaine hcl, 1 mg","code_information":[{"code":"J2003","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":0.17,"maximum":0.17,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.17}]}]},{"description":"Inj, furoscix, 20 mg","code_information":[{"code":"J1941","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":773.82,"maximum":773.82,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":773.82}]}]},{"description":"Diazoxide injection","code_information":[{"code":"J1730","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":267.7,"maximum":267.7,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":267.7}]}]},{"description":"Tinzaparin sodium injection","code_information":[{"code":"J1655","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":9.69,"maximum":9.69,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9.69}]}]},{"description":"Inj., brexanolone, 1 mg","code_information":[{"code":"J1632","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":243.39,"maximum":243.39,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":243.39}]}]},{"description":"Inj golodirsen 10 mg","code_information":[{"code":"J1429","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":522.72,"maximum":522.72,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":522.72}]}]},{"description":"Inj dexamethasone acetate","code_information":[{"code":"J1094","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":0.87,"maximum":0.87,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.87}]}]},{"description":"Argatroban nonesrd (accord)","code_information":[{"code":"J0891","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1.36,"maximum":4.95,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1.82,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3.5,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1.36,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":4.95},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1.85,"additional_payer_notes":"APC"}]}]},{"description":"Inj codeine phosphate /30 MG","code_information":[{"code":"J0745","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2.64,"maximum":2.64,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2.64}]}]},{"description":"Quinupristin/dalfopristin","code_information":[{"code":"J2770","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":11.6,"maximum":11.6,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11.6}]}]},{"description":"Inj theophylline per 40 MG","code_information":[{"code":"J2810","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2.85,"maximum":2.85,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2.85}]}]},{"description":"Ovine, 1000 USP units","code_information":[{"code":"J3472","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":289.72,"maximum":289.72,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":289.72}]}]},{"description":"Edetate disodium per 150 mg","code_information":[{"code":"J3520","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":0.87,"maximum":0.87,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.87}]}]},{"description":"Hypertonic saline sol","code_information":[{"code":"J7131","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":0.25,"maximum":0.25,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":0.25}]}]},{"description":"Intraut copper contraceptive","code_information":[{"code":"J7300","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3718.94,"maximum":3718.94,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3718.94}]}]},{"description":"Mannitol for inhaler","code_information":[{"code":"J7665","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3.22,"maximum":3.22,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3.22}]}]},{"description":"Terbutaline sulf comp con","code_information":[{"code":"J7680","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":34.35,"maximum":34.35,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34.35}]}]},{"description":"Cytarabine liposome inj","code_information":[{"code":"J9098","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1113.12,"maximum":1113.12,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1113.12}]}]},{"description":"Elliotts b solution per ml","code_information":[{"code":"J9175","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":31.42,"maximum":31.42,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31.42}]}]},{"description":"Interferon alfa-2b inj","code_information":[{"code":"J9214","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":34.35,"maximum":34.35,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34.35}]}]},{"description":"Inj., lumoxiti, 0.01 mg","code_information":[{"code":"J9313","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":17.55,"maximum":63.67,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23.39,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":45.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17.55,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":63.67},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23.86,"additional_payer_notes":"APC"}]}]},{"description":"Inj vocal cord bulking agent","code_information":[{"code":"L8607","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":167.95,"maximum":167.95,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":167.95}]}]},{"description":"Dronabinol (syndros) 0.1 mg","code_information":[{"code":"Q0155","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":10.59,"maximum":10.59,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10.59}]}]},{"description":"Trimethobenzamide HCl 250mg","code_information":[{"code":"Q0173","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1.77,"maximum":1.77,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1.77}]}]},{"description":"Bebtelovimab 175 mg","code_information":[{"code":"Q0222","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6860.7,"maximum":6860.7,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6860.7}]}]},{"description":"Sermorelin acetate injection","code_information":[{"code":"Q0515","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3.51,"maximum":3.51,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3.51}]}]},{"description":"Truskin, per sq centimeter","code_information":[{"code":"Q4167","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":92.32,"maximum":329.47,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":123.09,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":237.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":92.32,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":329.47},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":125.55,"additional_payer_notes":"APC"}]}]},{"description":"Neopatch, per sq centimeter","code_information":[{"code":"Q4176","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":92.32,"maximum":483.52,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":123.09,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":237.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":92.32,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":483.52},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":125.55,"additional_payer_notes":"APC"}]}]},{"description":"Coretext or protext, per cc","code_information":[{"code":"Q4246","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8766.45,"maximum":8766.45,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8766.45}]}]},{"description":"Enclose tl matrix, per sq cm","code_information":[{"code":"Q4351","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":92.32,"maximum":12261.79,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":123.09,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":237.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":92.32,"additional_payer_notes":"APC"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12261.79},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":125.55,"additional_payer_notes":"APC"}]}]},{"description":"Inj adalimumab-aaty, 1 mg","code_information":[{"code":"Q5141","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":118.62,"maximum":118.62,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":118.62}]}]},{"description":"Non-HEU TC-99M add-on/dose","code_information":[{"code":"Q9969","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":27.23,"maximum":27.23,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27.23}]}]},{"description":"Heart Transplant Or Implant Of Heart Assist System Without Mcc","code_information":[{"code":"002","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":62230.42,"maximum":233116.2,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":82973.89,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":176742.08},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":204437.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":195700.19},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":184708.34},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":82973.89,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":123709.26},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":148299.27},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":82973.89,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":82973.89,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":62230.42,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":82973.89,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":233116.2},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":154935.28},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":226069.41},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":200232.91},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":82973.89,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":170690.9},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":84633.37,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":194627.63}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Mcc","code_information":[{"code":"011","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":29952.08,"maximum":112200.98,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":39936.1,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":85067.6},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":98397.42},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":94192.31},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":88901.83},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":39936.1,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":59542.41},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":71377.81},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":39936.1,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":39936.1,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":29952.08,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":39936.1,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":112200.98},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":74571.78},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":108809.3},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":96373.95},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":39936.1,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":82155.11},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":40734.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":93676.08}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Mcc","code_information":[{"code":"020","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":43212.79,"maximum":161875.85,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":57617.05,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":122729.67},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":141961.02},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":135894.18},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":128261.44},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":57617.05,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":85903.69},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":102978.99},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":57617.05,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":57617.05,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":43212.79,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":57617.05,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":161875.85},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":107587.03},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":156982.56},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":139041.7},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":57617.05,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":118527.73},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":58769.39,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":135149.39}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Spinal Procedures With Mcc","code_information":[{"code":"028","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":32995.55,"maximum":123601.91,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":43994.07,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":93711.46},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":108395.74},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":103763.34},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":97935.29},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":43994.07,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":65592.61},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":78630.62},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":43994.07,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":43994.07,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":32995.55,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":43994.07,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":123601.91},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":82149.14},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":119865.59},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":106166.66},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":43994.07,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":90503.02},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":44873.95,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":103194.66}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Carotid Artery Stent Procedures Without Cc/Mcc","code_information":[{"code":"036","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":10669.2,"maximum":39967.01,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14225.6,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":30301.85},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":35050.05},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":33552.16},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":31667.64},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14225.6,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21209.55},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25425.42},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14225.6,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14225.6,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10669.2,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14225.6,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":39967.01},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26563.15},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38758.86},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34329.28},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14225.6,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29264.4},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14510.11,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33368.27}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":14203.28,"10th_percentile":14203.28,"90th_percentile":14203.28,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Spinal Disorders And Injuries Without Cc/Mcc","code_information":[{"code":"053","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":5377.43,"maximum":20143.97,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7169.91,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":15272.58},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17665.75},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16910.78},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15960.96},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7169.91,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10689.93},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12814.79},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7169.91,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7169.91,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5377.43,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7169.91,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":20143.97},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13388.22},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19535.04},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17302.46},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7169.91,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14749.69},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7313.31,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16818.1}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Mcc","code_information":[{"code":"061","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":15141.06,"maximum":56718.68,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20188.08,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":43002.49},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":49740.84},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":47615.12},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":44940.73},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20188.08,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30099.26},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36082.17},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20188.08,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20188.08,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15141.06,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20188.08,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":56718.68},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37696.75},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":55004.15},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":48717.96},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20188.08,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":41530.2},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20591.84,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":47354.16}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":25650.36,"10th_percentile":25650.36,"90th_percentile":25650.36,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":10496.09,"10th_percentile":10496.09,"90th_percentile":10496.09,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Transient Ischemia Without Thrombolytic","code_information":[{"code":"069","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":4386.74,"maximum":16432.8,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5848.99,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":12458.88},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14411.15},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13795.28},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13020.44},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5848.99,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8720.5},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10453.9},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5848.99,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5848.99,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4386.74,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5848.99,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":16432.8},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10921.68},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15936.06},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14114.8},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5848.99,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12032.32},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5965.97,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13719.67}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":6259.66,"10th_percentile":6259.66,"90th_percentile":6259.66,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":2859.45,"10th_percentile":2859.45,"90th_percentile":2859.45,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":5330.79,"10th_percentile":755.07,"90th_percentile":6223.65,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":1743.0,"10th_percentile":282.88,"90th_percentile":6264.79,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":13400.9,"10th_percentile":13400.9,"90th_percentile":13400.9,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Nontraumatic Stupor And Coma With Mcc","code_information":[{"code":"080","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":9939.91,"maximum":37235.07,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13253.21,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":28230.57},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":32654.21},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":31258.7},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":29503.0},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13253.21,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19759.77},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23687.47},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13253.21,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13253.21,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9939.91,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13253.21,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":37235.07},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24747.42},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36109.5},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31982.7},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13253.21,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27264.03},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13518.27,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31087.38}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":15406.09,"10th_percentile":15406.09,"90th_percentile":15406.09,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":14679.7,"10th_percentile":14679.7,"90th_percentile":14679.7,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Concussion With Mcc","code_information":[{"code":"088","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":7423.63,"maximum":27809.04,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9898.17,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":21084.02},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24387.82},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23345.59},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22034.34},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9898.17,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14757.6},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17691.01},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9898.17,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9898.17,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7423.63,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9898.17,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":27809.04},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18482.63},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26968.41},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23886.31},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9898.17,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20362.16},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10096.13,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23217.64}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Bacterial And Tuberculous Infections Of Nervous System Without Cc/Mcc","code_information":[{"code":"096","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":14164.1,"maximum":53058.94,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18885.46,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":40227.78},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":46531.35},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":44542.78},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":42040.96},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18885.46,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28157.13},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33753.99},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18885.46,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18885.46,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14164.1,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18885.46,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":53058.94},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35264.4},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":51455.04},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":45574.46},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18885.46,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38850.49},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19263.17,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":44298.66}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Orbital Procedures With Cc/Mcc","code_information":[{"code":"113","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":12911.44,"maximum":48366.5,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17215.26,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":36670.11},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":42416.2},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":40603.5},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":38322.93},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17215.26,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25666.96},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30768.85},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17215.26,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17215.26,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12911.44,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17215.26,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":48366.5},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32145.67},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":46904.45},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":41543.94},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17215.26,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35414.62},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17559.57,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":40380.97}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Disorders Of The Eye With Mcc Or Thrombolytic Agent","code_information":[{"code":"124","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":7266.02,"maximum":27218.63,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9688.02,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":20636.39},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23870.05},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22849.94},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21566.53},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9688.02,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14444.28},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17315.41},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9688.02,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9688.02,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7266.02,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9688.02,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":27218.63},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18090.23},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26395.85},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23379.18},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9688.02,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19929.86},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9881.78,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22724.71}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Major Head And Neck Procedures With Cc","code_information":[{"code":"141","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":11977.86,"maximum":44869.28,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15970.48,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":34018.62},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":39349.23},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":37667.6},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":35551.93},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15970.48,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23811.07},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28544.06},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15970.48,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15970.48,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11977.86,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15970.48,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":44869.28},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29821.33},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":43512.95},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38540.04},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15970.48,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32853.91},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16289.89,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37461.16}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Dysequilibrium","code_information":[{"code":"149","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":4127.54,"maximum":15461.81,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5503.38,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":11722.71},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13559.62},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12980.13},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12251.08},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5503.38,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8205.22},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9836.19},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5503.38,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5503.38,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4127.54,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5503.38,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15461.81},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10276.33},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14994.42},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13280.77},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5503.38,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11321.35},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5613.45,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12908.99}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":1731.22,"10th_percentile":1731.22,"90th_percentile":5821.99,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Dental And Oral Diseases With Mcc","code_information":[{"code":"157","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":9428.08,"maximum":35317.77,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12570.78,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":26776.93},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":30972.79},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":29649.14},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27983.84},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12570.78,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18742.31},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22467.76},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12570.78,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12570.78,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9428.08,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12570.78,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":35317.77},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23473.14},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34250.16},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30335.86},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12570.78,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25860.16},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12822.2,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29486.64}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Respiratory System O.R. Procedures Without Cc/Mcc","code_information":[{"code":"168","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":7503.81,"maximum":28109.39,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10005.08,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":21311.74},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24651.22},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23597.73},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22272.32},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10005.08,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14916.99},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17882.08},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10005.08,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10005.08,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7503.81,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10005.08,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":28109.39},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18682.25},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27259.68},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24144.29},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10005.08,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20582.08},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10205.18,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23468.4}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Respiratory Neoplasms With Cc","code_information":[{"code":"181","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":5881.57,"maximum":22032.46,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7842.09,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":16704.39},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19321.91},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18496.17},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17457.3},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7842.09,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11692.11},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14016.18},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7842.09,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7842.09,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5881.57,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7842.09,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":22032.46},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14643.37},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21366.45},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18924.57},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7842.09,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16132.47},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7998.93,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18394.8}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":8599.05,"10th_percentile":8599.05,"90th_percentile":8599.05,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Pulmonary Edema And Respiratory Failure","code_information":[{"code":"189","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":6784.4,"maximum":25414.48,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9045.87,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":19268.53},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22287.85},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21335.36},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20137.02},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9045.87,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13486.86},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16167.68},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9045.87,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9045.87,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6784.4,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9045.87,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":25414.48},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16891.14},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24646.23},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21829.52},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9045.87,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18608.83},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9226.79,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21218.43}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":8308.65,"10th_percentile":8308.65,"90th_percentile":8308.65,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":9815.27,"10th_percentile":7848.81,"90th_percentile":11493.41,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"1 through 10","median_amount":4670.69,"10th_percentile":4670.69,"90th_percentile":4670.69,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"1 through 10","median_amount":19299.73,"10th_percentile":18881.36,"90th_percentile":20439.69,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":11237.15,"10th_percentile":11237.15,"90th_percentile":11237.15,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"1 through 10","median_amount":13508.7,"10th_percentile":13508.7,"90th_percentile":13508.7,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"18","median_amount":9044.41,"10th_percentile":6653.54,"90th_percentile":9616.41,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":4394.5,"10th_percentile":4394.5,"90th_percentile":4394.5,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":8586.52,"10th_percentile":8586.52,"90th_percentile":8586.52,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":9589.71,"10th_percentile":8966.01,"90th_percentile":11202.26,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"25","median_amount":8152.62,"10th_percentile":5348.25,"90th_percentile":9623.41,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":18454.58,"10th_percentile":13288.58,"90th_percentile":18638.96,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":8166.73,"10th_percentile":8166.73,"90th_percentile":8226.68,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Interstitial Lung Disease With Cc","code_information":[{"code":"197","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":5212.14,"maximum":19524.75,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6949.52,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":14803.11},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17122.71},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16390.96},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15470.33},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6949.52,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10361.32},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12420.87},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6949.52,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6949.52,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5212.14,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6949.52,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":19524.75},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12976.67},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18934.55},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16770.6},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6949.52,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14296.29},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7088.51,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16301.12}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":71.25,"10th_percentile":71.25,"90th_percentile":71.25,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Respiratory System Diagnoses With Mcc","code_information":[{"code":"205","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":10055.24,"maximum":37667.08,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13406.98,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":28558.11},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":33033.07},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":31621.37},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":29845.3},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13406.98,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19989.03},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23962.3},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13406.98,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13406.98,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10055.24,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13406.98,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":37667.08},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25034.55},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36528.45},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32353.77},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13406.98,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27580.35},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13675.12,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31448.07}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":13753.62,"10th_percentile":13753.62,"90th_percentile":13753.62,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":14620.62,"10th_percentile":14620.62,"90th_percentile":14620.62,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Mcc","code_information":[{"code":"216","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":53723.83,"maximum":201250.39,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":71631.77,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":152582.33},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":176491.49},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":168948.96},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":159459.64},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":71631.77,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":106798.83},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":128027.5},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":71631.77,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":71631.77,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":53723.83,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":71631.77,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":201250.39},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":133756.41},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":195166.86},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":172862.08},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":71631.77,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":147358.32},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":73064.41,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":168023.01}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"1 through 10","median_amount":150528.21,"10th_percentile":150528.21,"90th_percentile":150528.21,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":75195.97,"10th_percentile":75195.97,"90th_percentile":75195.97,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":74762.26,"10th_percentile":74752.76,"90th_percentile":89518.25,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":103892.89,"10th_percentile":103892.89,"90th_percentile":103892.89,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Coronary Bypass With Ptca With Mcc","code_information":[{"code":"231","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":46294.16,"maximum":173418.72,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":61725.55,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":131481.15},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":152083.83},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":145584.37},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":137407.37},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":61725.55,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":92029.22},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":110322.1},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":61725.55,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":61725.55,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":46294.16,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":61725.55,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":173418.72},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":115258.74},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":168176.51},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":148956.33},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":61725.55,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":126979.58},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":62960.06,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":144786.48}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Amputation For Circulatory System Disorders Except Upper Limb And Toe Without Cc/Mcc","code_information":[{"code":"241","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":7602.66,"maximum":28479.68,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10136.88,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":21592.49},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24975.96},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23908.59},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22565.72},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10136.88,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15113.49},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18117.64},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10136.88,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10136.88,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7602.66,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10136.88,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":28479.68},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18928.36},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27618.78},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24462.35},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10136.88,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20853.22},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10339.62,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23777.55}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Vascular Procedures With Cc","code_information":[{"code":"253","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":14254.16,"maximum":53396.32,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19005.54,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":40483.57},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":46827.22},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":44826.01},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":42308.28},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19005.54,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28336.17},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33968.62},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19005.54,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19005.54,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14254.16,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19005.54,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":53396.32},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35488.63},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":51782.22},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":45864.25},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19005.54,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":39097.52},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19385.65,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":44580.34}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":19807.45,"10th_percentile":19807.45,"90th_percentile":19807.45,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":18478.85,"10th_percentile":18478.85,"90th_percentile":18478.85,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":24147.87,"10th_percentile":19794.45,"90th_percentile":24180.87,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":19548.96,"10th_percentile":18189.75,"90th_percentile":22599.47,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":38888.86,"10th_percentile":38888.86,"90th_percentile":38888.86,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cardiac Pacemaker Revision Except Device Replacement With Cc","code_information":[{"code":"261","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":10381.99,"maximum":38891.1,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13842.65,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":29486.13},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":34106.51},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":32648.94},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":30815.15},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13842.65,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20638.59},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24740.97},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13842.65,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13842.65,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10381.99,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13842.65,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":38891.1},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25848.07},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37715.48},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33405.14},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13842.65,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28476.6},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14119.5,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32470.0}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Aortic And Heart Assist Procedures Except Pulsation Balloon Without Mcc","code_information":[{"code":"269","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":23192.38,"maximum":86879.08,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":30923.18,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":65869.25},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":76190.75},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":72934.66},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":68838.16},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":30923.18,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":46104.67},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":55269.02},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":30923.18,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":30923.18,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23192.38,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":30923.18,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":86879.08},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":57742.17},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":84252.84},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":74623.94},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":30923.18,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":63614.06},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":31541.64,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":72534.94}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":21554.33,"10th_percentile":21554.33,"90th_percentile":21554.33,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":32230.05,"10th_percentile":32230.05,"90th_percentile":32237.35,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":32276.52,"10th_percentile":32276.52,"90th_percentile":38902.97,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":32023.94,"10th_percentile":32023.94,"90th_percentile":32023.94,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cardiac Defibrillator Implant Without Mcc","code_information":[{"code":"277","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":25363.24,"maximum":95011.14,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":33817.65,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":72034.74},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":83322.36},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":79761.5},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":75281.55},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":33817.65,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":50420.16},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":60442.31},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":33817.65,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":33817.65,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25363.24,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":33817.65,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":95011.14},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":63146.95},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":92139.08},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":81608.9},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":33817.65,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":69568.47},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":34494.0,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":79324.35}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":40826.39,"10th_percentile":40826.39,"90th_percentile":40826.39,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":35889.0,"10th_percentile":35889.0,"90th_percentile":35889.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":36408.88,"10th_percentile":36408.88,"90th_percentile":36408.88,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Acute Myocardial Infarction, Expired Without Cc/Mcc","code_information":[{"code":"285","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":3288.96,"maximum":12320.49,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4385.28,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":9341.04},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10804.75},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10343.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":9762.07},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4385.28,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6538.19},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7837.8},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4385.28,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4385.28,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3288.96,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4385.28,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":12320.49},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8188.53},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11948.06},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10582.56},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4385.28,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9021.23},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4472.99,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10286.32}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Heart Failure And Shock Without Cc/Mcc","code_information":[{"code":"293","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":3108.28,"maximum":11643.67,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4144.37,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":8827.9},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10211.21},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":9774.82},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":9225.8},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4144.37,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6179.02},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7407.24},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4144.37,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4144.37,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3108.28,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4144.37,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":11643.67},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7738.7},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11291.7},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10001.22},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4144.37,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8525.66},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4227.26,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9721.25}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Atherosclerosis Without Mcc","code_information":[{"code":"303","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":3696.99,"maximum":13848.98,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4929.32,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":10499.9},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12145.2},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11626.16},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10973.16},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4929.32,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7349.32},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8810.17},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4929.32,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4929.32,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3696.99,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4929.32,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":13848.98},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9204.4},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13430.34},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11895.44},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4929.32,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10140.41},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5027.91,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11562.45}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":5345.8,"10th_percentile":5345.8,"90th_percentile":5345.8,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":6263.04,"10th_percentile":6263.04,"90th_percentile":6263.04,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Angina Pectoris","code_information":[{"code":"311","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":3854.6,"maximum":14439.39,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5139.46,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":10947.53},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12662.98},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12121.81},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11440.97},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5139.46,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7662.64},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9185.77},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5139.46,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5139.46,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3854.6,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5139.46,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":14439.39},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9596.8},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14002.91},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12402.57},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5139.46,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10572.72},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5242.25,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12055.38}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Endovascular Cardiac Valve Procedures With Mcc","code_information":[{"code":"319","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":24508.74,"maximum":91810.15,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":32678.32,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":69607.85},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":80515.18},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":77074.28},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":72745.27},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":32678.32,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":48721.48},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":58405.97},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":32678.32,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":32678.32,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":24508.74,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":32678.32,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":91810.15},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":61019.49},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":89034.86},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":78859.44},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":32678.32,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":67224.66},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":33331.89,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":76651.87}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":34054.33,"10th_percentile":34054.33,"90th_percentile":34054.33,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Stomach, Esophageal And Duodenal Procedures With Cc","code_information":[{"code":"327","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":13422.72,"maximum":50281.74,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17896.96,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":38122.19},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":44095.81},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":42211.33},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":39840.46},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17896.96,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26683.33},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31987.25},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17896.96,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17896.96,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13422.72,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17896.96,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":50281.74},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33418.59},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":48761.79},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":43189.01},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17896.96,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36816.98},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18254.9,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":41979.99}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Peritoneal Adhesiolysis With Mcc","code_information":[{"code":"335","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":19610.18,"maximum":73460.05,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26146.9,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":55695.33},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":64422.61},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":61669.44},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":58205.67},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26146.9,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38983.52},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":46732.37},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26146.9,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26146.9,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19610.18,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26146.9,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":73460.05},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":48823.52},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":71239.46},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":63097.8},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26146.9,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":53788.47},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26669.84,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":61331.46}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":26420.01,"10th_percentile":26420.01,"90th_percentile":26420.01,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":26745.49,"10th_percentile":26745.49,"90th_percentile":26745.49,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Anal And Stomal Procedures Without Cc/Mcc","code_information":[{"code":"349","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":4781.04,"maximum":17909.86,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6374.72,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":13578.75},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15706.49},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15035.26},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14190.78},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6374.72,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9504.34},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11393.54},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6374.72,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6374.72,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4781.04,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6374.72,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17909.86},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11903.37},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17368.47},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15383.5},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6374.72,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13113.85},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6502.21,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14952.86}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":6822.4,"10th_percentile":6822.4,"90th_percentile":6822.4,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Digestive System O.R. Procedures With Cc","code_information":[{"code":"357","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":12770.86,"maximum":47839.86,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17027.81,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":36270.82},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":41954.35},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":40161.39},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":37905.65},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17027.81,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25387.48},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30433.82},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17027.81,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17027.81,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12770.86,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17027.81,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":47839.86},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31795.65},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":46393.73},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":41091.59},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17027.81,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35029.01},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17368.37,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":39941.28}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":17454.87,"10th_percentile":17454.87,"90th_percentile":17454.87,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":17476.27,"10th_percentile":17476.27,"90th_percentile":17476.27,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":33921.88,"10th_percentile":33921.88,"90th_percentile":33921.88,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":11917.74,"10th_percentile":11917.74,"90th_percentile":11917.74,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Major Gastrointestinal Disorders And Peritoneal Infections With Cc","code_information":[{"code":"372","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":5606.98,"maximum":21003.87,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7475.98,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":15924.54},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18419.86},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17632.67},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16642.3},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7475.98,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11146.26},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13361.83},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7475.98,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7475.98,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5606.98,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7475.98,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":21003.87},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13959.73},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20368.95},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18041.07},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7475.98,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15379.32},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7625.5,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17536.03}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":5313.49,"10th_percentile":5313.49,"90th_percentile":5313.49,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"1 through 10","median_amount":13022.15,"10th_percentile":13022.15,"90th_percentile":13022.15},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":5403.63,"10th_percentile":5403.63,"90th_percentile":5403.63,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":8029.31,"10th_percentile":8029.31,"90th_percentile":8029.31,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":15504.35,"10th_percentile":15504.35,"90th_percentile":15504.35,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Complicated Peptic Ulcer With Mcc","code_information":[{"code":"380","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":10775.74,"maximum":40366.1,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14367.65,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":30604.43},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":35400.05},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":33887.19},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":31983.86},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14367.65,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21421.34},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25679.31},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14367.65,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14367.65,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10775.74,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14367.65,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":40366.1},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26828.4},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":39145.89},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34672.07},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14367.65,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29556.62},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14655.0,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33701.47}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":14903.3,"10th_percentile":14903.3,"90th_percentile":14903.3,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":14925.21,"10th_percentile":14925.21,"90th_percentile":14925.21,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Gastrointestinal Obstruction With Mcc","code_information":[{"code":"388","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":8110.09,"maximum":30380.52,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10813.45,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":23033.65},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26642.95},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25504.34},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24071.84},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10813.45,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16122.23},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19326.88},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10813.45,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10813.45,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8110.09,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10813.45,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":30380.52},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20191.71},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29462.16},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26095.06},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10813.45,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22245.04},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11029.72,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25364.56}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":11110.13,"10th_percentile":11110.13,"90th_percentile":11110.13,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":11401.57,"10th_percentile":11401.57,"90th_percentile":13406.84,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":12642.25,"10th_percentile":12642.25,"90th_percentile":12642.25,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":13468.69,"10th_percentile":13468.69,"90th_percentile":13468.69,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Appendix Procedures With Mcc","code_information":[{"code":"397","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":13151.98,"maximum":49267.55,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17535.97,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":37353.26},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43206.39},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":41359.92},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":39036.87},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17535.97,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26145.12},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31342.06},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17535.97,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17535.97,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13151.98,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17535.97,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":49267.55},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32744.53},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":47778.26},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":42317.88},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17535.97,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36074.38},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17886.69,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":41133.25}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Cc","code_information":[{"code":"409","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":11957.0,"maximum":44791.11,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15942.66,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":33959.35},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":39280.67},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":37601.97},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":35489.99},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15942.66,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23769.58},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28494.33},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15942.66,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15942.66,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11957.0,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15942.66,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":44791.11},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29769.37},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":43437.14},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38472.89},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15942.66,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32796.67},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16261.51,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37395.89}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Laparoscopic Cholecystectomy Without C.D.E. With Mcc","code_information":[{"code":"417","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":13105.3,"maximum":49092.69,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17473.74,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":37220.68},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43053.04},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":41213.13},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":38898.32},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17473.74,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26052.33},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31230.82},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17473.74,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17473.74,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13105.3,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17473.74,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":49092.69},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32628.32},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":47608.68},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":42167.69},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17473.74,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35946.34},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17823.21,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":40987.26}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"1 through 10","median_amount":39088.85,"10th_percentile":39088.85,"90th_percentile":39088.85,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":18965.46,"10th_percentile":18965.46,"90th_percentile":18965.46,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":22218.1,"10th_percentile":22218.1,"90th_percentile":22218.1,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":10226.44,"10th_percentile":10226.44,"90th_percentile":10226.44,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":35597.22,"10th_percentile":35597.22,"90th_percentile":35597.22,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Hepatobiliary Or Pancreas O.R. Procedures Without Cc/Mcc","code_information":[{"code":"425","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":8239.14,"maximum":30863.96,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10985.52,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":23400.18},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27066.91},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25910.18},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24454.89},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10985.52,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16378.78},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19634.43},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10985.52,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10985.52,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8239.14,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10985.52,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":30863.96},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20513.02},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29930.99},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26510.3},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10985.52,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22599.02},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11205.23,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25768.18}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cirrhosis And Alcoholic Hepatitis Without Cc/Mcc","code_information":[{"code":"434","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":3912.81,"maximum":14657.45,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5217.08,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":11112.86},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12854.21},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12304.88},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11613.75},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5217.08,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7778.36},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9324.49},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5217.08,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5217.08,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3912.81,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5217.08,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":14657.45},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9741.73},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14214.38},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12589.88},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5217.08,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10732.39},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5321.42,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12237.44}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Cc","code_information":[{"code":"442","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":5301.1,"maximum":19858.02,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7068.13,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":15055.78},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17414.98},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16670.73},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15734.39},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7068.13,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10538.18},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12632.88},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7068.13,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7068.13,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5301.1,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7068.13,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":19858.02},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13198.17},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19257.74},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17056.85},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7068.13,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14540.31},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7209.49,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16579.37}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":5314.7,"10th_percentile":5314.7,"90th_percentile":5314.7,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":7495.54,"10th_percentile":7495.54,"90th_percentile":7500.22,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":5407.56,"10th_percentile":5407.56,"90th_percentile":5407.56,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":7494.03,"10th_percentile":7494.03,"90th_percentile":7494.03,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":14409.0,"10th_percentile":14409.0,"90th_percentile":14409.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Single Level Spinal Fusion Except Cervical Without Mcc","code_information":[{"code":"451","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":17740.27,"maximum":66455.34,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23653.69,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":50384.55},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":58279.65},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":55789.01},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":52655.52},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23653.69,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35266.28},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":42276.24},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23653.69,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23653.69,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17740.27,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23653.69,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":66455.34},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":44168.0},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":64446.48},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":57081.17},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23653.69,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":48659.52},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":24126.76,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":55483.25}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":23497.72,"10th_percentile":23497.72,"90th_percentile":23497.72,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"1 through 10","median_amount":48132.34,"10th_percentile":48132.34,"90th_percentile":48132.34,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":19660.91,"10th_percentile":19660.91,"90th_percentile":19660.91,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":23916.93,"10th_percentile":23916.93,"90th_percentile":23916.93,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":23232.41,"10th_percentile":23232.41,"90th_percentile":23232.41,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":46484.42,"10th_percentile":46484.42,"90th_percentile":46484.42,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Wound Debridement Or Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders With","code_information":[{"code":"465","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":10015.15,"maximum":37516.9,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13353.53,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":28444.25},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":32901.37},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":31495.3},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":29726.31},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13353.53,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19909.33},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23866.76},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13353.53,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13353.53,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10015.15,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13353.53,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":37516.9},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24934.74},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36382.82},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32224.78},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13353.53,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27470.39},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13620.6,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31322.69}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cervical Spinal Fusion Without Cc/Mcc","code_information":[{"code":"473","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":13406.8,"maximum":50222.08,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17875.73,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":38076.96},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":44043.49},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":42161.25},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":39793.19},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17875.73,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26651.67},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31949.29},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17875.73,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17875.73,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13406.8,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17875.73,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":50222.08},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33378.94},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":48703.94},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":43137.77},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17875.73,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36773.3},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18233.24,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":41930.18}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Hip And Femur Procedures Except Major Joint With Cc","code_information":[{"code":"481","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":11502.28,"maximum":43087.76,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15336.38,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":32667.92},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":37786.87},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":36172.02},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":34140.35},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15336.38,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22865.66},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27410.72},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15336.38,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15336.38,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11502.28,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15336.38,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":43087.76},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28637.28},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":41785.28},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37009.82},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15336.38,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31549.45},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15643.11,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35973.77}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":16610.66,"10th_percentile":16610.66,"90th_percentile":16610.66,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":16035.0,"10th_percentile":16035.0,"90th_percentile":16035.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":18138.42,"10th_percentile":16069.66,"90th_percentile":18633.03,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":16101.17,"10th_percentile":16031.19,"90th_percentile":19530.04,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":16035.69,"10th_percentile":16035.69,"90th_percentile":16035.69,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Mcc Or Insertion Of Antibioti","code_information":[{"code":"492","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":20163.19,"maximum":75531.64,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26884.25,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":57265.95},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":66239.34},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":63408.53},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":59847.08},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26884.25,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":40082.86},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":48050.23},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26884.25,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26884.25,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20163.19,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26884.25,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":75531.64},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":50200.35},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":73248.42},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":64877.17},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26884.25,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":55305.31},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27421.94,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":63061.02}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Soft Tissue Procedures With Mcc","code_information":[{"code":"500","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":17380.01,"maximum":65105.82,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23173.35,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":49361.39},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":57096.16},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":54656.1},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":51586.24},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23173.35,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34550.12},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":41417.74},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23173.35,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23173.35,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17380.01,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23173.35,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":65105.82},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":43271.08},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":63137.76},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":55922.02},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23173.35,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":47671.38},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23636.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":54356.55}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":24575.04,"10th_percentile":24575.04,"90th_percentile":24575.04,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Major Shoulder Or Elbow Joint Procedures Without Cc/Mcc","code_information":[{"code":"508","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":8316.57,"maximum":31154.02,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11088.76,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":23620.1},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27321.29},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26153.69},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24684.72},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11088.76,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16532.7},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19818.95},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11088.76,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11088.76,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8316.57,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11088.76,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":31154.02},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20705.8},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30212.28},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26759.45},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11088.76,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22811.41},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11310.54,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26010.35}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":9696.96,"10th_percentile":9696.96,"90th_percentile":9696.96,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/Mcc","code_information":[{"code":"517","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":8439.04,"maximum":31612.78,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11252.05,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":23967.91},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27723.6},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26538.81},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25048.21},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11252.05,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16776.15},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20110.79},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11252.05,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11252.05,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8439.04,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11252.05,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":31612.78},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21010.7},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30657.17},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27153.49},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11252.05,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23147.31},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11477.09,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26393.36}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":11593.65,"10th_percentile":11593.65,"90th_percentile":11593.65,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Fractures Of Hip And Pelvis With Mcc","code_information":[{"code":"535","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":7040.31,"maximum":26373.12,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9387.08,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":19995.35},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23128.56},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22140.14},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20896.6},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9387.08,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13995.59},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16777.53},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9387.08,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9387.08,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7040.31,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9387.08,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":26373.12},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17528.29},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25575.9},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22652.94},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9387.08,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19310.77},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9574.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22018.8}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":8158.5,"10th_percentile":8158.5,"90th_percentile":8158.5,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":10302.98,"10th_percentile":10302.98,"90th_percentile":10302.98,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":10321.7,"10th_percentile":10321.7,"90th_percentile":10321.7,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc","code_information":[{"code":"543","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":5645.43,"maximum":21147.87,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7527.24,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":16033.72},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18546.15},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17753.56},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16756.4},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7527.24,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11222.68},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13453.44},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7527.24,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7527.24,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5645.43,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7527.24,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":21147.87},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14055.44},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20508.6},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18164.76},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7527.24,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15484.76},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7677.78,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17656.26}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":7526.06,"10th_percentile":7526.06,"90th_percentile":7526.06,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"1 through 10","median_amount":16546.86,"10th_percentile":16546.86,"90th_percentile":16546.86,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":7667.14,"10th_percentile":7667.14,"90th_percentile":7667.14,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":7453.06,"10th_percentile":7453.06,"90th_percentile":8197.69,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":8227.46,"10th_percentile":8180.56,"90th_percentile":8882.96,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":8142.14,"10th_percentile":8142.14,"90th_percentile":8256.46,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":498.62,"10th_percentile":498.62,"90th_percentile":498.62,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Medical Back Problems With Mcc","code_information":[{"code":"551","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":9204.58,"maximum":34480.49,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12272.77,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":26142.13},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":30238.52},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28946.25},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27320.43},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12272.77,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18297.98},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21935.12},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12272.77,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12272.77,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9204.58,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12272.77,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":34480.49},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22916.66},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33438.2},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29616.69},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12272.77,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25247.09},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12518.23,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28787.6}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":13239.32,"10th_percentile":13239.32,"90th_percentile":13239.32,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":11074.42,"10th_percentile":11074.42,"90th_percentile":11074.42,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":12828.21,"10th_percentile":12828.21,"90th_percentile":12828.21,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":13231.53,"10th_percentile":13231.53,"90th_percentile":13231.53,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Aftercare, Musculoskeletal System And Connective Tissue With Mcc","code_information":[{"code":"559","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":10241.4,"maximum":38364.46,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13655.2,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":29086.85},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":33644.66},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":32206.82},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":30397.87},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13655.2,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20359.11},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24405.95},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13655.2,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13655.2,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10241.4,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13655.2,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":38364.46},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25498.05},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37204.76},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32952.78},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13655.2,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28090.99},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13928.3,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32030.31}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":8836.7,"10th_percentile":8836.7,"90th_percentile":8836.7,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Skin Debridement With Mcc","code_information":[{"code":"570","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":16151.53,"maximum":60503.9,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21535.37,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":45872.34},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":53060.39},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":50792.8},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":47939.93},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21535.37,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32107.99},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38490.18},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21535.37,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21535.37,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16151.53,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21535.37,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":60503.9},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":40212.51},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":58674.95},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":51969.24},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21535.37,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":44301.79},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21966.08,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":50514.42}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":27362.19,"10th_percentile":27362.19,"90th_percentile":27362.19,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Skin Graft Except For Skin Ulcer Or Cellulitis Without Cc/Mcc","code_information":[{"code":"578","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":8821.81,"maximum":33046.64,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11762.41,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":25055.02},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28981.06},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27742.53},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26184.32},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11762.41,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17537.07},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21022.96},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11762.41,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11762.41,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8821.81,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11762.41,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":33046.64},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21963.68},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32047.68},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28385.09},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11762.41,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24197.2},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11997.66,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27590.48}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Skin Ulcers With Mcc","code_information":[{"code":"592","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":10628.01,"maximum":39812.72,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14170.68,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":30184.87},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":34914.75},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":33422.63},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":31545.39},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14170.68,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21127.67},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25327.27},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14170.68,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14170.68,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10628.01,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14170.68,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":39812.72},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26460.6},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38609.24},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34196.75},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14170.68,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29151.42},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14454.09,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33239.45}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":15925.62,"10th_percentile":15925.62,"90th_percentile":15925.62,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Non-Malignant Breast Disorders With Cc/Mcc","code_information":[{"code":"600","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":5720.12,"maximum":21427.65,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7626.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":16245.84},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18791.51},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17988.43},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16978.08},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7626.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11371.15},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13631.42},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7626.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7626.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5720.12,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7626.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":21427.65},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14241.39},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20779.92},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18405.07},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7626.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15689.62},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7779.36,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17889.84}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Adrenal And Pituitary Procedures With Cc/Mcc","code_information":[{"code":"614","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":12036.62,"maximum":45089.4,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16048.83,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":34185.5},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":39542.26},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":37852.39},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":35726.34},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16048.83,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23927.88},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28684.09},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16048.83,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16048.83,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12036.62,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16048.83,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":45089.4},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29967.63},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":43726.41},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38729.11},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16048.83,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33015.08},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16369.81,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37644.93}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":16876.18,"10th_percentile":16876.18,"90th_percentile":16876.18,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Mcc","code_information":[{"code":"622","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":19545.92,"maximum":73219.36,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26061.23,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":55512.84},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":64211.53},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":61467.38},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":58014.96},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26061.23,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38855.79},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":46579.25},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26061.23,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26061.23,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19545.92,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26061.23,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":73219.36},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":48663.55},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":71006.04},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":62891.06},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26061.23,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":53612.23},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26582.45,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":61130.51}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":28254.64,"10th_percentile":28254.64,"90th_percentile":28254.64,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Endocrine, Nutritional And Metabolic O.R. Procedures Without Cc/Mcc","code_information":[{"code":"630","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":8015.08,"maximum":30024.63,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10686.77,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":22763.82},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26330.84},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25205.57},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23789.85},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10686.77,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15933.36},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19100.48},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10686.77,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10686.77,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8015.08,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10686.77,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":30024.63},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19955.17},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29117.03},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25789.37},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10686.77,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21984.45},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10900.51,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25067.42}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Endocrine Disorders With Cc","code_information":[{"code":"644","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":5628.95,"maximum":21086.16,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7505.27,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":15986.93},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18492.03},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17701.75},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16707.5},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7505.27,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11189.93},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13414.18},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7505.27,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7505.27,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5628.95,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7505.27,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":21086.16},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14014.43},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20448.75},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18111.75},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7505.27,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15439.58},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7655.38,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17604.73}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"1 through 10","median_amount":16958.63,"10th_percentile":16958.63,"90th_percentile":16958.63,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":8003.46,"10th_percentile":8003.46,"90th_percentile":8164.55,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":8161.96,"10th_percentile":8161.96,"90th_percentile":8161.96,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Kidney And Ureter Procedures For Neoplasm With Mcc","code_information":[{"code":"656","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":17484.35,"maximum":65496.69,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23312.47,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":49657.73},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":57438.94},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":54984.23},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":51895.94},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23312.47,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34757.54},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":41666.39},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23312.47,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23312.47,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17484.35,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23312.47,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":65496.69},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":43530.86},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":63516.81},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":56257.75},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23312.47,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":47957.58},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23778.72,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":54682.88}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":18984.93,"10th_percentile":18984.93,"90th_percentile":18984.93,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":25241.24,"10th_percentile":25241.24,"90th_percentile":25241.24,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":25232.53,"10th_percentile":25232.53,"90th_percentile":25232.53,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Minor Bladder Procedures Without Cc/Mcc","code_information":[{"code":"664","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":5749.22,"maximum":21536.68,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7665.63,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":16328.5},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18887.12},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18079.96},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17064.47},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7665.63,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11429.01},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13700.78},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7665.63,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7665.63,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5749.22,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7665.63,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":21536.68},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14313.86},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20885.66},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18498.72},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7665.63,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15769.45},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7818.94,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17980.87}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":7026.48,"10th_percentile":7026.48,"90th_percentile":7026.48,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Urethral Procedures Without Cc/Mcc","code_information":[{"code":"672","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":5928.25,"maximum":22207.32,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7904.33,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":16836.96},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19475.26},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18642.97},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17595.85},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7904.33,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11784.9},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14127.42},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7904.33,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7904.33,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5928.25,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7904.33,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":22207.32},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14759.58},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21536.03},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19074.77},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7904.33,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16260.51},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8062.42,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18540.79}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Kidney And Urinary Tract Neoplasms With Cc","code_information":[{"code":"687","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":5754.16,"maximum":21555.19,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7672.22,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":16342.54},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18903.36},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18095.51},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17079.14},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7672.22,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11438.83},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13712.56},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7672.22,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7672.22,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5754.16,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7672.22,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":21555.19},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14326.16},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20903.61},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18514.63},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7672.22,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15783.01},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7825.66,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17996.33}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Urethral Stricture","code_information":[{"code":"697","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":5918.91,"maximum":22172.35,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7891.88,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":16810.45},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19444.59},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18613.61},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17568.14},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7891.88,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11766.34},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14105.17},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7891.88,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7891.88,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5918.91,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7891.88,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":22172.35},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14736.34},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21502.11},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19044.73},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7891.88,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16234.9},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8049.72,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18511.59}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":7765.03,"10th_percentile":7765.03,"90th_percentile":7765.03,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":157.58,"10th_percentile":157.58,"90th_percentile":157.58,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Testes Procedures With Cc/Mcc","code_information":[{"code":"711","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":11443.52,"maximum":42867.64,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15258.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":32501.03},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":37593.84},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":35987.23},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":33965.94},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15258.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22748.84},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27270.69},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15258.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15258.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11443.52,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15258.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":42867.64},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28490.98},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":41571.81},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36820.75},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15258.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31388.28},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15563.19,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35789.99}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Malignancy, Male Reproductive System With Mcc","code_information":[{"code":"722","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":9938.26,"maximum":37228.9,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13251.01,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":28225.89},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":32648.8},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":31253.52},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":29498.11},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13251.01,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19756.49},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23683.54},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13251.01,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13251.01,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9938.26,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13251.01,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":37228.9},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24743.32},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36103.52},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31977.4},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13251.01,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27259.51},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13516.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31082.23}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Male Reproductive System Diagnoses Without Cc/Mcc","code_information":[{"code":"730","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":3690.4,"maximum":13824.29,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4920.53,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":10481.18},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12123.55},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11605.44},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10953.6},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4920.53,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7336.22},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8794.46},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4920.53,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4920.53,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3690.4,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4920.53,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":13824.29},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9187.99},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13406.4},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11874.24},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4920.53,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10122.34},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5018.94,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11541.84}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy Without Cc/Mcc","code_information":[{"code":"741","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":7831.66,"maximum":29337.53,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10442.21,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":22242.88},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25728.27},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24628.75},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23245.43},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10442.21,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15568.73},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18663.37},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10442.21,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10442.21,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7831.66,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10442.21,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":29337.53},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19498.51},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28450.7},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25199.19},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10442.21,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21481.34},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10651.05,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24493.77}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Female Reproductive System O.R. Procedures With Cc/Mcc","code_information":[{"code":"749","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":14100.39,"maximum":52820.31,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18800.52,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":40046.86},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":46322.07},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":44342.45},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":41851.88},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18800.52,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28030.49},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33602.18},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18800.52,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18800.52,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14100.39,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18800.52,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":52820.31},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35105.79},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":51223.62},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":45369.49},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18800.52,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38675.76},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19176.53,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":44099.43}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Menstrual And Other Female Reproductive System Disorders With Cc/Mcc","code_information":[{"code":"760","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":5532.85,"maximum":20726.15,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7377.13,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":15713.98},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18176.31},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17399.53},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16422.25},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7377.13,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10998.88},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13185.15},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7377.13,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7377.13,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5532.85,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7377.13,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":20726.15},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13775.15},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20099.63},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17802.53},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7377.13,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15175.97},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7524.67,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17304.17}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cesarean Section With Sterilization With Cc","code_information":[{"code":"784","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":5821.71,"maximum":21808.23,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7762.28,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":16534.38},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19125.26},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18307.93},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17279.63},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7762.28,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11573.11},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13873.53},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7762.28,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7762.28,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5821.71,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7762.28,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":21808.23},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14494.33},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21149.0},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18731.97},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7762.28,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15968.29},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7917.53,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18207.59}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"1 through 10","median_amount":12545.0,"10th_percentile":12545.0,"90th_percentile":12545.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":5374.15,"10th_percentile":5374.15,"90th_percentile":5374.15,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"1 through 10","median_amount":13261.25,"10th_percentile":13261.25,"90th_percentile":13261.25,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":4267.85,"10th_percentile":4267.85,"90th_percentile":4267.85,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":13198.0,"10th_percentile":13198.0,"90th_percentile":13198.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":5118.24,"10th_percentile":5118.24,"90th_percentile":5118.24,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Prematurity Without Major Problems","code_information":[{"code":"792","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":13450.18,"maximum":50384.6,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17933.57,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":38200.17},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":44186.02},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":42297.68},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":39921.96},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17933.57,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26737.92},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32052.68},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17933.57,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17933.57,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13450.18,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17933.57,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":50384.6},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33486.96},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":48861.54},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":43277.36},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17933.57,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36892.3},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18292.24,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":42065.87}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"1 through 10","median_amount":11061.27,"10th_percentile":11061.27,"90th_percentile":11061.27,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":8650.33,"10th_percentile":8650.33,"90th_percentile":9827.76,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"1 through 10","median_amount":3578.0,"10th_percentile":3578.0,"90th_percentile":3578.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":5002.11,"10th_percentile":5002.11,"90th_percentile":5002.11,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"1 through 10","median_amount":5784.69,"10th_percentile":5784.69,"90th_percentile":5784.69,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":5135.18,"10th_percentile":4608.0,"90th_percentile":13959.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":7263.81,"10th_percentile":7263.81,"90th_percentile":7263.81,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Splenic Procedures With Cc","code_information":[{"code":"800","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":15428.27,"maximum":57794.58,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20571.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":43818.21},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":50684.39},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":48518.34},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":45793.22},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20571.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30670.22},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36766.62},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20571.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20571.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15428.27,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20571.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":57794.58},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38411.83},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":56047.53},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":49642.1},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20571.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":42317.99},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20982.45,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":48252.43}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","code_information":[{"code":"808","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":12125.04,"maximum":45420.61,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16166.72,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":34436.62},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":39832.72},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":38130.43},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":35988.77},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16166.72,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24103.64},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28894.79},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16166.72,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16166.72,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12125.04,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16166.72,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":45420.61},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30187.76},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":44047.61},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":39013.59},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16166.72,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33257.6},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16490.05,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37921.46}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":20544.87,"10th_percentile":20544.87,"90th_percentile":20544.87,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":33105.5,"10th_percentile":33105.5,"90th_percentile":33105.5,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Reticuloendothelial And Immunity Disorders Without Cc/Mcc","code_information":[{"code":"816","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":3470.73,"maximum":13001.42,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4627.64,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":9857.3},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11401.91},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10914.64},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10301.6},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4627.64,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6899.54},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8270.98},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4627.64,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4627.64,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3470.73,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4627.64,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":13001.42},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8641.09},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12608.4},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11167.44},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4627.64,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9519.82},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4720.19,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10854.82}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Lymphoma And Non-Acute Leukemia With Other Procedures With Cc","code_information":[{"code":"824","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":12441.91,"maximum":46607.61,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16589.21,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":35336.56},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":40873.69},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":39126.91},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":36929.28},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16589.21,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24733.56},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29649.91},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16589.21,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16589.21,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12441.91,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16589.21,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":46607.61},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30976.67},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":45198.72},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":40033.15},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16589.21,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34126.73},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16920.99,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38912.47}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":32622.22,"10th_percentile":32622.22,"90th_percentile":32622.22,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Antepartum Diagnoses Without O.R. Procedures With Cc","code_information":[{"code":"832","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":3962.78,"maximum":14844.65,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5283.71,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":11254.8},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13018.39},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12462.03},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11762.08},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5283.71,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7877.71},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9443.58},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5283.71,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5283.71,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3962.78,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5283.71,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":14844.65},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9866.16},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14395.92},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12750.67},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5283.71,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10869.46},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5389.38,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12393.73}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":4507.21,"10th_percentile":4507.21,"90th_percentile":4507.21,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":4507.21,"10th_percentile":4507.21,"90th_percentile":4507.21,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":4325.51,"10th_percentile":4325.51,"90th_percentile":4325.51,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":4507.21,"10th_percentile":4507.21,"90th_percentile":4507.21,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Lymphoma And Non-Acute Leukemia With Mcc","code_information":[{"code":"840","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":17764.98,"maximum":66547.91,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23686.64,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":50454.74},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":58360.83},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":55866.72},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":52728.87},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23686.64,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35315.4},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":42335.14},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23686.64,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23686.64,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17764.98,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23686.64,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":66547.91},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":44229.53},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":64536.26},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":57160.68},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23686.64,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":48727.3},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":24160.37,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":55560.54}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":24007.69,"10th_percentile":24007.69,"90th_percentile":24007.69,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":24581.69,"10th_percentile":24581.69,"90th_percentile":24581.69,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Chemotherapy Without Acute Leukemia As Secondary Diagnosis Without Cc/Mcc","code_information":[{"code":"848","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":4664.62,"maximum":17473.74,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6219.49,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":13248.09},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15324.03},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14669.14},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13845.22},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6219.49,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9272.9},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11116.1},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6219.49,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6219.49,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4664.62,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6219.49,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17473.74},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11613.51},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16945.53},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15008.9},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6219.49,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12794.51},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6343.88,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14588.74}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Postoperative Or Post-Traumatic Infections With O.R. Procedures Without Cc/Mcc","code_information":[{"code":"858","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":7649.33,"maximum":28654.54,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10199.11,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":21725.06},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25129.31},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24055.38},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22704.27},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10199.11,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15206.29},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18228.88},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10199.11,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10199.11,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7649.33,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10199.11,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":28654.54},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19044.58},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27788.36},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24612.54},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10199.11,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20981.25},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10403.09,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23923.55}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Infectious And Parasitic Diseases Diagnoses Without Cc/Mcc","code_information":[{"code":"869","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":4007.26,"maximum":15011.29,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5343.02,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":11381.13},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13164.52},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12601.92},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11894.11},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5343.02,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7966.13},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9549.58},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5343.02,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5343.02,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4007.26,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5343.02,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15011.29},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9976.9},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14557.52},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12893.8},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5343.02,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10991.47},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5449.88,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12532.85}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":9325.96,"10th_percentile":9325.96,"90th_percentile":9325.96,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Disorders Of Personality And Impulse Control","code_information":[{"code":"883","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":10798.25,"maximum":40450.45,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14397.67,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":30668.38},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":35474.02},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":33958.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":32050.69},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14397.67,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21466.1},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25732.97},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14397.67,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14397.67,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10798.25,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14397.67,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":40450.45},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26884.45},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":39227.69},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34744.52},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14397.67,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29618.38},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14685.62,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33771.89}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":9358.92,"10th_percentile":9358.92,"90th_percentile":9358.92,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":12758.71,"10th_percentile":12758.71,"90th_percentile":12758.71,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"1 through 10","median_amount":1869.0,"10th_percentile":1869.0,"90th_percentile":1869.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":6069.44,"10th_percentile":6069.44,"90th_percentile":6069.44,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":14391.07,"10th_percentile":14391.07,"90th_percentile":14391.07,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":4430.75,"10th_percentile":4430.75,"90th_percentile":4430.75,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":6069.44,"10th_percentile":6034.86,"90th_percentile":6069.44,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without Mcc","code_information":[{"code":"897","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":4848.04,"maximum":18160.84,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6464.05,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":13769.03},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15926.59},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15245.96},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14389.64},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6464.05,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9637.53},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11553.2},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6464.05,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6464.05,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4848.04,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6464.05,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":18160.84},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12070.18},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17611.86},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15599.08},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6464.05,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13297.62},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6593.33,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15162.4}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"16","median_amount":7191.81,"10th_percentile":5412.12,"90th_percentile":7303.37,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":6212.36,"10th_percentile":5412.12,"90th_percentile":7345.73,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"1 through 10","median_amount":2522.94,"10th_percentile":1869.0,"90th_percentile":7476.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"1 through 10","median_amount":7303.37,"10th_percentile":3473.47,"90th_percentile":12450.77,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":7668.54,"10th_percentile":7191.81,"90th_percentile":7668.54,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":7303.37,"10th_percentile":7303.37,"90th_percentile":7303.37,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"14","median_amount":7668.54,"10th_percentile":6063.5,"90th_percentile":7668.54,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"1 through 10","median_amount":13704.51,"10th_percentile":13704.51,"90th_percentile":16087.1},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":5573.25,"10th_percentile":5412.12,"90th_percentile":5611.43,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":6023.96,"10th_percentile":6023.96,"90th_percentile":6070.75,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":7191.81,"10th_percentile":5783.08,"90th_percentile":13143.72,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"1 through 10","median_amount":11644.79,"10th_percentile":11644.79,"90th_percentile":11644.79},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"13","median_amount":7551.4,"10th_percentile":6610.81,"90th_percentile":7668.54,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":6790.56,"10th_percentile":6790.56,"90th_percentile":7085.89,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":8084.5,"10th_percentile":8084.5,"90th_percentile":11324.58,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":4057.43,"10th_percentile":3006.73,"90th_percentile":13143.72,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"1 through 10","median_amount":5083.26,"10th_percentile":5083.26,"90th_percentile":5083.26,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":4971.9,"10th_percentile":258.56,"90th_percentile":6971.9,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"17","median_amount":7303.37,"10th_percentile":1150.0,"90th_percentile":13157.13,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"1 through 10","median_amount":4503.0,"10th_percentile":4503.0,"90th_percentile":10984.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"14","median_amount":7303.37,"10th_percentile":2434.25,"90th_percentile":8566.5,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":6971.9,"10th_percentile":5412.12,"90th_percentile":7303.37,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":5377.96,"10th_percentile":5082.61,"90th_percentile":6969.11,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other O.R. Procedures For Injuries With Cc","code_information":[{"code":"908","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":10956.97,"maximum":41044.98,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14609.29,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":31119.13},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":35995.4},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":34457.1},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":32521.76},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14609.29,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21781.6},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26111.18},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14609.29,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14609.29,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10956.97,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14609.29,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":41044.98},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27279.59},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":39804.24},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35255.18},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14609.29,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30053.7},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14901.48,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34268.26}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"1 through 10","median_amount":28246.0,"10th_percentile":28246.0,"90th_percentile":28246.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":15636.02,"10th_percentile":15636.02,"90th_percentile":15636.02,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":14769.51,"10th_percentile":14769.51,"90th_percentile":18562.13,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Complications Of Treatment With Mcc","code_information":[{"code":"919","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":10054.13,"maximum":37662.96,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13405.51,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":28554.99},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":33029.46},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":31617.92},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":29842.04},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13405.51,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19986.84},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23959.68},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13405.51,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13405.51,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10054.13,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13405.51,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":37662.96},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25031.81},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36524.46},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32350.24},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13405.51,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27577.34},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13673.62,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31444.63}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"1 through 10","median_amount":26399.5,"10th_percentile":26399.5,"90th_percentile":26399.5,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":13788.01,"10th_percentile":13788.01,"90th_percentile":13788.01,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":14123.41,"10th_percentile":14123.41,"90th_percentile":14150.61,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":14123.41,"10th_percentile":12076.8,"90th_percentile":14145.31,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":12828.07,"10th_percentile":12828.07,"90th_percentile":12828.07,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Extensive Burns Or Full Thickness Burns With Mv >96 Hours Without Skin Graft","code_information":[{"code":"933","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":21385.63,"maximum":80110.94,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":28514.17,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":60737.84},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":70255.26},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":67252.83},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":63475.46},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":28514.17,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":42512.98},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":50963.4},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":28514.17,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":28514.17,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21385.63,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":28514.17,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":80110.94},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":53243.88},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":77689.29},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":68810.51},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":28514.17,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":58658.33},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":29084.45,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":66884.25}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Signs And Symptoms With Mcc","code_information":[{"code":"947","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":6971.12,"maximum":26113.92,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9294.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":19798.83},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22901.25},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21922.54},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20691.22},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9294.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13858.04},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16612.64},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9294.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9294.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6971.12,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9294.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":26113.92},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17356.01},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25324.53},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22430.3},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9294.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19120.97},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9480.72,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21802.39}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"1 through 10","median_amount":20060.86,"10th_percentile":20060.86,"90th_percentile":20060.86,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":7841.8,"10th_percentile":7841.8,"90th_percentile":7841.8,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":9961.36,"10th_percentile":9961.36,"90th_percentile":9994.36,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"1 through 10","median_amount":26457.47,"10th_percentile":26457.47,"90th_percentile":26457.47,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":546.15,"10th_percentile":546.15,"90th_percentile":546.15,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other O.R. Procedures For Multiple Significant Trauma With Cc","code_information":[{"code":"958","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":23141.32,"maximum":86687.76,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":30855.09,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":65724.2},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":76022.97},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":72774.05},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":68686.57},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":30855.09,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":46003.15},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":55147.31},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":30855.09,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":30855.09,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23141.32,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":30855.09,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":86687.76},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":57615.01},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":84067.31},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":74459.61},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":30855.09,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":63473.98},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":31472.19,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":72375.21}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Hiv With Major Related Condition With Cc","code_information":[{"code":"975","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":7111.7,"maximum":26640.56,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9482.27,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":20198.12},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23363.1},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22364.65},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21108.5},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9482.27,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14137.52},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16947.67},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9482.27,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9482.27,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7111.7,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9482.27,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":26640.56},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17706.03},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25835.25},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22882.65},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9482.27,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19506.59},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9671.92,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22242.08}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc","code_information":[{"code":"989","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":6585.6,"maximum":24669.77,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8780.8,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":18703.92},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21634.77},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20710.18},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19546.96},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8780.8,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13091.67},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15693.93},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8780.8,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8780.8,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6585.6,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8780.8,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":24669.77},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16396.19},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23924.04},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21189.86},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8780.8,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18063.55},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8956.42,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20596.68}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck Without Major O.R.","code_information":[{"code":"004","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":76067.2,"maximum":284949.06,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":101422.94,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":216040.29},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":249893.11},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":239213.68},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":225777.82},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":101422.94,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":151215.73},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":181273.27},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":101422.94,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":101422.94,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":76067.2,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":101422.94,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":284949.06},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":189384.79},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":276335.43},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":244754.24},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":101422.94,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":208643.64},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":103451.4,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":237902.64}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy Without Cc/Mcc","code_information":[{"code":"013","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":15825.87,"maximum":59283.99,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21101.16,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":44947.43},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":51990.55},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":49768.69},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":46973.34},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21101.16,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31460.61},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37714.12},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21101.16,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21101.16,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15825.87,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21101.16,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":59283.99},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":39401.73},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":57491.91},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":50921.41},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21101.16,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":43408.55},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21523.18,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":49495.92}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage Without Cc/Mcc","code_information":[{"code":"022","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":17449.21,"maximum":65365.03,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23265.61,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":49557.91},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":57323.47},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":54873.7},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":51791.62},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23265.61,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34687.68},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":41582.63},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23265.61,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23265.61,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17449.21,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23265.61,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":65365.03},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":43443.35},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":63389.13},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":56144.66},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23265.61,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":47861.18},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23730.92,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":54572.96}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Spinal Procedures Without Cc/Mcc","code_information":[{"code":"030","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":12055.3,"maximum":45159.35,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16073.73,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":34238.53},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":39603.6},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":37911.1},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":35781.76},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16073.73,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23965.0},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28728.58},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16073.73,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16073.73,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12055.3,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16073.73,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":45159.35},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30014.11},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":43794.24},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38789.18},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16073.73,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33066.3},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16395.2,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37703.33}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":17212.43,"10th_percentile":17212.43,"90th_percentile":17212.43,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Extracranial Procedures With Cc","code_information":[{"code":"038","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":8910.77,"maximum":33379.9,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11881.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":25307.69},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":29273.33},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28022.3},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26448.38},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11881.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17713.92},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21234.97},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11881.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11881.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8910.77,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11881.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":33379.9},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22185.18},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32370.87},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28671.34},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11881.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24441.22},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12118.65,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27868.72}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":10836.69,"10th_percentile":10836.69,"90th_percentile":10836.69,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":15095.67,"10th_percentile":15095.67,"90th_percentile":15095.67,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":14826.17,"10th_percentile":14826.17,"90th_percentile":14826.17,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":8824.03,"10th_percentile":8824.03,"90th_percentile":8824.03,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Nervous System Neoplasms Without Mcc","code_information":[{"code":"055","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":5599.3,"maximum":20975.07,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7465.73,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":15902.7},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18394.6},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17608.49},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16619.48},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7465.73,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11130.97},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13343.51},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7465.73,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7465.73,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5599.3,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7465.73,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":20975.07},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13940.59},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20341.02},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18016.33},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7465.73,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15358.23},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7615.04,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17511.99}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":6537.43,"10th_percentile":6537.43,"90th_percentile":6537.43,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent Without Cc/Mcc","code_information":[{"code":"063","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":7709.2,"maximum":28878.78,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10278.93,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":21895.07},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25325.96},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24243.63},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22881.94},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10278.93,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15325.28},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18371.53},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10278.93,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10278.93,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7709.2,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10278.93,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":28878.78},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19193.61},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28005.81},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24805.15},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10278.93,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21145.44},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10484.51,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24110.76}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":10890.88,"10th_percentile":10890.88,"90th_percentile":10890.88,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":22465.26,"10th_percentile":22465.26,"90th_percentile":22465.26,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":21160.5,"10th_percentile":21160.5,"90th_percentile":21160.5,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Cerebrovascular Disorders With Cc","code_information":[{"code":"071","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":5634.44,"maximum":21106.73,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7512.59,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":16002.52},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18510.07},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17719.02},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16723.8},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7512.59,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11200.84},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13427.26},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7512.59,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7512.59,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5634.44,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7512.59,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":21106.73},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14028.1},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20468.7},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18129.42},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7512.59,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15454.64},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7662.84,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17621.91}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":7294.93,"10th_percentile":7294.93,"90th_percentile":7294.93,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":14673.75,"10th_percentile":14673.75,"90th_percentile":14673.75,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":8181.13,"10th_percentile":8181.13,"90th_percentile":8181.13,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":14711.19,"10th_percentile":14711.19,"90th_percentile":14711.19,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":8212.93,"10th_percentile":8212.93,"90th_percentile":8212.93,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Traumatic Stupor And Coma >1 Hour With Mcc","code_information":[{"code":"082","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":12551.74,"maximum":47019.04,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16735.66,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":35648.5},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":41234.51},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":39472.31},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":37255.28},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16735.66,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24951.9},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29911.65},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16735.66,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16735.66,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12551.74,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16735.66,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":47019.04},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31250.12},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":45597.72},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":40386.55},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16735.66,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34427.99},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17070.37,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":39255.98}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":17283.48,"10th_percentile":17283.48,"90th_percentile":17283.48,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Concussion Without Cc/Mcc","code_information":[{"code":"090","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":4520.74,"maximum":16934.76,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6027.65,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":12839.45},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14851.35},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14216.66},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13418.16},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6027.65,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8986.87},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10773.22},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6027.65,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6027.65,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4520.74,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6027.65,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":16934.76},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11255.29},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16422.84},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14545.94},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6027.65,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12399.86},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6148.2,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14138.75}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Cc","code_information":[{"code":"098","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":12602.81,"maximum":47210.36,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16803.75,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":35793.56},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":41402.29},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":39632.92},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":37406.87},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16803.75,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25053.42},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30033.36},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16803.75,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16803.75,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12602.81,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16803.75,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":47210.36},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31377.27},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":45783.26},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":40550.88},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16803.75,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34568.08},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17139.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":39415.71}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":14871.19,"10th_percentile":14871.19,"90th_percentile":14871.19,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Extraocular Procedures Except Orbit","code_information":[{"code":"115","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":8429.15,"maximum":31575.75,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11238.87,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":23939.84},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27691.13},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26507.72},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25018.87},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11238.87,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16756.5},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20087.24},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11238.87,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11238.87,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8429.15,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11238.87,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":31575.75},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20986.09},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30621.26},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27121.68},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11238.87,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23120.2},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11463.65,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26362.44}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":10214.8,"10th_percentile":10214.8,"90th_percentile":10214.8,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Sinus And Mastoid Procedures With Cc/Mcc","code_information":[{"code":"135","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":11916.91,"maximum":44640.94,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15889.21,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":33845.49},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":39148.97},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":37475.9},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":35371.0},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15889.21,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23689.89},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28398.79},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15889.21,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15889.21,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11916.91,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15889.21,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":44640.94},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29669.56},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":43291.5},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38343.9},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15889.21,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32686.71},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16206.99,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37270.51}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Ear, Nose, Mouth And Throat O.R. Procedures With Mcc","code_information":[{"code":"143","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":20575.06,"maximum":77074.53,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27433.41,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":58435.72},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":67592.41},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":64703.78},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":61069.58},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27433.41,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":40901.63},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":49031.75},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27433.41,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27433.41,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20575.06,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27433.41,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":77074.53},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":51225.8},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":74744.67},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":66202.42},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27433.41,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":56435.04},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27982.08,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":64349.17}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Epistaxis Without Mcc","code_information":[{"code":"151","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":4030.88,"maximum":15099.75,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5374.51,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":11448.2},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13242.09},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12676.18},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11964.2},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5374.51,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8013.08},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9605.86},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5374.51,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5374.51,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4030.88,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5374.51,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15099.75},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10035.7},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14643.3},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12969.78},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5374.51,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11056.24},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5482.0,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12606.71}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Dental And Oral Diseases Without Cc/Mcc","code_information":[{"code":"159","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":3890.84,"maximum":14575.16,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5187.79,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":11050.47},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12782.05},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12235.8},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11548.55},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5187.79,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7734.69},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9272.14},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5187.79,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5187.79,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3890.84,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5187.79,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":14575.16},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9687.04},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14134.58},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12519.2},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5187.79,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10672.14},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5291.55,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12168.74}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Pulmonary Embolism With Mcc Or Acute Cor Pulmonale","code_information":[{"code":"175","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":7543.35,"maximum":28257.51,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10057.8,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":21424.04},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24781.12},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23722.07},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22389.68},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10057.8,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14995.59},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17976.3},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10057.8,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10057.8,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7543.35,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10057.8,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":28257.51},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18780.7},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27403.32},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24271.51},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10057.8,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20690.54},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10258.96,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23592.06}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":8509.68,"10th_percentile":8509.68,"90th_percentile":8509.68,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":11514.91,"10th_percentile":11514.91,"90th_percentile":11514.91,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":9183.65,"10th_percentile":9183.65,"90th_percentile":9183.65,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":10946.18,"10th_percentile":10946.18,"90th_percentile":12784.62,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"1 through 10","median_amount":18051.95,"10th_percentile":18051.95,"90th_percentile":18051.95,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":10953.18,"10th_percentile":10953.18,"90th_percentile":12779.13,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":21015.32,"10th_percentile":21015.32,"90th_percentile":21015.32,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Major Chest Trauma With Mcc","code_information":[{"code":"183","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":8401.7,"maximum":31472.89,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11202.26,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":23861.85},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27600.93},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26421.37},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24937.37},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11202.26,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16701.92},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20021.8},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11202.26,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11202.26,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8401.7,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11202.26,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":31472.89},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20917.73},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30521.51},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27033.33},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11202.26,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23044.88},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11426.31,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26276.57}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":10961.38,"10th_percentile":10961.38,"90th_percentile":10961.38,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Chronic Obstructive Pulmonary Disease With Cc","code_information":[{"code":"191","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":4629.47,"maximum":17342.08,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6172.63,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":13148.27},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15208.56},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14558.61},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13740.9},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6172.63,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9203.03},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11032.34},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6172.63,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6172.63,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4629.47,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6172.63,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17342.08},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11526.01},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16817.85},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14895.81},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6172.63,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12698.11},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6296.08,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14478.82}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"1 through 10","median_amount":13947.44,"10th_percentile":13947.44,"90th_percentile":13947.44,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":6629.26,"10th_percentile":6629.26,"90th_percentile":6629.26,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":4962.07,"10th_percentile":4962.07,"90th_percentile":4962.07,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":6406.01,"10th_percentile":807.06,"90th_percentile":6748.39,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":5083.92,"10th_percentile":4725.78,"90th_percentile":6706.02,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":12940.62,"10th_percentile":12940.62,"90th_percentile":12940.62,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Pneumothorax With Mcc","code_information":[{"code":"199","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":9687.84,"maximum":36290.82,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12917.12,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":27514.67},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":31826.13},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":30466.01},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28754.83},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12917.12,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19258.68},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23086.78},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12917.12,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12917.12,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9687.84,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12917.12,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":36290.82},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24119.85},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35193.8},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31171.65},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12917.12,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26572.64},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13175.46,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30299.03}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":14030.58,"10th_percentile":14030.58,"90th_percentile":14030.58,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"1 through 10","median_amount":24586.9,"10th_percentile":24586.9,"90th_percentile":24586.9,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Respiratory System Diagnosis With Ventilator Support >96 Hours","code_information":[{"code":"207","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":35337.2,"maximum":132373.75,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":47116.26,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":100362.02},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":116088.42},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":111127.27},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":104885.61},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":47116.26,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":70247.62},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":84210.92},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":47116.26,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":47116.26,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":35337.2,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":47116.26,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":132373.75},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":87979.14},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":128372.27},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":113701.15},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":47116.26,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":96925.89},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":48058.59,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":110518.22}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization Without Cc/Mcc","code_information":[{"code":"218","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":36109.33,"maximum":135266.15,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":48145.77,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":102554.95},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":118624.99},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":113555.43},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":107177.39},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":48145.77,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":71782.55},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":86050.95},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":48145.77,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":48145.77,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":36109.33,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":48145.77,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":135266.15},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":89901.51},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":131177.24},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":116185.55},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":48145.77,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":99043.74},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":49108.69,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":112933.08}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Coronary Bypass With Cardiac Catheterization Or Open Ablation With Mcc","code_information":[{"code":"233","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":41984.85,"maximum":157275.98,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":55979.8,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":119242.18},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":137927.05},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":132032.6},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":124616.76},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":55979.8,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":83462.65},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":100052.73},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":55979.8,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":55979.8,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":41984.85,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":55979.8,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":157275.98},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":104529.84},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":152521.74},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":135090.68},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":55979.8,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":115159.65},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":57099.4,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":131308.99}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"1 through 10","median_amount":252519.86,"10th_percentile":252519.86,"90th_percentile":252519.86,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":60569.4,"10th_percentile":60569.4,"90th_percentile":60569.4,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":83169.73,"10th_percentile":83169.73,"90th_percentile":83169.73,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":117738.43,"10th_percentile":117738.43,"90th_percentile":117738.43,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Permanent Cardiac Pacemaker Implant With Cc","code_information":[{"code":"243","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":11702.18,"maximum":43836.58,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15602.91,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":33235.65},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":38443.57},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":36800.64},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":34733.67},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15602.91,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23263.04},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27887.09},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15602.91,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15602.91,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11702.18,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15602.91,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":43836.58},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29134.96},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":42511.46},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37653.0},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15602.91,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32097.75},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15914.97,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36598.95}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":16291.07,"10th_percentile":15723.47,"90th_percentile":17769.08,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":17458.47,"10th_percentile":17046.64,"90th_percentile":19852.08,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"1 through 10","median_amount":35611.37,"10th_percentile":35611.37,"90th_percentile":35611.37,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":17761.47,"10th_percentile":16857.51,"90th_percentile":18249.58,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":33933.93,"10th_percentile":33933.93,"90th_percentile":33933.93,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Upper Limb And Toe Amputation For Circulatory System Disorders With Mcc","code_information":[{"code":"255","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":14813.2,"maximum":55490.54,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19750.94,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":42071.35},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":48663.79},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":46584.1},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43967.62},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19750.94,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29447.52},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35300.87},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19750.94,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19750.94,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14813.2,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19750.94,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":55490.54},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36880.5},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":53813.13},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":47663.06},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19750.94,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":40630.94},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20145.96,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":46328.79}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":25094.95,"10th_percentile":25094.95,"90th_percentile":25094.95,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Vein Ligation And Stripping","code_information":[{"code":"263","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":16790.2,"maximum":62896.4,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22386.94,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":47686.27},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":55158.55},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":52801.3},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":49835.62},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22386.94,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33377.64},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":40012.19},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22386.94,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22386.94,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16790.2,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22386.94,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":62896.4},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":41802.64},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":60995.13},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":54024.26},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22386.94,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":46053.62},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22834.68,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":52511.92}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":17518.01,"10th_percentile":17518.01,"90th_percentile":17518.01,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":28444.17,"10th_percentile":28444.17,"90th_percentile":28444.17,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Major Cardiovascular Procedures With Cc","code_information":[{"code":"271","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":19530.0,"maximum":73159.71,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26040.0,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":55467.61},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":64159.21},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":61417.3},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":57967.69},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26040.0,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38824.13},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":46541.3},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26040.0,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26040.0,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19530.0,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26040.0,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":73159.71},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":48623.9},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":70948.19},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":62839.82},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26040.0,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":53568.55},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26560.8,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":61080.7}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":26682.06,"10th_percentile":26682.06,"90th_percentile":26682.06,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":26523.57,"10th_percentile":26523.57,"90th_percentile":26523.57,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":26676.16,"10th_percentile":26676.16,"90th_percentile":26676.16,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"1 through 10","median_amount":70582.35,"10th_percentile":70582.35,"90th_percentile":70582.35,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":51369.78,"10th_percentile":51369.78,"90th_percentile":51369.78,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures Without Mcc","code_information":[{"code":"279","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":19805.13,"maximum":74190.36,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26406.84,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":56249.02},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":65063.06},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":62282.53},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":58784.32},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26406.84,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":39371.07},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":47196.96},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26406.84,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26406.84,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19805.13,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26406.84,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":74190.36},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":49308.9},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":71947.68},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":63725.09},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26406.84,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":54323.2},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26934.98,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":61941.18}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc","code_information":[{"code":"287","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":5876.62,"maximum":22013.95,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7835.5,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":16690.35},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19305.67},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18480.63},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17442.63},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7835.5,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11682.28},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14004.4},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7835.5,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7835.5,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5876.62,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7835.5,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":22013.95},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14631.06},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21348.5},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18908.67},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7835.5,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16118.92},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7992.21,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18379.34}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":8473.03,"10th_percentile":8445.41,"90th_percentile":8501.94,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"1 through 10","median_amount":26851.49,"10th_percentile":26851.49,"90th_percentile":26851.49,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":8445.0,"10th_percentile":8445.0,"90th_percentile":8450.5,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":7578.3,"10th_percentile":7578.3,"90th_percentile":7578.3,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"13","median_amount":8445.01,"10th_percentile":8310.01,"90th_percentile":8458.41,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":10065.5,"10th_percentile":10065.5,"90th_percentile":10065.5,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":9237.86,"10th_percentile":9237.86,"90th_percentile":9237.86,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"11","median_amount":8442.11,"10th_percentile":7835.23,"90th_percentile":9269.55,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":16251.79,"10th_percentile":16251.79,"90th_percentile":16793.11,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":9237.86,"10th_percentile":9237.86,"90th_percentile":9237.86,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":8576.85,"10th_percentile":8576.85,"90th_percentile":8576.85,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cardiac Arrest, Unexplained With Cc","code_information":[{"code":"297","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":3481.71,"maximum":13042.56,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4642.28,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":9888.5},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11437.99},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10949.18},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10334.2},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4642.28,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6921.38},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8297.16},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4642.28,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4642.28,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3481.71,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4642.28,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":13042.56},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8668.43},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12648.3},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11202.78},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4642.28,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9549.94},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4735.13,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10889.17}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Hypertension Without Mcc","code_information":[{"code":"305","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":4146.76,"maximum":15533.81,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5529.01,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":11777.29},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13622.76},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13040.58},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12308.13},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5529.01,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8243.43},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9881.99},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5529.01,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5529.01,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4146.76,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5529.01,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15533.81},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10324.19},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15064.25},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13342.62},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5529.01,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11374.07},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5639.59,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12969.11}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":4881.06,"10th_percentile":4881.06,"90th_percentile":4881.06,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":7041.48,"10th_percentile":7041.48,"90th_percentile":7041.48,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":5872.46,"10th_percentile":5402.12,"90th_percentile":6004.69,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":11307.79,"10th_percentile":11307.79,"90th_percentile":11307.79,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Chest Pain","code_information":[{"code":"313","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":3954.0,"maximum":14811.74,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5272.0,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":11229.84},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12989.52},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12434.4},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11736.0},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5272.0,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7860.24},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9422.64},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5272.0,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5272.0,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3954.0,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5272.0,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":14811.74},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9844.28},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14364.0},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12722.4},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5272.0,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10845.36},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5377.44,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12366.25}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":5661.15,"10th_percentile":5661.15,"90th_percentile":5661.15,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":6343.75,"10th_percentile":6343.75,"90th_percentile":6343.75,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":6428.95,"10th_percentile":6428.95,"90th_percentile":6428.95,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":2222.84,"10th_percentile":2222.84,"90th_percentile":2222.84,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Percutaneous Cardiovascular Procedures With Intraluminal Device With Mcc Or 4+ Arteries/Intraluminal","code_information":[{"code":"321","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":14941.71,"maximum":55971.92,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19922.28,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":42436.32},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":49085.95},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":46988.22},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":44349.04},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19922.28,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29702.97},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35607.11},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19922.28,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19922.28,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14941.71,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19922.28,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":55971.92},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37200.44},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":54279.96},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":48076.54},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19922.28,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":40983.41},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20320.73,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":46730.69}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":17451.78,"10th_percentile":17451.78,"90th_percentile":17451.78,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":21912.67,"10th_percentile":20313.27,"90th_percentile":25312.66,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"1 through 10","median_amount":43646.69,"10th_percentile":43646.69,"90th_percentile":43646.69,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"1 through 10","median_amount":44357.32,"10th_percentile":44357.32,"90th_percentile":44357.32,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":22997.71,"10th_percentile":22997.71,"90th_percentile":22997.71,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":22053.36,"10th_percentile":21778.37,"90th_percentile":27358.29,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":19339.84,"10th_percentile":19339.84,"90th_percentile":19339.84,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":22051.37,"10th_percentile":20969.87,"90th_percentile":22192.91,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"1 through 10","median_amount":56856.23,"10th_percentile":56856.23,"90th_percentile":56856.23,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"1 through 10","median_amount":52126.2,"10th_percentile":52126.2,"90th_percentile":52126.2,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"12","median_amount":22047.88,"10th_percentile":21332.48,"90th_percentile":22084.38,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":42457.18,"10th_percentile":42457.18,"90th_percentile":42457.18,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":29901.75,"10th_percentile":29901.75,"90th_percentile":29901.75,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Major Small And Large Bowel Procedures With Mcc","code_information":[{"code":"329","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":25242.43,"maximum":94558.55,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":33656.57,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":71691.61},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":82925.46},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":79381.56},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":74922.95},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":33656.57,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":50179.99},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":60154.4},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":33656.57,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":33656.57,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25242.43,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":33656.57,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":94558.55},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":62846.15},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":91700.18},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":81220.16},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":33656.57,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":69237.08},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":34329.7,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":78946.5}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":90.0,"10th_percentile":90.0,"90th_percentile":90.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"1 through 10","median_amount":82196.54,"10th_percentile":82196.54,"90th_percentile":82196.54,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"1 through 10","median_amount":71619.86,"10th_percentile":71619.86,"90th_percentile":71619.86,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":35586.32,"10th_percentile":35586.32,"90th_percentile":35586.32,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":35563.32,"10th_percentile":34739.28,"90th_percentile":35607.42,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":35598.32,"10th_percentile":35598.32,"90th_percentile":42054.92,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":69167.79,"10th_percentile":69167.79,"90th_percentile":69167.79,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Peritoneal Adhesiolysis Without Cc/Mcc","code_information":[{"code":"337","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":8429.7,"maximum":31577.81,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11239.6,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":23941.4},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27692.94},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26509.45},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25020.5},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11239.6,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16757.6},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20088.55},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11239.6,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11239.6,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8429.7,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11239.6,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":31577.81},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20987.46},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30623.25},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27123.45},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11239.6,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23121.71},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11464.39,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26364.16}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":11889.03,"10th_percentile":11889.03,"90th_percentile":12228.59,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Lung Transplant","code_information":[{"code":"007","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":71118.12,"maximum":266409.7,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":94824.16,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":201984.27},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":233634.56},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":223649.95},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":211088.26},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":94824.16,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":141377.33},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":169479.27},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":94824.16,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":94824.16,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":71118.12,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":94824.16,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":266409.7},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":177063.03},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":258356.49},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":228830.03},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":94824.16,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":195068.86},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":96720.64,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":222424.22}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Autologous Bone Marrow Transplant Without Cc/Mcc","code_information":[{"code":"017","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":29832.35,"maximum":111752.52,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":39776.47,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":84727.58},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":98004.12},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":93815.82},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":88546.49},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":39776.47,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":59304.42},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":71092.51},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":39776.47,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":39776.47,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":29832.35,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":39776.47,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":111752.52},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":74273.72},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":108374.39},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":95988.74},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":39776.47,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":81826.73},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":40572.0,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":93301.65}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Craniotomy And Endovascular Intracranial Procedures With Mcc","code_information":[{"code":"025","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":24968.94,"maximum":93534.08,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":33291.92,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":70914.88},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":82027.01},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":78521.51},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":74111.21},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":33291.92,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":49636.32},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":59502.66},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":33291.92,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":33291.92,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":24968.94,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":33291.92,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":93534.08},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":62165.26},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":90706.67},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":80340.19},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":33291.92,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":68486.94},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":33957.76,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":78091.16}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":32677.04,"10th_percentile":32677.04,"90th_percentile":34652.75,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Ventricular Shunt Procedures Without Cc/Mcc","code_information":[{"code":"033","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":9132.08,"maximum":34208.95,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12176.11,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":25936.25},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":30000.38},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28718.28},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27105.27},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12176.11,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18153.88},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21762.37},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12176.11,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12176.11,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9132.08,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12176.11,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":34208.95},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22736.18},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33174.86},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29383.44},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12176.11,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25048.26},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12419.63,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28560.89}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Peripheral, Cranial Nerve And Other Nervous System Procedures With Cc Or Peripheral Neurostimulator","code_information":[{"code":"041","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":12074.52,"maximum":45231.35,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16099.36,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":34293.12},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":39666.75},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":37971.55},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":35838.81},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16099.36,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24003.21},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28774.39},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16099.36,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16099.36,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12074.52,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16099.36,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":45231.35},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30061.97},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":43864.07},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38851.03},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16099.36,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33119.02},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16421.35,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37763.44}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"1 through 10","median_amount":59948.66,"10th_percentile":59948.66,"90th_percentile":59948.66,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":16047.2,"10th_percentile":16047.2,"90th_percentile":16047.2,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Multiple Sclerosis And Cerebellar Ataxia With Mcc","code_information":[{"code":"058","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":9388.0,"maximum":35167.59,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12517.33,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":26663.07},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":30841.09},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":29523.07},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27864.85},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12517.33,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18662.61},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22372.23},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12517.33,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12517.33,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9388.0,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12517.33,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":35167.59},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23373.33},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34104.53},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30206.87},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12517.33,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25750.2},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12767.68,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29361.26}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":10090.02,"10th_percentile":10090.02,"90th_percentile":10090.02,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Intracranial Hemorrhage Or Cerebral Infarction Without Cc/Mcc","code_information":[{"code":"066","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":3758.49,"maximum":14079.38,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5011.32,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":10674.59},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12347.26},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11819.59},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11155.72},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5011.32,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7471.59},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8956.74},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5011.32,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5011.32,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3758.49,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5011.32,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":14079.38},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9357.53},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13653.78},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12093.35},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5011.32,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10309.12},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5111.55,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11754.81}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":5442.15,"10th_percentile":5442.15,"90th_percentile":5442.15,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":5477.78,"10th_percentile":5477.78,"90th_percentile":5477.78,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":5471.48,"10th_percentile":5471.48,"90th_percentile":5503.08,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":8247.3,"10th_percentile":8247.3,"90th_percentile":8247.3,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cranial And Peripheral Nerve Disorders Without Mcc","code_information":[{"code":"074","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":5660.8,"maximum":21205.47,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7547.74,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":16077.39},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18596.66},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17801.92},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16802.04},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7547.74,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11253.24},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13490.08},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7547.74,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7547.74,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5660.8,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7547.74,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":21205.47},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14093.73},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20564.46},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18214.24},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7547.74,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15526.94},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7698.69,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17704.35}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":5107.22,"10th_percentile":5107.22,"90th_percentile":5107.22,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":8100.68,"10th_percentile":8100.68,"90th_percentile":8100.68,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":6091.22,"10th_percentile":188.96,"90th_percentile":7000.09,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Traumatic Stupor And Coma <1 Hour With Mcc","code_information":[{"code":"085","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":12476.5,"maximum":46737.21,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16635.34,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":35434.82},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":40987.35},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":39235.71},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":37031.97},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16635.34,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24802.33},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29732.36},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16635.34,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16635.34,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12476.5,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16635.34,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":46737.21},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31062.8},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":45324.41},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":40144.47},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16635.34,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34221.63},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16968.05,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":39020.68}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":17577.19,"10th_percentile":17577.19,"90th_percentile":17577.19,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":17549.7,"10th_percentile":17549.7,"90th_percentile":17549.7,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":32701.67,"10th_percentile":32701.67,"90th_percentile":32701.67,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Disorders Of Nervous System Without Cc/Mcc","code_information":[{"code":"093","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":4373.01,"maximum":16381.37,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5830.68,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":12419.89},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14366.05},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13752.1},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12979.69},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5830.68,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8693.21},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10421.18},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5830.68,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5830.68,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4373.01,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5830.68,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":16381.37},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10887.5},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15886.19},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14070.62},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5830.68,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11994.67},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5947.29,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13676.73}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Seizures Without Mcc","code_information":[{"code":"101","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":4956.77,"maximum":18568.16,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6609.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":14077.85},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16283.81},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15587.9},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14712.38},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6609.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9853.68},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11812.33},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6609.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6609.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4956.77,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6609.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":18568.16},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12340.9},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18006.87},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15948.94},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6609.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13595.86},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6741.21,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15502.47}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":1403.12,"10th_percentile":1403.12,"90th_percentile":1403.12,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"1 through 10","median_amount":14375.75,"10th_percentile":14375.75,"90th_percentile":14375.75,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":5539.02,"10th_percentile":5539.02,"90th_percentile":5539.02,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":7160.38,"10th_percentile":7160.38,"90th_percentile":7160.38,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":7178.38,"10th_percentile":7178.38,"90th_percentile":7233.9,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":13595.86,"10th_percentile":13595.86,"90th_percentile":13595.86,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":5334.46,"10th_percentile":5334.46,"90th_percentile":5334.46,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Acute Major Eye Infections With Cc/Mcc","code_information":[{"code":"121","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":6388.45,"maximum":23931.24,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8517.93,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":18143.99},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20987.1},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20090.19},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18961.79},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8517.93,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12699.75},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15224.11},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8517.93,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8517.93,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6388.45,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8517.93,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":23931.24},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15905.35},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23207.84},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20555.51},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8517.93,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17522.79},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8688.29,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19980.08}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Mouth Procedures Without Cc/Mcc","code_information":[{"code":"138","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":4866.71,"maximum":18230.78,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6488.95,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":13822.06},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15987.93},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15304.67},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14445.06},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6488.95,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9674.65},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11597.7},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6488.95,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6488.95,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4866.71,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6488.95,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":18230.78},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12116.67},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17679.69},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15659.15},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6488.95,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13348.83},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6618.73,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15220.8}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Ear, Nose, Mouth And Throat Malignancy With Mcc","code_information":[{"code":"146","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":11628.04,"maximum":43558.86,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15504.06,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":33025.09},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":38200.01},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":36567.5},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":34513.62},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15504.06,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23115.66},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27710.41},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15504.06,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15504.06,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11628.04,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15504.06,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":43558.86},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28950.38},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":42242.13},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37414.46},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15504.06,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31894.4},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15814.14,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36367.09}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Ear, Nose, Mouth And Throat Diagnoses With Mcc","code_information":[{"code":"154","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":8586.21,"maximum":32164.1,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11448.28,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":24385.91},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28207.1},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27001.65},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25485.05},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11448.28,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17068.73},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20461.52},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11448.28,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11448.28,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8586.21,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11448.28,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":32164.1},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21377.13},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31191.83},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27627.05},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11448.28,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23551.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11677.25,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26853.66}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Major Chest Procedures Without Cc/Mcc","code_information":[{"code":"165","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":10512.14,"maximum":39378.65,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14016.19,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":29855.78},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":34534.08},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":33058.23},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":31201.46},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14016.19,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20897.32},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25051.14},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14016.19,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14016.19,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10512.14,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14016.19,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":39378.65},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26172.11},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38188.29},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33823.91},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14016.19,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28833.59},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14296.51,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32877.05}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"1 through 10","median_amount":61515.94,"10th_percentile":61515.94,"90th_percentile":61515.94,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":13550.87,"10th_percentile":13550.87,"90th_percentile":13550.87,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"1 through 10","median_amount":86507.8,"10th_percentile":86507.8,"90th_percentile":86507.8},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":14436.3,"10th_percentile":14436.3,"90th_percentile":14436.3,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":5110.38,"10th_percentile":5110.38,"90th_percentile":5110.38,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":13382.06,"10th_percentile":13382.06,"90th_percentile":13382.06,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Respiratory Infections And Inflammations With Cc","code_information":[{"code":"178","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":5359.86,"maximum":20078.14,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7146.48,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":15222.67},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17608.02},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16855.52},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15908.8},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7146.48,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10654.99},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12772.91},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7146.48,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7146.48,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5359.86,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7146.48,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":20078.14},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13344.47},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19471.2},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17245.92},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7146.48,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14701.49},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7289.41,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16763.14}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":7437.48,"10th_percentile":7195.41,"90th_percentile":7659.29,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":7655.99,"10th_percentile":7655.99,"90th_percentile":7655.99,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":7716.61,"10th_percentile":7636.49,"90th_percentile":7727.71,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":13059.79,"10th_percentile":13059.79,"90th_percentile":13059.79,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":7691.52,"10th_percentile":7606.92,"90th_percentile":13463.89,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":14944.0,"10th_percentile":14944.0,"90th_percentile":14944.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Pleural Effusion With Mcc","code_information":[{"code":"186","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":8558.75,"maximum":32061.24,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11411.67,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":24307.92},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28116.9},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26915.3},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25403.55},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11411.67,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17014.14},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20396.09},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11411.67,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11411.67,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8558.75,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11411.67,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":32061.24},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21308.76},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31092.08},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27538.7},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11411.67,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23475.69},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11639.9,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26767.78}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":12236.76,"10th_percentile":12236.76,"90th_percentile":12236.76,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":12269.76,"10th_percentile":12269.76,"90th_percentile":12269.76,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":264.31,"10th_percentile":264.31,"90th_percentile":264.31,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Simple Pneumonia And Pleurisy With Cc","code_information":[{"code":"194","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":4425.73,"maximum":16578.86,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5900.97,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":12569.62},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14539.24},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13917.89},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13136.17},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5900.97,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8798.01},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10546.81},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5900.97,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5900.97,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4425.73,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5900.97,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":16578.86},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11018.76},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16077.71},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14240.25},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5900.97,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12139.27},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6018.99,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13841.61}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":4458.69,"10th_percentile":4458.69,"90th_percentile":4458.69,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":5855.12,"10th_percentile":4580.02,"90th_percentile":6410.72,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"1 through 10","median_amount":21697.95,"10th_percentile":21697.95,"90th_percentile":21697.95,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"1 through 10","median_amount":10231.69,"10th_percentile":10231.69,"90th_percentile":10231.69,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":6361.71,"10th_percentile":6361.71,"90th_percentile":6361.71,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":4499.98,"10th_percentile":4499.98,"90th_percentile":4499.98,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":4681.62,"10th_percentile":4681.62,"90th_percentile":4681.62,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"14","median_amount":6404.02,"10th_percentile":5584.52,"90th_percentile":6714.32,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"12","median_amount":6421.03,"10th_percentile":6005.93,"90th_percentile":6436.22,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":12351.66,"10th_percentile":12351.66,"90th_percentile":12351.66,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Bronchitis And Asthma With Cc/Mcc","code_information":[{"code":"202","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":5333.5,"maximum":19979.39,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7111.34,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":15147.81},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17521.42},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16772.62},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15830.56},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7111.34,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10602.59},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12710.09},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7111.34,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7111.34,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5333.5,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7111.34,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":19979.39},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13278.84},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19375.44},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17161.1},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7111.34,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14629.19},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7253.57,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16680.7}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":7983.84,"10th_percentile":7983.84,"90th_percentile":7983.84,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":1239.22,"10th_percentile":1239.22,"90th_percentile":1239.22,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":6326.58,"10th_percentile":6326.58,"90th_percentile":6326.58,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":7493.19,"10th_percentile":7392.96,"90th_percentile":9046.44,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":7075.44,"10th_percentile":7075.44,"90th_percentile":7508.79,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Concomitant Aortic And Mitral Valve Procedures","code_information":[{"code":"212","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":59716.88,"maximum":223700.46,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":79622.51,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":169603.34},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":196179.64},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":187795.71},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":177247.83},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":79622.51,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":118712.55},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":142309.35},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":79622.51,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":79622.51,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":59716.88,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":79622.51,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":223700.46},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":148677.33},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":216938.3},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":192145.35},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":79622.51,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":163796.57},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":81214.96,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":186766.47}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/M","code_information":[{"code":"221","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":27679.07,"maximum":103686.29,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":36905.43,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":78612.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":90930.25},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":87044.25},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":82155.26},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":36905.43,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":55023.86},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":65961.1},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":36905.43,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":36905.43,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27679.07,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":36905.43,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":103686.29},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":68912.69},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":100551.99},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":89060.33},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":36905.43,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":75920.53},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":37643.54,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":86567.2}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Coronary Bypass Without Cardiac Catheterization Without Mcc","code_information":[{"code":"236","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":23003.48,"maximum":86171.41,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":30671.3,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":65332.71},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":75570.14},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":72340.58},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":68277.44},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":30671.3,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":45729.13},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":54818.83},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":30671.3,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":30671.3,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23003.48,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":30671.3,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":86171.41},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":57271.83},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":83566.56},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":74016.1},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":30671.3,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":63095.89},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":31284.73,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":71944.11}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":31654.3,"10th_percentile":31654.3,"90th_percentile":31654.3,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"1 through 10","median_amount":64136.42,"10th_percentile":64136.42,"90th_percentile":64136.42,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":31878.86,"10th_percentile":31668.56,"90th_percentile":37454.22,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"1 through 10","median_amount":84587.37,"10th_percentile":84587.37,"90th_percentile":84587.37,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":32009.3,"10th_percentile":32009.3,"90th_percentile":32009.3,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Percutaneous Cardiovascular Procedures Without Intraluminal Device With Mcc","code_information":[{"code":"250","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":11985.56,"maximum":44898.08,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15980.74,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":34040.45},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":39374.48},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":37691.78},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":35574.75},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15980.74,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23826.35},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28562.38},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15980.74,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15980.74,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11985.56,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15980.74,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":44898.08},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29840.47},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":43540.88},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38564.78},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15980.74,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32875.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16300.35,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37485.2}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":17451.78,"10th_percentile":17451.78,"90th_percentile":17451.78,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cardiac Pacemaker Device Replacement With Mcc","code_information":[{"code":"258","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":17255.35,"maximum":64638.84,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23007.13,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":49007.33},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":56686.63},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":54264.07},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":51216.23},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23007.13,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34302.31},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":41120.66},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23007.13,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23007.13,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17255.35,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23007.13,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":64638.84},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":42960.71},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":62684.9},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":55520.91},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23007.13,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":47329.45},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23467.27,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":53966.67}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Endovascular Cardiac Valve Replacement And Supplement Procedures With Mcc","code_information":[{"code":"266","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":33655.1,"maximum":126072.59,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":44873.47,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":95584.65},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":110562.46},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":105837.47},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":99892.92},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":44873.47,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":66903.74},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":80202.37},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":44873.47,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":44873.47,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":33655.1,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":44873.47,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":126072.59},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":83791.22},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":122261.58},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":108288.83},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":44873.47,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":92312.09},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":45770.94,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":105257.41}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":46402.99,"10th_percentile":46014.37,"90th_percentile":46851.86,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":46401.0,"10th_percentile":46401.0,"90th_percentile":46403.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":46429.1,"10th_percentile":46397.51,"90th_percentile":46538.48,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Percutaneous And Other Intracardiac Procedures Without Mcc","code_information":[{"code":"274","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":18076.9,"maximum":67716.39,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":24102.54,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":51340.64},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":59385.56},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":56847.66},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":53654.71},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":24102.54,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35935.49},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":43078.48},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":24102.54,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":24102.54,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18076.9,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":24102.54,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":67716.39},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":45006.13},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":65669.42},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":58164.34},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":24102.54,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":49582.88},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":24584.59,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":56536.1}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":24171.5,"10th_percentile":23882.4,"90th_percentile":24182.4,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"1 through 10","median_amount":48682.2,"10th_percentile":48682.2,"90th_percentile":48682.2,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":24178.49,"10th_percentile":24178.49,"90th_percentile":24178.49,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"1 through 10","median_amount":64970.63,"10th_percentile":64970.63,"90th_percentile":64970.63,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"17","median_amount":24176.99,"10th_percentile":24028.77,"90th_percentile":25731.28,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"67","median_amount":24177.0,"10th_percentile":24028.78,"90th_percentile":30354.46,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":42672.22,"10th_percentile":42672.22,"90th_percentile":42672.22,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"1 through 10","median_amount":62259.96,"10th_percentile":62259.96,"90th_percentile":62259.96,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"28","median_amount":24178.81,"10th_percentile":24043.05,"90th_percentile":30491.03,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":47011.62,"10th_percentile":46546.59,"90th_percentile":48958.76,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":23077.14,"10th_percentile":23077.14,"90th_percentile":23077.14,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Acute Myocardial Infarction, Discharged Alive Without Cc/Mcc","code_information":[{"code":"282","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":3971.02,"maximum":14875.51,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5294.69,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":11278.19},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13045.45},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12487.94},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11786.53},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5294.69,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7894.08},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9463.21},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5294.69,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5294.69,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3971.02,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5294.69,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":14875.51},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9886.66},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14425.85},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12777.18},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5294.69,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10892.06},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5400.58,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12419.5}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"1 through 10","median_amount":11309.38,"10th_percentile":11309.38,"90th_percentile":11309.38,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"1 through 10","median_amount":15869.02,"10th_percentile":15869.02,"90th_percentile":15869.02},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":6075.78,"10th_percentile":5735.98,"90th_percentile":6732.78,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":5739.12,"10th_percentile":5739.12,"90th_percentile":5739.12,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":10442.73,"10th_percentile":10442.73,"90th_percentile":10442.73,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":5912.23,"10th_percentile":5912.23,"90th_percentile":5912.23,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Acute And Subacute Endocarditis Without Cc/Mcc","code_information":[{"code":"290","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":5105.6,"maximum":19125.66,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6807.46,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":14500.53},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16772.72},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16055.92},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15154.11},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6807.46,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10149.53},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12166.98},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6807.46,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6807.46,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5105.6,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6807.46,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":19125.66},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12711.43},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18547.52},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16427.8},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6807.46,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14004.07},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6943.61,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15967.92}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Peripheral Vascular Disorders With Cc","code_information":[{"code":"300","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":5862.35,"maximum":21960.46,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7816.47,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":16649.8},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19258.77},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18435.73},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17400.25},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7816.47,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11653.9},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13970.37},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7816.47,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7816.47,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5862.35,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7816.47,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":21960.46},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14595.51},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21296.63},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18862.73},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7816.47,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16079.75},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7972.8,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18334.69}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":8022.08,"10th_percentile":8022.08,"90th_percentile":8022.08,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":8341.59,"10th_percentile":8341.59,"90th_percentile":8341.59,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":1629.78,"10th_percentile":1629.78,"90th_percentile":1629.78,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cardiac Arrhythmia And Conduction Disorders With Mcc","code_information":[{"code":"308","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":6611.96,"maximum":24768.52,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8815.95,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":18778.79},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21721.36},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20793.08},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19625.2},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8815.95,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13144.07},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15756.75},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8815.95,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8815.95,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6611.96,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8815.95,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":24768.52},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16461.82},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24019.8},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21274.68},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8815.95,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18135.85},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8992.27,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20679.12}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"1 through 10","median_amount":15004.25,"10th_percentile":15004.25,"90th_percentile":15004.25,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"1 through 10","median_amount":18808.42,"10th_percentile":18808.42,"90th_percentile":18808.42,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"1 through 10","median_amount":13164.82,"10th_percentile":13164.82,"90th_percentile":13164.82,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":9356.94,"10th_percentile":9356.94,"90th_percentile":9356.94,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":9107.28,"10th_percentile":7379.44,"90th_percentile":9375.94,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":18164.47,"10th_percentile":18164.47,"90th_percentile":18164.47,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":81.38,"10th_percentile":81.38,"90th_percentile":81.38,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Circulatory System Diagnoses Without Cc/Mcc","code_information":[{"code":"316","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":3745.86,"maximum":14032.07,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4994.48,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":10638.71},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12305.77},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11779.87},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11118.23},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4994.48,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7446.49},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8926.64},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4994.48,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4994.48,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3745.86,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4994.48,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":14032.07},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9326.09},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13607.9},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12052.71},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4994.48,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10274.47},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5094.37,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11715.31}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"1 through 10","median_amount":11285.34,"10th_percentile":11285.34,"90th_percentile":11285.34,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":1305.11,"10th_percentile":1305.11,"90th_percentile":1305.11,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Coronary Intravascular Lithotripsy With Intraluminal Device Without Mcc","code_information":[{"code":"324","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":17304.22,"maximum":64821.93,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23072.3,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":49146.15},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":56847.19},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":54417.77},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":51361.3},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23072.3,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34399.47},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":41237.14},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23072.3,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23072.3,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17304.22,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23072.3,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":64821.93},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":43082.39},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":62862.45},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":55678.17},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23072.3,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":47463.51},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23533.75,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":54119.53}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":23102.91,"10th_percentile":23102.91,"90th_percentile":23102.91,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"1 through 10","median_amount":34169.63,"10th_percentile":34169.63,"90th_percentile":34169.63,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":24323.99,"10th_percentile":24323.99,"90th_percentile":24745.39,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":29316.15,"10th_percentile":24758.99,"90th_percentile":29328.57,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":24753.7,"10th_percentile":22785.39,"90th_percentile":29314.97,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":23045.85,"10th_percentile":23045.85,"90th_percentile":23045.85,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Rectal Resection With Mcc","code_information":[{"code":"332","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":19883.66,"maximum":74484.53,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26511.55,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":56472.06},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":65321.05},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":62529.49},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":59017.41},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26511.55,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":39527.18},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":47384.1},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26511.55,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26511.55,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19883.66,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26511.55,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":74484.53},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":49504.42},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":72232.97},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":63977.77},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26511.55,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":54538.6},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27041.78,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":62186.79}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Minor Small And Large Bowel Procedures Without Cc/Mcc","code_information":[{"code":"346","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":6514.21,"maximum":24402.34,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8685.61,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":18501.16},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21400.23},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20485.67},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19335.06},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8685.61,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12949.75},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15523.8},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8685.61,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8685.61,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6514.21,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8685.61,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":24402.34},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16218.45},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23664.69},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20960.15},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8685.61,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17867.73},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8859.32,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20373.4}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Hernia Procedures Except Inguinal And Femoral With Cc","code_information":[{"code":"354","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":9239.18,"maximum":34610.1,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12318.9,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":26240.39},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":30352.18},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":29055.05},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27423.12},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12318.9,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18366.76},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22017.57},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12318.9,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12318.9,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9239.18,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12318.9,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":34610.1},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23002.8},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33563.88},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29728.01},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12318.9,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25341.99},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12565.28,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28895.81}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":15657.91,"10th_percentile":15657.91,"90th_percentile":15657.91,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":9305.49,"10th_percentile":9305.49,"90th_percentile":9305.49,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":13199.87,"10th_percentile":13199.87,"90th_percentile":13199.87,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Major Esophageal Disorders With Cc","code_information":[{"code":"369","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":5492.76,"maximum":20575.97,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7323.68,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":15600.12},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18044.61},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17273.45},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16303.26},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7323.68,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10919.18},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13089.62},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7323.68,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7323.68,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5492.76,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7323.68,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":20575.97},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13675.34},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19953.99},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17673.53},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7323.68,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15066.01},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7470.15,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17178.79}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":4296.78,"10th_percentile":4296.78,"90th_percentile":4296.78,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":13887.39,"10th_percentile":13887.39,"90th_percentile":13887.39,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Gastrointestinal Hemorrhage With Mcc","code_information":[{"code":"377","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":10038.76,"maximum":37605.36,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13385.01,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":28511.32},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":32978.95},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":31569.56},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":29796.4},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13385.01,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19956.28},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23923.04},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13385.01,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13385.01,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10038.76,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13385.01,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":37605.36},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24993.53},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36468.6},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32300.76},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13385.01,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27535.16},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13652.71,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31396.54}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":14105.19,"10th_percentile":14105.19,"90th_percentile":14105.19,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"1 through 10","median_amount":30126.18,"10th_percentile":30126.18,"90th_percentile":30126.18,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"1 through 10","median_amount":28358.47,"10th_percentile":28358.47,"90th_percentile":28358.47,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":14081.59,"10th_percentile":14081.59,"90th_percentile":14081.59,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":14133.19,"10th_percentile":14133.19,"90th_percentile":14133.19,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":8696.72,"10th_percentile":8696.72,"90th_percentile":8696.72,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":13995.24,"10th_percentile":13382.13,"90th_percentile":17131.59,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":14233.1,"10th_percentile":14081.6,"90th_percentile":17006.59,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Inflammatory Bowel Disease With Mcc","code_information":[{"code":"385","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":8689.46,"maximum":32550.85,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11585.94,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":24679.13},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28546.27},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27326.32},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25791.49},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11585.94,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17273.97},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20707.56},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11585.94,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11585.94,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8689.46,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11585.94,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":32550.85},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21634.17},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31566.89},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27959.24},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11585.94,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23834.18},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11817.66,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27176.56}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"1 through 10","median_amount":46128.95,"10th_percentile":46128.95,"90th_percentile":46128.95,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":9168.25,"10th_percentile":9168.25,"90th_percentile":9168.25,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":13332.57,"10th_percentile":13332.57,"90th_percentile":13332.57,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":11216.2,"10th_percentile":11216.2,"90th_percentile":11216.2,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Digestive System Diagnoses With Mcc","code_information":[{"code":"393","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":8782.82,"maximum":32900.58,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11710.42,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":24944.28},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28852.97},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27619.91},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26068.59},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11710.42,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17459.56},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20930.04},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11710.42,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11710.42,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8782.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11710.42,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":32900.58},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21866.61},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31906.04},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28259.63},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11710.42,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24090.26},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11944.63,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27468.54}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"1 through 10","median_amount":20156.75,"10th_percentile":20156.75,"90th_percentile":20156.75,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"1 through 10","median_amount":17484.04,"10th_percentile":17484.04,"90th_percentile":17484.04,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":11717.72,"10th_percentile":11717.72,"90th_percentile":12876.99,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":12836.39,"10th_percentile":12836.39,"90th_percentile":12836.39,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"1 through 10","median_amount":33072.76,"10th_percentile":33072.76,"90th_percentile":33072.76,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":11036.89,"10th_percentile":11036.89,"90th_percentile":11036.89,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":15215.2,"10th_percentile":15215.2,"90th_percentile":15215.2,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Pancreas, Liver And Shunt Procedures With Cc","code_information":[{"code":"406","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":15926.92,"maximum":59662.51,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21235.89,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":45234.42},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":52322.51},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":50086.45},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":47273.26},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21235.89,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31661.48},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37954.92},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21235.89,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21235.89,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15926.92,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21235.89,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":59662.51},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":39653.3},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":57858.99},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":51246.53},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21235.89,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":43685.71},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21660.61,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":49811.95}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cholecystectomy Except By Laparoscope Without C.D.E. With Mcc","code_information":[{"code":"414","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":19564.6,"maximum":73289.31,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26086.13,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":55565.87},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":64272.87},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":61526.1},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":58070.38},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26086.13,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38892.9},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":46623.75},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26086.13,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26086.13,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19564.6,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26086.13,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":73289.31},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":48710.04},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":71073.87},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":62951.14},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26086.13,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":53663.44},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26607.85,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":61188.9}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Hepatobiliary Diagnostic Procedures Without Cc/Mcc","code_information":[{"code":"422","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":7685.58,"maximum":28790.32,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10247.44,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":21828.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25248.38},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24169.37},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22811.85},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10247.44,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15278.34},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18315.26},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10247.44,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10247.44,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7685.58,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10247.44,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":28790.32},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19134.82},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27920.03},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24729.17},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10247.44,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21080.67},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10452.39,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24036.9}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Combined Anterior And Posterior Cervical Spinal Fusion Without Mcc","code_information":[{"code":"430","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":31670.96,"maximum":118639.97,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":42227.95,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":89949.46},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":104044.25},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":99597.82},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":94003.73},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":42227.95,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":62959.43},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":75474.04},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":42227.95,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":42227.95,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":31670.96,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":42227.95,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":118639.97},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":78851.31},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":115053.65},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":101904.66},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":42227.95,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":86869.83},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":43072.51,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":99051.96}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Disorders Of Pancreas Except Malignancy With Cc","code_information":[{"code":"439","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":4619.59,"maximum":17305.05,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6159.45,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":13120.2},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15176.09},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14527.52},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13711.56},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6159.45,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9183.38},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11008.78},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6159.45,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6159.45,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4619.59,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6159.45,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17305.05},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11501.4},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16781.94},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14864.0},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6159.45,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12671.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6282.64,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14447.9}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":5190.56,"10th_percentile":5190.56,"90th_percentile":5190.56,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"1 through 10","median_amount":12891.37,"10th_percentile":12891.37,"90th_percentile":12902.33,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":5190.56,"10th_percentile":5190.56,"90th_percentile":5190.56,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":6138.67,"10th_percentile":6138.67,"90th_percentile":6674.31,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":6540.38,"10th_percentile":5866.01,"90th_percentile":6662.07,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":10570.35,"10th_percentile":10570.35,"90th_percentile":12346.12,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":3928.71,"10th_percentile":3928.71,"90th_percentile":5190.56,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":6404.72,"10th_percentile":6404.72,"90th_percentile":6404.72,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Multiple Level Spinal Fusion Except Cervical With Mcc","code_information":[{"code":"447","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":36693.09,"maximum":137452.94,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":48924.12,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":104212.92},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":120542.75},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":115391.23},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":108910.08},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":48924.12,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":72943.03},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":87442.1},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":48924.12,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":48924.12,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":36693.09,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":48924.12,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":137452.94},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":91354.91},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":133297.92},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":118063.87},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":48924.12,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":100644.94},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":49902.6,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":114758.82}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Bilateral Or Multiple Major Joint Procedures Of Lower Extremity Without Mcc","code_information":[{"code":"462","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":14607.82,"maximum":54721.15,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19477.09,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":41488.02},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":47989.06},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":45938.2},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43358.0},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19477.09,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29039.22},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34811.42},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19477.09,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19477.09,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14607.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19477.09,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":54721.15},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36369.14},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":53067.0},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":47002.2},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19477.09,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":40067.58},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19866.63,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":45686.43}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc","code_information":[{"code":"470","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":10592.86,"maximum":39681.06,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14123.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":30085.05},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":34799.28},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":33312.1},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":31441.07},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14123.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21057.8},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25243.51},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14123.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14123.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10592.86,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14123.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":39681.06},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26373.1},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38481.56},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34083.66},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14123.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29055.02},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14406.3,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33129.53}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":12960.32,"10th_percentile":12960.32,"90th_percentile":12960.32,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":14602.8,"10th_percentile":14602.8,"90th_percentile":14602.8,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":14615.4,"10th_percentile":14243.75,"90th_percentile":15330.62,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"1 through 10","median_amount":37658.49,"10th_percentile":37658.49,"90th_percentile":37658.49,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":14610.11,"10th_percentile":14602.81,"90th_percentile":14626.51,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":28401.29,"10th_percentile":28401.29,"90th_percentile":28401.29,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Biopsies Of Musculoskeletal System And Connective Tissue With Cc","code_information":[{"code":"478","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":13505.09,"maximum":50590.32,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18006.79,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":38356.14},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":44366.43},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":42470.38},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":40084.96},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18006.79,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26847.09},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32183.55},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18006.79,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18006.79,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13505.09,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18006.79,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":50590.32},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33623.68},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":49061.04},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":43454.06},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18006.79,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37042.93},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18366.93,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":42237.62}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":16971.89,"10th_percentile":16971.89,"90th_percentile":16971.89,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":17543.73,"10th_percentile":17543.73,"90th_percentile":17543.73,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Knee Procedures With Principal Diagnosis Of Infection Without Cc/Mcc","code_information":[{"code":"487","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":8601.04,"maximum":32219.65,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11468.05,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":24428.02},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28255.81},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27048.27},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25529.06},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11468.05,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17098.21},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20496.86},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11468.05,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11468.05,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8601.04,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11468.05,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":32219.65},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21414.04},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31245.69},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27674.75},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11468.05,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23591.67},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11697.41,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26900.03}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur Without Cc/Mcc","code_information":[{"code":"497","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":6635.57,"maximum":24856.98,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8847.43,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":18845.86},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21798.94},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20867.34},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19695.29},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8847.43,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13191.01},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15813.02},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8847.43,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8847.43,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6635.57,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8847.43,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":24856.98},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16520.61},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24105.59},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21350.66},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8847.43,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18200.62},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9024.38,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20752.98}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Foot Procedures Without Cc/Mcc","code_information":[{"code":"505","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":9845.45,"maximum":36881.23,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13127.27,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":27962.3},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":32343.9},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":30961.66},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":29222.64},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13127.27,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19572.0},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23462.37},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13127.27,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13127.27,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9845.45,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13127.27,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":36881.23},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24512.26},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35766.36},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31678.78},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13127.27,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27004.95},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13389.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30791.97}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures Without Cc/Mcc","code_information":[{"code":"514","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":5614.12,"maximum":21030.61,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7485.5,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":15944.81},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18443.31},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17655.12},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16663.49},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7485.5,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11160.45},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13378.84},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7485.5,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7485.5,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5614.12,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7485.5,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":21030.61},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13977.51},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20394.89},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18064.04},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7485.5,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15398.9},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7635.21,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17558.36}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Hip Replacement With Principal Diagnosis Of Hip Fracture Without Mcc","code_information":[{"code":"522","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":11629.7,"maximum":43565.03,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15506.26,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":33029.77},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":38205.43},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":36572.68},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":34518.51},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15506.26,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23118.93},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27714.34},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15506.26,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15506.26,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11629.7,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15506.26,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":43565.03},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28954.49},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":42248.12},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37419.76},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15506.26,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31898.92},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15816.39,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36372.24}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":16356.3,"10th_percentile":16356.3,"90th_percentile":19802.47,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":16326.8,"10th_percentile":16241.67,"90th_percentile":16343.3,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":16364.6,"10th_percentile":16326.8,"90th_percentile":19551.95,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":16350.5,"10th_percentile":16350.5,"90th_percentile":19738.29,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":31754.31,"10th_percentile":31754.31,"90th_percentile":31754.31,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Osteomyelitis With Cc","code_information":[{"code":"540","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":7118.84,"maximum":26667.3,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9491.79,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":20218.39},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23386.55},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22387.1},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21129.69},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9491.79,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14151.71},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16964.68},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9491.79,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9491.79,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7118.84,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9491.79,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":26667.3},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17723.8},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25861.19},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22905.62},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9491.79,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19526.17},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9681.63,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22264.41}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Septic Arthritis With Mcc","code_information":[{"code":"548","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":10603.85,"maximum":39722.2,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14138.47,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":30116.25},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":34835.37},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":33346.64},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":31473.67},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14138.47,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21079.64},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25269.69},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14138.47,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14138.47,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10603.85,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14138.47,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":39722.2},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26400.44},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38521.46},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34119.0},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14138.47,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29085.15},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14421.24,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33163.88}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without Mcc","code_information":[{"code":"556","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":4561.37,"maximum":17086.99,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6081.83,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":12954.87},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14984.85},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14344.46},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13538.78},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6081.83,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9067.66},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10870.06},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6081.83,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6081.83,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4561.37,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6081.83,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17086.99},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11356.47},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16570.47},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14676.7},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6081.83,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12511.33},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6203.47,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14265.85}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":166.88,"10th_percentile":166.88,"90th_percentile":166.88,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":169.24,"10th_percentile":169.24,"90th_percentile":169.24,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":6374.03,"10th_percentile":6374.03,"90th_percentile":6374.03,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":113.09,"10th_percentile":113.09,"90th_percentile":113.09,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Musculoskeletal System And Connective Tissue Diagnoses With Mcc","code_information":[{"code":"564","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":8476.93,"maximum":31754.72,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11302.57,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":24075.53},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27848.09},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26657.97},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25160.68},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11302.57,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16851.48},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20201.09},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11302.57,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11302.57,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8476.93,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11302.57,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":31754.72},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21105.04},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30794.82},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27275.41},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11302.57,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23251.25},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11528.62,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26511.87}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":12716.11,"10th_percentile":12716.11,"90th_percentile":12716.11,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":12169.63,"10th_percentile":12169.63,"90th_percentile":12169.63,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":5889.93,"10th_percentile":5889.93,"90th_percentile":5889.93,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Skin Graft For Skin Ulcer Or Cellulitis Without Cc/Mcc","code_information":[{"code":"575","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":9868.52,"maximum":36967.63,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13158.02,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":28027.81},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":32419.68},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":31034.19},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":29291.1},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13158.02,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19617.85},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23517.34},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13158.02,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13158.02,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9868.52,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13158.02,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":36967.63},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24569.68},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35850.15},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31752.99},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13158.02,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27068.21},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13421.18,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30864.1}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Mastectomy For Malignancy Without Cc/Mcc","code_information":[{"code":"583","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":9469.82,"maximum":35474.12,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12626.43,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":26895.47},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":31109.9},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":29780.39},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28107.72},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12626.43,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18825.27},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22567.22},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12626.43,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12626.43,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9469.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12626.43,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":35474.12},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23577.05},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34401.78},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30470.15},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12626.43,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25974.64},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12878.96,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29617.17}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Malignant Breast Disorders With Mcc","code_information":[{"code":"597","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":9155.15,"maximum":34295.35,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12206.87,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":26001.76},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":30076.15},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28790.82},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27173.73},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12206.87,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18199.73},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21817.34},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12206.87,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12206.87,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9155.15,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12206.87,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":34295.35},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22793.61},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33258.65},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29457.66},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12206.87,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25111.53},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12451.01,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28633.03}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Trauma To The Skin, Subcutaneous Tissue And Breast Without Mcc","code_information":[{"code":"605","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":5030.36,"maximum":18843.82,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6707.15,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":14286.85},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16525.56},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15819.32},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14930.8},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6707.15,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9999.97},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11987.69},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6707.15,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6707.15,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5030.36,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6707.15,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":18843.82},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12524.11},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18274.2},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16185.72},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6707.15,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13797.71},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6841.29,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15732.62}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"1 through 10","median_amount":5511.38,"10th_percentile":5511.38,"90th_percentile":5511.38,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":7153.86,"10th_percentile":7153.86,"90th_percentile":7153.86,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":6231.38,"10th_percentile":6231.38,"90th_percentile":6231.38,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":7838.4,"10th_percentile":7838.4,"90th_percentile":8527.4,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"O.R. Procedures For Obesity With Mcc","code_information":[{"code":"619","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":15856.63,"maximum":59399.19,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21142.17,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":45034.78},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":52091.58},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":49865.4},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":47064.62},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21142.17,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31521.75},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37787.4},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21142.17,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21142.17,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15856.63,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21142.17,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":59399.19},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":39478.29},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":57603.63},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":51020.36},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21142.17,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":43492.91},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21565.01,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":49592.11}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Thyroid, Parathyroid And Thyroglossal Procedures Without Cc/Mcc","code_information":[{"code":"627","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":7294.58,"maximum":27325.6,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9726.1,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":20717.5},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23963.86},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22939.74},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21651.29},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9726.1,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14501.05},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17383.46},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9726.1,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9726.1,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7294.58,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9726.1,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":27325.6},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18161.33},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26499.59},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23471.06},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9726.1,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20008.18},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9920.62,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22814.02}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without Mcc","code_information":[{"code":"641","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":4273.61,"maximum":16009.02,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5698.15,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":12137.59},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14039.51},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13439.51},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12684.66},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5698.15,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8495.61},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10184.3},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5698.15,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5698.15,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4273.61,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5698.15,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":16009.02},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10640.03},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15525.09},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13750.79},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5698.15,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11722.03},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5812.11,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13365.86}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":7138.15,"10th_percentile":7138.15,"90th_percentile":7138.15,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"1 through 10","median_amount":12231.55,"10th_percentile":12231.55,"90th_percentile":12231.55,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":4963.39,"10th_percentile":4963.39,"90th_percentile":4963.39,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":6014.67,"10th_percentile":6014.67,"90th_percentile":6051.78,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":4479.73,"10th_percentile":4479.73,"90th_percentile":4479.73,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":6128.43,"10th_percentile":5633.93,"90th_percentile":7256.39,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"1 through 10","median_amount":15590.93,"10th_percentile":15590.93,"90th_percentile":15590.93,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"12","median_amount":4540.23,"10th_percentile":282.58,"90th_percentile":6139.89,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":11770.23,"10th_percentile":8972.25,"90th_percentile":12020.23,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":3241.23,"10th_percentile":3241.23,"90th_percentile":3241.23,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Major Bladder Procedures With Mcc","code_information":[{"code":"653","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":28536.87,"maximum":106899.61,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":38049.16,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":81048.25},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":93748.25},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":89741.83},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":84701.32},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":38049.16,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":56729.1},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":68005.29},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":38049.16,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":38049.16,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":28536.87,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":38049.16,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":106899.61},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":71048.35},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":103668.18},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":91820.39},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":38049.16,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":78273.37},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":38810.14,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":89249.99}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Kidney And Ureter Procedures For Non-Neoplasm Without Cc/Mcc","code_information":[{"code":"661","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":5686.06,"maximum":21300.1,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7581.42,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":16149.13},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18679.65},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17881.36},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16877.02},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7581.42,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11303.46},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13550.28},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7581.42,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7581.42,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5686.06,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7581.42,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":21300.1},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14156.62},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20656.23},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18295.52},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7581.42,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15596.23},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7733.05,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17783.36}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"1 through 10","median_amount":14085.4,"10th_percentile":14085.4,"90th_percentile":14085.4,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"1 through 10","median_amount":16011.88,"10th_percentile":16011.88,"90th_percentile":16011.88,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":3863.1,"10th_percentile":3863.1,"90th_percentile":3863.1,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":7411.79,"10th_percentile":7411.79,"90th_percentile":7411.79,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":5241.29,"10th_percentile":5241.29,"90th_percentile":5241.29,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":498.37,"10th_percentile":498.37,"90th_percentile":498.37,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":13876.44,"10th_percentile":13876.44,"90th_percentile":13876.44,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":5990.8,"10th_percentile":5990.8,"90th_percentile":5990.8,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":15310.71,"10th_percentile":15310.71,"90th_percentile":15463.68,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Transurethral Procedures With Cc","code_information":[{"code":"669","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":8523.06,"maximum":31927.53,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11364.08,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":24206.54},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27999.63},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26803.04},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25297.6},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11364.08,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16943.18},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20311.02},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11364.08,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11364.08,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8523.06,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11364.08,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":31927.53},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21219.89},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30962.4},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27423.84},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11364.08,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23377.78},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11591.36,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26656.14}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":12012.27,"10th_percentile":11299.07,"90th_percentile":14449.85,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":12333.37,"10th_percentile":12333.37,"90th_percentile":12333.37,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Renal Failure With Cc","code_information":[{"code":"683","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":4809.6,"maximum":18016.83,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6412.8,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":13659.85},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15800.31},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15125.07},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14275.54},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6412.8,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9561.11},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11461.59},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6412.8,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6412.8,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4809.6,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6412.8,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":18016.83},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11974.47},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17472.21},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15475.39},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6412.8,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13192.18},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6541.06,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15042.17}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":6306.14,"10th_percentile":6306.14,"90th_percentile":6306.14,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"1 through 10","median_amount":7860.92,"10th_percentile":7860.92,"90th_percentile":7860.92,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"1 through 10","median_amount":13864.17,"10th_percentile":13864.17,"90th_percentile":13864.17,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":6900.84,"10th_percentile":6900.84,"90th_percentile":6900.84,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":6884.34,"10th_percentile":6884.34,"90th_percentile":6884.34,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":8325.46,"10th_percentile":8325.46,"90th_percentile":8325.46,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"15","median_amount":6900.84,"10th_percentile":6717.29,"90th_percentile":8158.41,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"16","median_amount":6187.91,"10th_percentile":692.31,"90th_percentile":6884.35,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":13257.5,"10th_percentile":13257.5,"90th_percentile":13257.5,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":7929.01,"10th_percentile":7929.01,"90th_percentile":7929.01,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":5444.23,"10th_percentile":5444.23,"90th_percentile":5444.23,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Urinary Stones Without Mcc","code_information":[{"code":"694","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":4292.84,"maximum":16081.02,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5723.78,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":12192.17},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14102.65},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13499.96},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12741.71},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5723.78,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8533.82},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10230.11},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5723.78,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5723.78,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4292.84,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5723.78,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":16081.02},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10687.88},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15594.92},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13812.64},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5723.78,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11774.75},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5838.26,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13425.97}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Major Male Pelvic Procedures Without Cc/Mcc","code_information":[{"code":"708","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":8425.3,"maximum":31561.35,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11233.74,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":23928.92},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27678.5},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26495.63},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25007.46},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11233.74,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16748.86},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20078.08},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11233.74,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11233.74,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8425.3,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11233.74,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":31561.35},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20976.52},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30607.29},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27109.31},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11233.74,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23109.65},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11458.41,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26350.42}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"1 through 10","median_amount":45913.84,"10th_percentile":45913.84,"90th_percentile":45913.84,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":832.8,"10th_percentile":832.8,"90th_percentile":832.8,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Male Reproductive System And Other O.R. Procedures For Malignancy Without Cc/Mcc","code_information":[{"code":"716","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":8078.24,"maximum":30261.21,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10770.98,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":22943.19},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26538.31},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25404.17},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23977.3},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10770.98,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16058.91},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19250.98},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10770.98,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10770.98,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8078.24,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10770.98,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":30261.21},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20112.41},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29346.45},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25992.57},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10770.98,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22157.67},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10986.4,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25264.94}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Inflammation Of The Male Reproductive System With Mcc","code_information":[{"code":"727","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":8143.58,"maximum":30506.01,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10858.11,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":23128.79},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26753.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25609.68},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24171.27},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10858.11,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16188.82},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19406.71},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10858.11,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10858.11,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8143.58,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10858.11,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":30506.01},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20275.11},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29583.86},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26202.84},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10858.11,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22336.92},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11075.27,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25469.33}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy Without Cc/Mcc","code_information":[{"code":"738","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":8064.5,"maximum":30209.78,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10752.67,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":22904.19},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26493.21},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25361.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23936.55},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10752.67,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16031.61},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19218.26},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10752.67,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10752.67,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8064.5,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10752.67,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":30209.78},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20078.23},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29296.58},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25948.4},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10752.67,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22120.02},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10967.72,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25222.0}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Vagina, Cervix And Vulva Procedures With Cc/Mcc","code_information":[{"code":"746","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":9539.56,"maximum":35735.38,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12719.42,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":27093.55},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":31339.02},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":29999.72},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28314.73},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12719.42,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18963.92},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22733.43},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12719.42,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12719.42,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9539.56,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12719.42,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":35735.38},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23750.69},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34655.15},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30694.56},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12719.42,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26165.94},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12973.81,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29835.3}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":12977.95,"10th_percentile":12977.95,"90th_percentile":12977.95,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Infections, Female Reproductive System With Mcc","code_information":[{"code":"757","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":7863.51,"maximum":29456.85,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10484.68,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":22333.34},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25832.91},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24728.91},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23339.97},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10484.68,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15632.05},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18739.28},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10484.68,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10484.68,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7863.51,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10484.68,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":29456.85},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19577.81},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28566.41},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25301.67},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10484.68,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21568.71},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10694.37,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24593.38}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":9334.41,"10th_percentile":9334.41,"90th_percentile":9334.41,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Postpartum And Post Abortion Diagnoses Without O.R. Procedures","code_information":[{"code":"776","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":3595.39,"maximum":13468.4,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4793.85,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":10211.36},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11811.44},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11306.67},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10671.61},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4793.85,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7147.36},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8568.06},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4793.85,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4793.85,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3595.39,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4793.85,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":13468.4},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8951.46},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13061.27},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11568.55},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4793.85,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9861.75},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4889.73,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11244.7}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1989.76,"10th_percentile":1989.76,"90th_percentile":1989.76,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"1 through 10","median_amount":9388.74,"10th_percentile":9388.74,"90th_percentile":9388.74,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":10641.14,"10th_percentile":10641.0,"90th_percentile":10641.14,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":88.6,"10th_percentile":88.6,"90th_percentile":88.6,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Neonates, Died Or Transferred To Another Acute Care Facility","code_information":[{"code":"789","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":9897.08,"maximum":37074.61,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13196.1,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":28108.91},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":32513.49},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":31123.99},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":29375.86},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13196.1,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19674.62},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23585.39},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13196.1,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13196.1,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9897.08,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13196.1,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":37074.61},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24640.78},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35953.89},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31844.87},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13196.1,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27146.54},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13460.02,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30953.42}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1005.88,"10th_percentile":1005.88,"90th_percentile":1005.88,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Vaginal Delivery With Sterilization And/Or D&C With Cc","code_information":[{"code":"797","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":5493.86,"maximum":20580.09,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7325.14,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":15603.24},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18048.22},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17276.91},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16306.52},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7325.14,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10921.37},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13092.23},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7325.14,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7325.14,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5493.86,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7325.14,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":20580.09},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13678.08},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19957.98},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17677.07},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7325.14,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15069.03},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7471.64,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17182.22}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Vaginal Delivery Without Sterilization Or D&C With Mcc","code_information":[{"code":"805","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":5926.6,"maximum":22201.15,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7902.14,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":16832.28},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19469.85},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18637.78},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17590.96},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7902.14,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11781.63},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14123.49},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7902.14,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7902.14,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5926.6,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7902.14,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":22201.15},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14755.48},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21530.04},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19069.46},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7902.14,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16255.99},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8060.18,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18535.64}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":2783.78,"10th_percentile":2783.78,"90th_percentile":2783.78,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"1 through 10","median_amount":7131.39,"10th_percentile":7131.39,"90th_percentile":7131.39,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":6728.32,"10th_percentile":6728.32,"90th_percentile":6728.32,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":2838.97,"10th_percentile":2838.97,"90th_percentile":2838.97,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Coagulation Disorders","code_information":[{"code":"813","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":8376.44,"maximum":31378.26,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11168.58,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":23790.1},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27517.94},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26341.93},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24862.39},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11168.58,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16651.7},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19961.6},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11168.58,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11168.58,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8376.44,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11168.58,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":31378.26},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20854.83},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30429.74},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26952.05},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11168.58,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22975.59},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11391.95,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26197.56}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":6274.51,"10th_percentile":6274.51,"90th_percentile":6274.51,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":12063.13,"10th_percentile":12063.13,"90th_percentile":12081.13,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":11988.94,"10th_percentile":11988.94,"90th_percentile":12133.12,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Lymphoma And Leukemia With Major O.R. Procedures With Cc","code_information":[{"code":"821","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":12293.63,"maximum":46052.17,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16391.51,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":34915.44},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":40386.58},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":38660.62},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":36489.18},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16391.51,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24438.8},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29296.56},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16391.51,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16391.51,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12293.63,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16391.51,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":46052.17},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30607.5},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":44660.07},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":39556.06},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16391.51,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33720.03},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16719.34,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38448.74}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures With Cc/Mcc","code_information":[{"code":"829","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":17353.65,"maximum":65007.08,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23138.2,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":49286.52},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":57009.56},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":54573.2},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":51508.0},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23138.2,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34497.72},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":41354.92},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23138.2,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23138.2,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17353.65,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23138.2,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":65007.08},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":43205.45},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":63042.0},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":55837.2},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23138.2,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":47599.08},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23600.96,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":54274.11}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":23883.38,"10th_percentile":23883.38,"90th_percentile":23883.38,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":46451.28,"10th_percentile":46451.28,"90th_percentile":46451.28,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Chemotherapy With Acute Leukemia As Secondary Diagnosis Or With High Dose Chemotherapy Agent With Mc","code_information":[{"code":"837","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":26383.59,"maximum":98833.39,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":35178.12,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":74932.67},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":86674.38},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":82970.26},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":78310.09},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":35178.12,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":52448.54},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":62873.87},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":35178.12,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":35178.12,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26383.59,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":35178.12,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":98833.39},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":65687.32},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":95845.79},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":84891.98},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":35178.12,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":72367.17},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":35881.68,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":82515.53}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses Without Cc/Mcc","code_information":[{"code":"845","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":4676.7,"maximum":17519.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6235.6,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":13282.41},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15363.72},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14707.13},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13881.08},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6235.6,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9296.92},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11144.89},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6235.6,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6235.6,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4676.7,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6235.6,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17519.0},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11643.59},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16989.42},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15047.77},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6235.6,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12827.65},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6360.31,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14626.53}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Infectious And Parasitic Diseases With O.R. Procedures Without Cc/Mcc","code_information":[{"code":"855","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":8222.12,"maximum":30800.19,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10962.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":23351.83},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27010.99},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25856.64},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24404.36},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10962.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16344.93},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19593.86},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10962.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10962.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8222.12,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10962.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":30800.19},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20470.63},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29869.14},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26455.52},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10962.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22552.32},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11182.08,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25714.93}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Viral Illness Without Mcc","code_information":[{"code":"866","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":4775.55,"maximum":17889.29,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6367.4,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":13563.15},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15688.45},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15017.99},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14174.48},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6367.4,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9493.42},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11380.46},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6367.4,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6367.4,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4775.55,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6367.4,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17889.29},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11889.7},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17348.52},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15365.83},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6367.4,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13098.78},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6494.75,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14935.68}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":6832.52,"10th_percentile":5519.79,"90th_percentile":6863.59,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":6884.2,"10th_percentile":6884.2,"90th_percentile":6884.2,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Acute Adjustment Reaction And Psychosocial Dysfunction","code_information":[{"code":"880","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":5273.09,"maximum":19753.1,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7030.79,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":14976.24},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17322.97},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16582.65},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15651.26},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7030.79,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10482.5},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12566.14},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7030.79,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7030.79,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5273.09,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7030.79,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":19753.1},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13128.44},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19155.99},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16966.73},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7030.79,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14463.49},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7171.41,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16491.77}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":6912.88,"10th_percentile":4032.25,"90th_percentile":6912.88,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"1 through 10","median_amount":9525.0,"10th_percentile":9525.0,"90th_percentile":14951.28,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":6810.25,"10th_percentile":6810.25,"90th_percentile":6810.25,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":5996.5,"10th_percentile":5996.5,"90th_percentile":5996.5,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"1 through 10","median_amount":13377.47,"10th_percentile":13377.47,"90th_percentile":13377.47},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":9651.29,"10th_percentile":9651.29,"90th_percentile":9651.29,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":7402.33,"10th_percentile":7402.33,"90th_percentile":7402.33,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":7575.67,"10th_percentile":7575.67,"90th_percentile":9115.41,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":8277.0,"10th_percentile":8277.0,"90th_percentile":8277.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":7226.76,"10th_percentile":7226.76,"90th_percentile":7226.76,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Alcohol, Drug Abuse Or Dependence, Left Ama","code_information":[{"code":"894","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":3387.8,"maximum":12690.78,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4517.07,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":9621.79},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11129.49},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10653.86},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10055.47},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4517.07,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6734.7},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8073.37},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4517.07,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4517.07,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3387.8,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4517.07,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":12690.78},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8434.63},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12307.16},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10900.62},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4517.07,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9292.36},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4607.41,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10595.47}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":5633.75,"10th_percentile":5633.75,"90th_percentile":5633.75,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"1 through 10","median_amount":11047.4,"10th_percentile":11047.4,"90th_percentile":11047.4},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":20169.63,"10th_percentile":20169.63,"90th_percentile":20169.63,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":5022.25,"10th_percentile":5022.25,"90th_percentile":5022.25,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":9307.83,"10th_percentile":9307.83,"90th_percentile":9307.83,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"1 through 10","median_amount":1126.6,"10th_percentile":1126.6,"90th_percentile":1126.6,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":5561.81,"10th_percentile":5561.81,"90th_percentile":5561.81,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":3547.36,"10th_percentile":3547.36,"90th_percentile":3547.36,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Skin Grafts For Injuries Without Cc/Mcc","code_information":[{"code":"905","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":8146.33,"maximum":30516.3,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10861.77,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":23136.59},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26762.02},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25618.32},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24179.42},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10861.77,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16194.28},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19413.26},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10861.77,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10861.77,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8146.33,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10861.77,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":30516.3},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20281.95},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29593.83},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26211.68},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10861.77,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22344.45},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11079.01,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25477.91}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Allergic Reactions Without Mcc","code_information":[{"code":"916","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":3659.09,"maximum":13707.03,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4878.79,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":10392.28},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12020.72},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11507.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10860.69},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4878.79,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7274.0},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8719.87},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4878.79,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4878.79,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3659.09,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4878.79,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":13707.03},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9110.06},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13292.69},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11773.52},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4878.79,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10036.48},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4976.37,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11443.94}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":6209.84,"10th_percentile":6209.84,"90th_percentile":6209.84,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":9079.98,"10th_percentile":9079.98,"90th_percentile":9079.98,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":3998.85,"10th_percentile":3998.85,"90th_percentile":3998.85,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Extensive Burns Or Full Thickness Burns With Mv >96 Hours With Skin Graft","code_information":[{"code":"927","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":117249.73,"maximum":439219.5,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":156332.97,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":333003.75},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":385184.37},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":368723.14},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":348013.15},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":156332.97,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":233083.41},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":279413.99},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":156332.97,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":156332.97,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":117249.73,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":156332.97,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":439219.5},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":291917.06},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":425942.48},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":377263.34},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":156332.97,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":321602.58},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":159459.63,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":366702.31}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"O.R. Procedures With Diagnoses Of Other Contact With Health Services Without Cc/Mcc","code_information":[{"code":"941","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":11135.44,"maximum":41713.56,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14847.26,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":31626.04},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":36581.74},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":35018.38},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":33051.51},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14847.26,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22136.4},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26536.51},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14847.26,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14847.26,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11135.44,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14847.26,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":41713.56},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27723.95},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":40452.62},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35829.46},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14847.26,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30543.25},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15144.21,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34826.46}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Craniotomy For Multiple Significant Trauma","code_information":[{"code":"955","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":36964.93,"maximum":138471.25,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":49286.57,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":104984.97},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":121435.78},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":116246.1},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":109716.93},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":49286.57,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":73483.42},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":88089.91},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":49286.57,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":49286.57,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":36964.93,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":49286.57,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":138471.25},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":92031.71},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":134285.45},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":118938.54},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":49286.57,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":101390.56},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":50272.3,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":115609.0}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Hiv With Extensive O.R. Procedures With Mcc","code_information":[{"code":"969","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":33616.11,"maximum":125926.53,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":44821.48,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":95473.92},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":110434.37},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":105714.85},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":99777.19},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":44821.48,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":66826.23},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":80109.45},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":44821.48,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":44821.48,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":33616.11,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":44821.48,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":125926.53},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":83694.15},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":122119.94},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":108163.37},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":44821.48,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":92205.14},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":45717.91,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":105135.47}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc","code_information":[{"code":"983","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":9412.71,"maximum":35260.17,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12550.28,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":26733.26},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":30922.27},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":29600.78},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27938.2},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12550.28,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18711.74},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22431.12},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12550.28,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12550.28,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9412.71,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12550.28,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":35260.17},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23434.85},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34194.3},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30286.38},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12550.28,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25817.98},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12801.29,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29438.55}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":12936.37,"10th_percentile":12936.37,"90th_percentile":12936.37,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":12302.36,"10th_percentile":12302.36,"90th_percentile":12302.36,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Inguinal And Femoral Hernia Procedures With Cc","code_information":[{"code":"351","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":8372.04,"maximum":31361.8,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11162.72,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":23777.63},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27503.5},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26328.12},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24849.35},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11162.72,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16642.97},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19951.13},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11162.72,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11162.72,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8372.04,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11162.72,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":31361.8},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20843.89},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30413.78},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26937.92},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11162.72,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22963.54},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11385.97,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26183.82}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Percutaneous Coronary Atherectomy With Intraluminal Device With Mcc","code_information":[{"code":"359","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":18883.63,"maximum":70738.4,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25178.17,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":53631.84},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":62035.78},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":59384.62},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":56049.18},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25178.17,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37539.2},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":45000.96},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25178.17,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25178.17,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18883.63,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25178.17,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":70738.4},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":47014.64},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":68600.07},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":60760.06},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25178.17,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":51795.63},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25681.73,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":59059.16}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Digestive Malignancy With Mcc","code_information":[{"code":"374","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":11745.02,"maximum":43997.04,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15660.02,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":33357.3},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":38584.29},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":36935.35},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":34860.81},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15660.02,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23348.19},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27989.17},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15660.02,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15660.02,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11745.02,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15660.02,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":43997.04},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29241.61},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":42667.07},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37790.83},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15660.02,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32215.24},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15973.22,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36732.92}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":16809.74,"10th_percentile":16809.74,"90th_percentile":16809.74,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":16352.36,"10th_percentile":16352.36,"90th_percentile":16352.36,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":15561.8,"10th_percentile":15561.8,"90th_percentile":15561.8,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Complicated Peptic Ulcer Without Cc/Mcc","code_information":[{"code":"382","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":4396.63,"maximum":16469.83,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5862.17,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":12486.96},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14443.62},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13826.36},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13049.78},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5862.17,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8740.15},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10477.45},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5862.17,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5862.17,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4396.63,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5862.17,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":16469.83},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10946.29},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15971.97},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14146.6},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5862.17,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12059.44},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5979.41,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13750.59}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Gastrointestinal Obstruction Without Cc/Mcc","code_information":[{"code":"390","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":2987.47,"maximum":11191.09,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3983.29,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":8484.77},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":9814.3},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":9394.88},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8867.2},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3983.29,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5938.85},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7119.33},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3983.29,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3983.29,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2987.47,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3983.29,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":11191.09},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7437.9},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10852.8},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9612.48},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3983.29,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8194.27},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4062.96,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9343.39}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"1 through 10","median_amount":8534.68,"10th_percentile":8534.68,"90th_percentile":8534.68,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":3674.9,"10th_percentile":3674.9,"90th_percentile":3674.9,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":4500.66,"10th_percentile":4487.66,"90th_percentile":4503.06,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":4523.56,"10th_percentile":4523.56,"90th_percentile":4523.56,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":8242.47,"10th_percentile":8242.47,"90th_percentile":8242.47,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Appendix Procedures Without Cc/Mcc","code_information":[{"code":"399","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":6286.3,"maximum":23548.61,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8381.74,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":17853.89},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20651.53},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19768.97},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18658.61},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8381.74,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12496.69},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14980.69},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8381.74,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8381.74,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6286.3,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8381.74,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":23548.61},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15651.04},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22836.77},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20226.85},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8381.74,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17242.62},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8549.37,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19660.62}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":8703.6,"10th_percentile":8703.6,"90th_percentile":8703.6,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":16782.62,"10th_percentile":16782.62,"90th_percentile":16782.62,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cholecystectomy With C.D.E. With Mcc","code_information":[{"code":"411","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":18140.61,"maximum":67955.03,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":24187.48,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":51521.57},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":59594.84},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":57047.99},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":53843.79},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":24187.48,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36062.13},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":43230.29},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":24187.48,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":24187.48,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18140.61,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":24187.48,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":67955.03},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":45164.73},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":65900.84},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":58369.31},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":24187.48,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":49757.61},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":24671.23,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":56735.33}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Laparoscopic Cholecystectomy Without C.D.E. Without Cc/Mcc","code_information":[{"code":"419","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":7500.51,"maximum":28097.05,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10000.68,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":21302.38},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24640.4},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23587.37},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22262.54},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10000.68,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14910.44},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17874.22},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10000.68,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10000.68,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7500.51,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10000.68,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":28097.05},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18674.05},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27247.71},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24133.69},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10000.68,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20573.05},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10200.69,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23458.09}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":10141.97,"10th_percentile":10141.97,"90th_percentile":10141.97,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":10218.14,"10th_percentile":10218.14,"90th_percentile":10218.14,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"1 through 10","median_amount":27105.48,"10th_percentile":27105.48,"90th_percentile":27105.48,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":3213.09,"10th_percentile":3213.09,"90th_percentile":3213.09,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":8501.0,"10th_percentile":8501.0,"90th_percentile":8501.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Cc","code_information":[{"code":"427","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":39642.11,"maximum":148500.03,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":52856.15,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":112588.5},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":130230.76},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":124665.22},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":117663.18},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":52856.15,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":78805.46},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":94469.82},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":52856.15,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":52856.15,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":39642.11,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":52856.15,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":148500.03},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":98697.1},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":144011.07},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":127552.66},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":52856.15,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":108733.77},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":53913.27,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":123981.98}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"1 through 10","median_amount":102079.52,"10th_percentile":102079.52,"90th_percentile":102079.52,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"1 through 10","median_amount":91587.7,"10th_percentile":91587.7,"90th_percentile":91587.7,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":55036.44,"10th_percentile":55036.44,"90th_percentile":55036.44,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":108190.14,"10th_percentile":108190.14,"90th_percentile":108190.14,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Malignancy Of Hepatobiliary System Or Pancreas With Cc","code_information":[{"code":"436","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":6211.62,"maximum":23268.83,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8282.16,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":17641.77},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20406.18},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19534.1},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18436.93},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8282.16,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12348.22},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14802.71},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8282.16,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8282.16,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6211.62,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8282.16,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":23268.83},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15465.09},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22565.45},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19986.54},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8282.16,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17037.76},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8447.8,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19427.04}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":7134.45,"10th_percentile":7134.45,"90th_percentile":7134.45,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":8755.81,"10th_percentile":8755.81,"90th_percentile":8755.81,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Disorders Of The Biliary Tract With Mcc","code_information":[{"code":"444","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":9176.02,"maximum":34373.52,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12234.69,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":26061.03},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":30144.71},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28856.44},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27235.67},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12234.69,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18241.22},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21867.07},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12234.69,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12234.69,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9176.02,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12234.69,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":34373.52},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22845.56},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33334.46},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29524.8},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12234.69,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25168.77},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12479.38,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28698.29}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":13061.83,"10th_percentile":13045.33,"90th_percentile":15545.01,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":11726.9,"10th_percentile":11726.9,"90th_percentile":11726.9,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Or Infection With Cc","code_information":[{"code":"457","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":32747.33,"maximum":122672.06,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":43663.11,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":93006.47},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":107580.29},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":102982.74},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":97198.53},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":43663.11,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":65099.16},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":78039.09},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":43663.11,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":43663.11,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":32747.33,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":43663.11,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":122672.06},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":81531.14},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":118963.85},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":105367.98},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":43663.11,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":89822.18},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":44536.37,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":102418.33}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":47413.37,"10th_percentile":47413.37,"90th_percentile":47413.37,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":36842.08,"10th_percentile":36842.08,"90th_percentile":36842.08,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Revision Of Hip Or Knee Replacement With Cc","code_information":[{"code":"467","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":19366.9,"maximum":72548.72,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25822.53,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":55004.38},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":63623.39},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":60904.38},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":57483.58},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25822.53,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38499.89},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":46152.61},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25822.53,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25822.53,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19366.9,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25822.53,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":72548.72},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":48217.83},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":70355.67},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":62315.02},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25822.53,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":53121.18},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26338.98,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":60570.59}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"1 through 10","median_amount":71166.23,"10th_percentile":71166.23,"90th_percentile":71166.23,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Amputation For Musculoskeletal System And Connective Tissue Disorders With Cc","code_information":[{"code":"475","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":12497.38,"maximum":46815.38,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16663.17,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":35494.09},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":41055.9},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":39301.34},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":37093.91},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16663.17,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24843.82},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29782.09},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16663.17,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16663.17,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12497.38,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16663.17,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":46815.38},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31114.76},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":45400.22},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":40211.62},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16663.17,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34278.87},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16996.43,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":39085.94}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":19211.7,"10th_percentile":19211.7,"90th_percentile":19211.7,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Major Joint Or Limb Reattachment Procedures Of Upper Extremities","code_information":[{"code":"483","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":15222.34,"maximum":57023.14,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20296.45,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":43233.32},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":50007.85},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":47870.71},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":45181.97},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20296.45,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30260.83},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36275.86},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20296.45,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20296.45,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15222.34,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20296.45,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":57023.14},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37899.11},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":55299.41},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":48979.47},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20296.45,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":41753.13},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20702.38,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":47608.35}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":19747.09,"10th_percentile":19747.09,"90th_percentile":19747.09,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":18266.76,"10th_percentile":18266.76,"90th_percentile":18266.76,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":19618.76,"10th_percentile":19618.76,"90th_percentile":19618.76,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"1 through 10","median_amount":51307.41,"10th_percentile":51307.41,"90th_percentile":51307.41,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/Mcc","code_information":[{"code":"494","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":11019.02,"maximum":41277.44,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14692.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":31295.38},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":36199.27},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":34652.26},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":32705.95},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14692.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21904.96},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26259.07},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14692.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14692.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11019.02,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14692.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":41277.44},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27434.09},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":40029.68},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35454.86},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14692.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30223.91},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14985.87,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34462.34}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":18718.83,"10th_percentile":18718.83,"90th_percentile":18718.83,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":14620.93,"10th_percentile":14620.93,"90th_percentile":14620.93,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":13847.95,"10th_percentile":13847.95,"90th_percentile":13847.95,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":5092.6,"10th_percentile":5092.6,"90th_percentile":5092.6,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Soft Tissue Procedures Without Cc/Mcc","code_information":[{"code":"502","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":7391.23,"maximum":27687.67,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9854.97,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":20992.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24281.38},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23243.69},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21938.17},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9854.97,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14693.19},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17613.79},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9854.97,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9854.97,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7391.23,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9854.97,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":27687.67},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18401.97},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26850.71},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23782.05},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9854.97,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20273.29},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10052.07,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23116.3}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Cc","code_information":[{"code":"511","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":11419.36,"maximum":42777.13,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15225.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":32432.4},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":37514.46},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":35911.24},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":33894.22},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15225.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22700.81},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27213.11},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15225.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15225.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11419.36,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15225.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":42777.13},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28430.83},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":41484.03},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36743.0},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15225.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31322.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15530.34,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35714.42}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":15367.59,"10th_percentile":15367.59,"90th_percentile":15367.59,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Back And Neck Procedures Except Spinal Fusion With Cc","code_information":[{"code":"519","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":10984.42,"maximum":41147.83,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14645.9,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":31197.12},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":36085.61},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":34543.45},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":32603.26},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14645.9,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21836.18},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26176.62},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14645.9,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14645.9,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10984.42,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14645.9,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":41147.83},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27347.95},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":39903.99},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35343.53},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14645.9,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30129.01},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14938.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34354.14}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":17800.13,"10th_percentile":17800.13,"90th_percentile":17800.13,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":11727.94,"10th_percentile":11727.94,"90th_percentile":11727.94,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh With Cc/Mcc","code_information":[{"code":"537","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":5240.69,"maximum":19631.73,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6987.59,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":14884.22},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17216.53},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16480.76},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15555.09},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6987.59,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10418.09},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12488.92},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6987.59,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6987.59,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5240.69,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6987.59,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":19631.73},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13047.77},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19038.29},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16862.48},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6987.59,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14374.62},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7127.34,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16390.44}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Connective Tissue Disorders With Mcc","code_information":[{"code":"545","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":13628.66,"maximum":51053.18,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18171.54,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":38707.07},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":44772.35},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":42858.96},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":40451.71},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18171.54,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27092.72},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32478.01},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18171.54,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18171.54,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13628.66,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18171.54,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":51053.18},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33931.32},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":49509.92},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":43851.64},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18171.54,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37381.85},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18534.97,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":42624.07}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":34549.32,"10th_percentile":34549.32,"90th_percentile":34549.32,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Bone Diseases And Arthropathies With Mcc","code_information":[{"code":"553","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":7118.84,"maximum":26667.3,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9491.79,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":20218.39},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23386.55},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22387.1},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21129.69},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9491.79,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14151.71},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16964.68},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9491.79,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9491.79,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7118.84,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9491.79,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":26667.3},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17723.8},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25861.19},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22905.62},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9491.79,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19526.17},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9681.63,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22264.41}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":12059.97,"10th_percentile":12059.97,"90th_percentile":12059.97,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Aftercare, Musculoskeletal System And Connective Tissue Without Cc/Mcc","code_information":[{"code":"561","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":4414.75,"maximum":16537.72,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5886.33,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":12538.43},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14503.16},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13883.35},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13103.57},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5886.33,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8776.18},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10520.64},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5886.33,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5886.33,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4414.75,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5886.33,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":16537.72},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10991.41},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16037.81},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14204.91},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5886.33,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12109.15},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6004.06,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13807.26}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":5406.82,"10th_percentile":5406.82,"90th_percentile":5406.82,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Skin Debridement Without Cc/Mcc","code_information":[{"code":"572","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":6295.1,"maximum":23581.52,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8393.46,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":17878.84},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20680.4},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19796.6},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18684.69},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8393.46,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12514.16},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15001.63},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8393.46,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8393.46,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6295.1,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8393.46,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":23581.52},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15672.91},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22868.69},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20255.12},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8393.46,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17266.72},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8561.33,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19688.1}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Skin, Subcutaneous Tissue And Breast Procedures With Cc","code_information":[{"code":"580","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":9489.59,"maximum":35548.17,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12652.79,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":26951.62},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":31174.85},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":29842.56},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28166.4},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12652.79,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18864.58},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22614.34},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12652.79,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12652.79,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9489.59,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12652.79,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":35548.17},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23626.27},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34473.6},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30533.76},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12652.79,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26028.86},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12905.85,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29679.0}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":13739.5,"10th_percentile":13739.5,"90th_percentile":13740.36,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Skin Ulcers Without Cc/Mcc","code_information":[{"code":"594","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":4760.18,"maximum":17831.69,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6346.9,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":13519.48},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15637.94},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14969.64},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14128.84},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6346.9,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9462.86},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11343.81},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6346.9,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6346.9,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4760.18,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6346.9,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17831.69},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11851.42},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17292.66},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15316.36},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6346.9,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13056.61},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6473.84,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14887.59}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cellulitis With Mcc","code_information":[{"code":"602","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":7805.3,"maximum":29238.78,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10407.07,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":22168.02},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25641.67},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24545.85},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23167.19},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10407.07,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15516.33},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18600.55},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10407.07,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10407.07,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7805.3,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10407.07,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":29238.78},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19432.88},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28354.94},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25114.37},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10407.07,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21409.04},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10615.21,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24411.32}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":9523.59,"10th_percentile":9237.35,"90th_percentile":13222.9,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":11092.05,"10th_percentile":9761.65,"90th_percentile":12396.07,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":10251.68,"10th_percentile":9258.74,"90th_percentile":11262.9,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":22130.56,"10th_percentile":22130.56,"90th_percentile":22130.56,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":7111.89,"10th_percentile":7111.89,"90th_percentile":7111.89,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Mcc Or Insertion Of","code_information":[{"code":"616","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":19151.62,"maximum":71742.3,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25535.5,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":54392.98},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":62916.18},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":60227.4},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":56844.62},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25535.5,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38071.95},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":45639.6},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25535.5,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25535.5,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19151.62,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25535.5,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":71742.3},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":47681.86},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":69573.63},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":61622.36},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25535.5,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":52530.71},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26046.21,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":59897.32}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":29933.62,"10th_percentile":29933.62,"90th_percentile":29933.62,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":17133.52,"10th_percentile":17133.52,"90th_percentile":17133.52,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc","code_information":[{"code":"624","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":6875.01,"maximum":25753.91,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9166.68,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":19525.88},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22585.53},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21620.31},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20405.97},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9166.68,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13666.99},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16383.62},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9166.68,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9166.68,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6875.01,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9166.68,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":25753.91},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17116.74},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24975.41},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22121.07},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9166.68,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18857.37},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9350.01,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21501.82}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Diabetes With Cc","code_information":[{"code":"638","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":4921.63,"maximum":18436.5,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6562.17,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":13978.03},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16168.34},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15477.37},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14608.06},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6562.17,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9783.82},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11728.57},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6562.17,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6562.17,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4921.63,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6562.17,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":18436.5},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12253.39},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17879.19},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15835.85},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6562.17,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13499.46},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6693.41,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15392.55}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":7759.5,"10th_percentile":7759.5,"90th_percentile":7759.5,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":6633.31,"10th_percentile":6633.31,"90th_percentile":6942.82,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":6612.21,"10th_percentile":6612.21,"90th_percentile":6612.21,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":7131.03,"10th_percentile":7131.03,"90th_percentile":7131.03,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":4238.93,"10th_percentile":4238.93,"90th_percentile":4238.93,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":6633.31,"10th_percentile":6633.31,"90th_percentile":6633.31,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":6930.98,"10th_percentile":6295.03,"90th_percentile":7117.13,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":5306.25,"10th_percentile":5143.53,"90th_percentile":7528.99,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":13815.78,"10th_percentile":10020.5,"90th_percentile":13815.78,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":6612.21,"10th_percentile":6612.21,"90th_percentile":6832.76,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Kidney Transplant With Hemodialysis With Mcc","code_information":[{"code":"650","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":25818.5,"maximum":96716.54,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":34424.67,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":73327.74},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":84817.96},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":81193.18},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":76632.82},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":34424.67,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":51325.18},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":61527.22},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":34424.67,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":34424.67,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25818.5,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":34424.67,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":96716.54},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":64280.41},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":93792.93},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":83073.74},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":34424.67,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":70817.19},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":35113.16,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":80748.19}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Kidney And Ureter Procedures For Neoplasm Without Cc/Mcc","code_information":[{"code":"658","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":8521.96,"maximum":31923.41,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11362.61,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":24203.42},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27996.02},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26799.59},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25294.34},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11362.61,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16941.0},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20308.41},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11362.61,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11362.61,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8521.96,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11362.61,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":31923.41},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21217.16},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30958.41},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27420.31},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11362.61,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23374.76},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11589.86,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26652.71}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":12343.06,"10th_percentile":12343.06,"90th_percentile":12343.06,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Prostatectomy With Cc","code_information":[{"code":"666","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":9606.56,"maximum":35986.35,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12808.75,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":27283.83},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":31559.12},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":30210.41},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28513.59},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12808.75,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19097.11},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22893.09},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12808.75,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12808.75,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9606.56,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12808.75,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":35986.35},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23917.5},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34898.54},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30910.13},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12808.75,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26349.71},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13064.92,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30044.84}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"1 through 10","median_amount":30583.04,"10th_percentile":30583.04,"90th_percentile":30583.04,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":12763.5,"10th_percentile":12763.5,"90th_percentile":12763.5,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Kidney And Urinary Tract Procedures With Cc","code_information":[{"code":"674","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":12842.8,"maximum":48109.35,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17123.73,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":36475.14},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":42190.68},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":40387.62},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":38119.18},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17123.73,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25530.5},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30605.26},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17123.73,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17123.73,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12842.8,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17123.73,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":48109.35},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31974.77},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":46655.07},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":41323.06},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17123.73,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35226.33},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17466.2,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":40166.27}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Kidney And Urinary Tract Infections With Mcc","code_information":[{"code":"689","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":6371.98,"maximum":23869.53,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8495.97,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":18097.2},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20932.97},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20038.38},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18912.89},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8495.97,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12667.0},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15184.85},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8495.97,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8495.97,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6371.98,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8495.97,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":23869.53},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15864.33},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23147.99},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20502.5},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8495.97,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17477.6},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8665.89,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19928.56}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":7850.44,"10th_percentile":7850.44,"90th_percentile":9022.95,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":8410.08,"10th_percentile":8410.08,"90th_percentile":9083.72,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":9063.73,"10th_percentile":8381.26,"90th_percentile":10646.33,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"17","median_amount":8844.18,"10th_percentile":280.43,"90th_percentile":9579.18,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":54.55,"10th_percentile":54.55,"90th_percentile":54.55,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Kidney And Urinary Tract Diagnoses With Cc","code_information":[{"code":"699","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":5574.04,"maximum":20880.44,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7432.05,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":15830.96},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18311.62},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17529.05},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16544.5},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7432.05,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11080.76},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13283.31},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7432.05,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7432.05,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5574.04,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7432.05,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":20880.44},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13877.7},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20249.25},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17935.05},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7432.05,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15288.95},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7580.69,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17432.98}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":7320.73,"10th_percentile":7320.73,"90th_percentile":7320.73,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":5025.91,"10th_percentile":5025.91,"90th_percentile":5025.91,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":7904.42,"10th_percentile":7904.42,"90th_percentile":7904.42,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":7898.93,"10th_percentile":7898.93,"90th_percentile":7898.93,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":7913.88,"10th_percentile":7898.93,"90th_percentile":7920.93,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":1085.34,"10th_percentile":358.66,"90th_percentile":9442.94,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":15150.57,"10th_percentile":15150.57,"90th_percentile":15150.57,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":6479.1,"10th_percentile":6479.1,"90th_percentile":6479.1,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Transurethral Prostatectomy With Cc/Mcc","code_information":[{"code":"713","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":8256.16,"maximum":30927.73,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11008.22,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":23448.53},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27122.84},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25963.72},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24505.42},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11008.22,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16412.62},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19675.0},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11008.22,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11008.22,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8256.16,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11008.22,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":30927.73},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20555.4},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29992.83},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26565.08},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11008.22,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22645.71},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11228.38,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25821.42}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":21565.64,"10th_percentile":21565.64,"90th_percentile":21565.64,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Malignancy, Male Reproductive System Without Cc/Mcc","code_information":[{"code":"724","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":3600.88,"maximum":13488.97,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4801.18,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":10226.95},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11829.48},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11323.94},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10687.91},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4801.18,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7158.28},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8581.15},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4801.18,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4801.18,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3600.88,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4801.18,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":13488.97},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8965.13},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13081.22},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11586.22},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4801.18,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9876.81},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4897.2,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11261.88}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy Without Cc/Mcc","code_information":[{"code":"735","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":7389.03,"maximum":27679.44,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9852.04,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":20985.76},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24274.17},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23236.79},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21931.65},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9852.04,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14688.82},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17608.56},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9852.04,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9852.04,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7389.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9852.04,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":27679.44},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18396.5},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26842.73},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23774.99},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9852.04,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20267.27},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10049.08,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23109.43}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Uterine And Adnexa Procedures For Non-Malignancy Without Cc/Mcc","code_information":[{"code":"743","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":6813.5,"maximum":25523.51,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9084.67,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":19351.2},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22383.47},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21426.89},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20223.41},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9084.67,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13544.72},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16237.04},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9084.67,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9084.67,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6813.5,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9084.67,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":25523.51},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16963.61},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24751.97},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21923.17},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9084.67,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18688.66},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9266.36,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21309.46}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":18056.02,"10th_percentile":18056.02,"90th_percentile":18056.02,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Malignancy, Female Reproductive System With Mcc","code_information":[{"code":"754","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":10113.99,"maximum":37887.19,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13485.32,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":28724.99},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":33226.11},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":31806.16},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":30019.71},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13485.32,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20105.84},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24102.33},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13485.32,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13485.32,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10113.99,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13485.32,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":37887.19},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25180.85},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36741.92},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32542.84},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13485.32,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27741.53},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13755.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31631.84}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Vaginal Delivery With O.R. Procedures Except Sterilization And/Or D&C","code_information":[{"code":"768","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":5884.87,"maximum":22044.81,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7846.49,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":16713.75},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19332.74},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18506.53},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17467.08},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7846.49,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11698.66},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14024.03},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7846.49,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7846.49,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5884.87,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7846.49,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":22044.81},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14651.57},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21378.42},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18935.17},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7846.49,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16141.51},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8003.42,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18405.11}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"1 through 10","median_amount":7561.0,"10th_percentile":7561.0,"90th_percentile":7561.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"1 through 10","median_amount":15283.52,"10th_percentile":15283.52,"90th_percentile":15283.52,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":9197.85,"10th_percentile":9197.85,"90th_percentile":9197.85,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":7201.0,"10th_percentile":7201.0,"90th_percentile":7201.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cesarean Section Without Sterilization With Mcc","code_information":[{"code":"786","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":9058.5,"maximum":33933.28,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12078.0,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":25727.25},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":29758.63},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28486.87},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26886.85},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12078.0,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18007.59},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21587.01},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12078.0,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12078.0,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9058.5,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12078.0,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":33933.28},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22552.97},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32907.53},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29146.67},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12078.0,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24846.42},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12319.56,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28330.74}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"1 through 10","median_amount":12545.0,"10th_percentile":12545.0,"90th_percentile":12545.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":13198.0,"10th_percentile":13198.0,"90th_percentile":13198.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Neonate With Other Significant Problems","code_information":[{"code":"794","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":8105.14,"maximum":30362.01,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10806.86,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":23019.61},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26626.71},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25488.79},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24057.17},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10806.86,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16112.4},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19315.1},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10806.86,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10806.86,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8105.14,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10806.86,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":30362.01},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20179.41},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29444.21},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26079.15},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10806.86,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22231.48},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11023.0,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25349.1}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"14","median_amount":1453.91,"10th_percentile":1453.91,"90th_percentile":2132.79,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"1 through 10","median_amount":4099.43,"10th_percentile":2489.47,"90th_percentile":5505.95,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"19","median_amount":2212.2,"10th_percentile":1015.69,"90th_percentile":3641.8,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":2186.72,"10th_percentile":1526.61,"90th_percentile":9601.04,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"1 through 10","median_amount":2802.0,"10th_percentile":2802.0,"90th_percentile":2802.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":6485.05,"10th_percentile":6485.05,"90th_percentile":6485.05,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"1 through 10","median_amount":4356.07,"10th_percentile":4356.07,"90th_percentile":4922.39},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":4846.65,"10th_percentile":4846.65,"90th_percentile":4846.65,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"1 through 10","median_amount":3577.99,"10th_percentile":3577.99,"90th_percentile":3578.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":1789.0,"10th_percentile":1789.0,"90th_percentile":1789.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":2082.59,"10th_percentile":2082.59,"90th_percentile":2082.59,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"1 through 10","median_amount":4964.57,"10th_percentile":4964.57,"90th_percentile":4964.57},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1526.61,"10th_percentile":1526.61,"90th_percentile":2186.72,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"1 through 10","median_amount":3470.81,"10th_percentile":3470.81,"90th_percentile":5038.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":3632.41,"10th_percentile":3632.41,"90th_percentile":3632.41,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":2082.59,"10th_percentile":2082.59,"90th_percentile":2132.79,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"34","median_amount":2626.77,"10th_percentile":1240.8,"90th_percentile":4963.2,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"14","median_amount":2082.59,"10th_percentile":2082.59,"90th_percentile":3994.58,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other O.R. Procedures Of The Blood And Blood Forming Organs With Mcc","code_information":[{"code":"802","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":21879.33,"maximum":81960.35,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":29172.44,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":62140.01},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":71877.15},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":68805.41},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":64940.83},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":29172.44,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":43494.42},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":52139.92},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":29172.44,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":29172.44,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21879.33,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":29172.44,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":81960.35},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":54473.05},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":79482.8},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":70399.05},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":29172.44,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":60012.5},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":29755.89,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":68428.31}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","code_information":[{"code":"810","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":5747.57,"maximum":21530.51,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7663.43,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":16323.82},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18881.71},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18074.78},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17059.58},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7663.43,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11425.73},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13696.85},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7663.43,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7663.43,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5747.57,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7663.43,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":21530.51},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14309.75},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20879.67},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18493.42},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7663.43,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15764.94},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7816.7,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17975.72}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Antepartum Diagnoses With O.R. Procedures With Cc","code_information":[{"code":"818","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":6365.93,"maximum":23846.9,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8487.91,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":18080.04},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20913.13},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20019.38},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18894.96},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8487.91,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12654.99},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15170.45},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8487.91,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8487.91,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6365.93,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8487.91,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":23846.9},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15849.29},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23126.04},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20483.06},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8487.91,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17461.03},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8657.67,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19909.67}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Mcc","code_information":[{"code":"826","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":25688.9,"maximum":96231.05,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":34251.86,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":72959.65},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":84392.19},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":80785.61},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":76248.14},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":34251.86,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":51067.54},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":61218.37},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":34251.86,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":34251.86,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25688.9,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":34251.86,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":96231.05},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":63957.74},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":93322.11},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":82656.73},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":34251.86,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":70461.7},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":34936.9,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":80342.85}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Acute Leukemia With Mcc","code_information":[{"code":"834","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":30148.67,"maximum":112937.45,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":40198.23,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":85625.97},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":99043.29},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":94810.57},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":89485.37},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":40198.23,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":59933.24},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":71846.32},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":40198.23,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":40198.23,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":30148.67,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":40198.23,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":112937.45},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":75061.26},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":109523.51},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":97006.53},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":40198.23,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":82694.36},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":41002.19,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":94290.95}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Lymphoma And Non-Acute Leukemia Without Cc/Mcc","code_information":[{"code":"842","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":5548.78,"maximum":20785.81,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7398.37,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":15759.21},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18228.63},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17449.61},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16469.52},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7398.37,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11030.54},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13223.1},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7398.37,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7398.37,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5548.78,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7398.37,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":20785.81},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13814.81},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20157.48},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17853.77},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7398.37,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15219.66},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7546.34,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17353.97}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":8172.54,"10th_percentile":8172.54,"90th_percentile":8172.54,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Acute Leukemia With Other Procedures","code_information":[{"code":"850","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":47555.05,"maximum":178142.02,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":63406.73,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":135062.22},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":156226.04},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":149549.57},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":141149.85},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":63406.73,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":94535.76},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":113326.88},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":63406.73,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":63406.73,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":47555.05,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":63406.73,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":178142.02},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":118397.97},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":172757.03},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":153013.37},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":63406.73,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":130438.05},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":64674.86,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":148729.94}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Postoperative And Post-Traumatic Infections Without Mcc","code_information":[{"code":"863","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":5480.13,"maximum":20528.66,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7306.84,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":15564.25},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18003.11},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17233.73},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16265.77},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7306.84,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10894.07},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13059.52},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7306.84,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7306.84,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5480.13,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7306.84,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":20528.66},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13643.9},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19908.11},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17632.89},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7306.84,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15031.37},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7452.98,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17139.28}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":2852.72,"10th_percentile":2852.72,"90th_percentile":2852.72,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"1 through 10","median_amount":15595.44,"10th_percentile":15595.44,"90th_percentile":15595.44,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"1 through 10","median_amount":10915.9,"10th_percentile":10915.9,"90th_percentile":10915.9,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":7776.32,"10th_percentile":7776.32,"90th_percentile":7776.32,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc","code_information":[{"code":"871","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":10667.55,"maximum":39960.84,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14223.4,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":30297.17},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":35044.64},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":33546.98},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":31662.75},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14223.4,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21206.27},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25421.5},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14223.4,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14223.4,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10667.55,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14223.4,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":39960.84},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26559.04},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38752.88},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34323.98},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14223.4,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29259.88},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14507.87,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33363.12}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":8917.52,"10th_percentile":8917.52,"90th_percentile":8917.52,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"15","median_amount":15231.46,"10th_percentile":13553.58,"90th_percentile":16429.35,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"1 through 10","median_amount":38270.4,"10th_percentile":33677.56,"90th_percentile":74065.35,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"1 through 10","median_amount":27234.02,"10th_percentile":25620.94,"90th_percentile":30602.87,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":9363.4,"10th_percentile":9363.4,"90th_percentile":18350.94,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"1 through 10","median_amount":51295.53,"10th_percentile":51295.53,"90th_percentile":51295.53},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":17668.91,"10th_percentile":17668.91,"90th_percentile":17668.91,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"20","median_amount":13785.8,"10th_percentile":6779.79,"90th_percentile":16699.82,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":16515.97,"10th_percentile":16515.97,"90th_percentile":16515.97,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":15169.32,"10th_percentile":15169.32,"90th_percentile":15169.32,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"1 through 10","median_amount":3250.0,"10th_percentile":3250.0,"90th_percentile":3250.0},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":9363.4,"10th_percentile":9363.4,"90th_percentile":9363.4,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"84","median_amount":15201.56,"10th_percentile":13579.06,"90th_percentile":15513.77,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"1 through 10","median_amount":40368.16,"10th_percentile":40368.16,"90th_percentile":40368.16,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":26827.03,"10th_percentile":26827.03,"90th_percentile":26827.03,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"1 through 10","median_amount":37249.31,"10th_percentile":37249.31,"90th_percentile":37249.31,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"56","median_amount":13765.26,"10th_percentile":6154.63,"90th_percentile":16587.13,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"19","median_amount":26899.33,"10th_percentile":12351.66,"90th_percentile":29555.11,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":17477.09,"10th_percentile":17477.09,"90th_percentile":17477.09,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":13922.18,"10th_percentile":13922.17,"90th_percentile":16855.47,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Psychoses","code_information":[{"code":"885","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":7670.75,"maximum":28734.77,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10227.67,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":21785.89},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25199.67},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24122.74},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22767.84},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10227.67,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15248.87},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18279.92},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10227.67,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10227.67,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7670.75,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10227.67,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":28734.77},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19097.9},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27866.16},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24681.46},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10227.67,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21040.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10432.22,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23990.53}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"20","median_amount":5544.88,"10th_percentile":4161.5,"90th_percentile":8464.41,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"12","median_amount":10487.51,"10th_percentile":9274.58,"90th_percentile":10950.58,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"11","median_amount":6063.0,"10th_percentile":1519.0,"90th_percentile":20167.65,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"27","median_amount":5715.0,"10th_percentile":1905.0,"90th_percentile":11430.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"1 through 10","median_amount":5892.0,"10th_percentile":5892.0,"90th_percentile":5892.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":6932.54,"10th_percentile":6099.5,"90th_percentile":6932.54,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"28","median_amount":7039.14,"10th_percentile":4968.27,"90th_percentile":7760.23,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"1 through 10","median_amount":10046.76,"10th_percentile":10046.76,"90th_percentile":10046.76,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":5216.68,"10th_percentile":4968.27,"90th_percentile":5822.12,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"1 through 10","median_amount":6853.34,"10th_percentile":6853.34,"90th_percentile":14546.75},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":5492.87,"10th_percentile":5492.87,"90th_percentile":6932.54,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"1 through 10","median_amount":9451.58,"10th_percentile":8844.7,"90th_percentile":10164.25,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":5805.25,"10th_percentile":5805.25,"90th_percentile":5805.25,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"11","median_amount":8956.33,"10th_percentile":6331.04,"90th_percentile":10907.15,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":5544.88,"10th_percentile":5492.87,"90th_percentile":7760.23,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":9317.7,"10th_percentile":9317.7,"90th_percentile":9317.7,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":4655.77,"10th_percentile":4655.77,"90th_percentile":4655.77,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"1 through 10","median_amount":9866.67,"10th_percentile":9866.67,"90th_percentile":9866.67},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":5492.87,"10th_percentile":4213.5,"90th_percentile":10869.8,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"11","median_amount":10503.68,"10th_percentile":9274.58,"90th_percentile":10948.66,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"1 through 10","median_amount":6160.48,"10th_percentile":4853.12,"90th_percentile":11467.98,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":5591.29,"10th_percentile":5591.29,"90th_percentile":5591.29,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":3051.6,"10th_percentile":3051.6,"90th_percentile":3851.41,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"1 through 10","median_amount":17673.67,"10th_percentile":17673.67,"90th_percentile":17673.67,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":10869.8,"10th_percentile":4211.75,"90th_percentile":11139.86,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"13","median_amount":3602.4,"10th_percentile":1355.75,"90th_percentile":7154.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"1 through 10","median_amount":6004.0,"10th_percentile":3503.0,"90th_percentile":7320.8,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"15","median_amount":5492.87,"10th_percentile":4870.1,"90th_percentile":8441.25,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"51","median_amount":7039.14,"10th_percentile":4968.27,"90th_percentile":9139.86,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":9557.61,"10th_percentile":6271.06,"90th_percentile":12994.97,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Wound Debridements For Injuries With Cc","code_information":[{"code":"902","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":10513.78,"maximum":39384.83,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14018.38,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":29860.46},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":34539.49},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":33063.42},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":31206.35},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14018.38,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20900.6},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25055.06},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14018.38,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14018.38,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10513.78,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14018.38,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":39384.83},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26176.21},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38194.28},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33829.22},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14018.38,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28838.11},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14298.75,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32882.21}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Traumatic Injury With Mcc","code_information":[{"code":"913","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":8976.67,"maximum":33626.76,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11968.89,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":25494.86},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":29489.82},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28229.54},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26643.98},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11968.89,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17844.93},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21392.01},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11968.89,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11968.89,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8976.67,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11968.89,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":33626.76},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22349.25},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32610.27},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28883.38},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11968.89,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24621.98},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12208.27,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28074.83}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Complications Of Treatment Without Cc/Mcc","code_information":[{"code":"921","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":3780.46,"maximum":14161.67,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5040.61,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":10736.97},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12419.42},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11888.67},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11220.92},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5040.61,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7515.26},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9009.09},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5040.61,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5040.61,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3780.46,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5040.61,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":14161.67},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9412.22},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13733.58},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12164.03},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5040.61,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10369.37},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5141.42,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11823.51}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":5475.46,"10th_percentile":5475.46,"90th_percentile":5475.46,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":3519.98,"10th_percentile":3519.98,"90th_percentile":3519.98,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Non-Extensive Burns","code_information":[{"code":"935","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":11312.82,"maximum":42378.03,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15083.76,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":32129.82},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":37164.46},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":35576.2},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":33578.0},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15083.76,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22489.02},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26959.22},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15083.76,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15083.76,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11312.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15083.76,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":42378.03},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28165.58},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":41097.0},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36400.2},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15083.76,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31029.78},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15385.44,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35381.22}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Aftercare With Cc/Mcc","code_information":[{"code":"949","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":6533.43,"maximum":24474.34,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8711.24,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":18555.75},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21463.38},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20546.12},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19392.11},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8711.24,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12987.95},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15569.6},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8711.24,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8711.24,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6533.43,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8711.24,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":24474.34},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16266.3},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23734.52},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21022.0},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8711.24,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17920.45},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8885.46,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20433.51}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"1 through 10","median_amount":43495.83,"10th_percentile":43495.83,"90th_percentile":43495.83,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"1 through 10","median_amount":11180.0,"10th_percentile":11180.0,"90th_percentile":11180.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":33596.24,"10th_percentile":33596.24,"90th_percentile":33596.24,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":83475.0,"10th_percentile":83475.0,"90th_percentile":83475.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":4627.24,"10th_percentile":4627.24,"90th_percentile":4627.24,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Multiple Significant Trauma With Mcc","code_information":[{"code":"963","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":15013.1,"maximum":56239.35,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20017.47,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":42639.08},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":49320.49},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":47212.73},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":44560.94},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20017.47,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29844.89},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35777.24},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20017.47,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20017.47,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15013.1,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20017.47,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":56239.35},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37378.18},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":54539.31},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":48306.25},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20017.47,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":41179.23},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20417.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":46953.97}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Hiv With Or Without Other Related Condition","code_information":[{"code":"977","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":7126.53,"maximum":26696.1,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9502.04,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":20240.23},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23411.81},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22411.28},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21152.51},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9502.04,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14166.99},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16983.0},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9502.04,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9502.04,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7126.53,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9502.04,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":26696.1},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17742.95},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25889.12},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22930.36},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9502.04,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19547.26},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9692.08,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22288.45}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck With Major","code_information":[{"code":"003","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":116561.62,"maximum":436641.84,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":155415.5,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":331049.44},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":382923.83},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":366559.2},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":345970.76},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":155415.5,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":231715.51},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":277774.19},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":155415.5,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":155415.5,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":116561.62,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":155415.5,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":436641.84},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":290203.88},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":423442.74},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":375049.28},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":155415.5,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":319715.19},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":158523.81,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":364550.24}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":165983.3,"10th_percentile":165983.3,"90th_percentile":165983.3,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Cc","code_information":[{"code":"012","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":23152.84,"maximum":86730.96,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":30870.46,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":65756.95},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":76060.86},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":72810.32},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":68720.8},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":30870.46,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":46026.07},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":55174.79},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":30870.46,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":30870.46,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23152.84,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":30870.46,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":86730.96},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":57643.72},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":84109.2},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":74496.72},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":30870.46,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":63505.61},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":31487.87,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":72411.28}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Cc","code_information":[{"code":"021","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":29071.76,"maximum":108903.31,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":38762.35,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":82567.4},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":95505.45},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":91423.93},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":86288.94},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":38762.35,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":57792.41},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":69279.96},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":38762.35,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":38762.35,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":29071.76,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":38762.35,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":108903.31},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":72380.06},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":105611.31},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":93541.45},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":38762.35,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":79740.51},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":39537.6,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":90922.87}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Spinal Procedures With Cc Or Spinal Neurostimulators","code_information":[{"code":"029","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":18735.35,"maximum":70182.96,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":24980.47,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":53210.73},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":61548.68},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":58918.33},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":55609.08},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":24980.47,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37244.44},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":44647.61},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":24980.47,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":24980.47,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18735.35,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":24980.47,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":70182.96},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":46645.48},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":68061.42},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":60282.97},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":24980.47,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":51388.93},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25480.08,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":58595.42}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":25996.94,"10th_percentile":25996.94,"90th_percentile":25996.94,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"1 through 10","median_amount":56444.92,"10th_percentile":56444.92,"90th_percentile":56444.92,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":50061.82,"10th_percentile":50061.82,"90th_percentile":50061.82,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":17212.43,"10th_percentile":17212.43,"90th_percentile":17212.43,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Extracranial Procedures With Mcc","code_information":[{"code":"037","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":18079.1,"maximum":67724.62,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":24105.47,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":51346.88},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":59392.78},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":56854.57},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":53661.23},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":24105.47,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35939.86},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":43083.71},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":24105.47,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":24105.47,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18079.1,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":24105.47,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":67724.62},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":45011.6},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":65677.4},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":58171.41},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":24105.47,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":49588.9},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":24587.58,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":56542.97}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Nervous System Neoplasms With Mcc","code_information":[{"code":"054","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":8385.22,"maximum":31411.17,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11180.29,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":23815.06},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27546.8},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26369.56},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24888.47},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11180.29,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16669.17},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19982.54},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11180.29,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11180.29,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8385.22,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11180.29,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":31411.17},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20876.71},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30461.66},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26980.32},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11180.29,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22999.69},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11403.9,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26225.04}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":10795.08,"10th_percentile":10795.08,"90th_percentile":10795.08,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":11910.22,"10th_percentile":11910.22,"90th_percentile":11910.22,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":11539.02,"10th_percentile":11539.02,"90th_percentile":11539.02,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Cc","code_information":[{"code":"062","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":9649.95,"maximum":36148.87,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12866.6,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":27407.05},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":31701.65},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":30346.84},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28642.36},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12866.6,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19183.35},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22996.48},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12866.6,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12866.6,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9649.95,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12866.6,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":36148.87},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24025.51},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35056.14},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31049.72},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12866.6,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26468.7},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13123.93,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30180.53}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":7408.36,"10th_percentile":7408.36,"90th_percentile":7408.36,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":13821.91,"10th_percentile":13821.91,"90th_percentile":13821.91,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Cerebrovascular Disorders With Mcc","code_information":[{"code":"070","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":9142.52,"maximum":34248.03,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12190.02,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":25965.89},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":30034.66},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28751.1},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27136.24},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12190.02,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18174.62},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21787.24},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12190.02,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12190.02,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9142.52,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12190.02,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":34248.03},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22762.16},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33212.76},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29417.02},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12190.02,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25076.88},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12433.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28593.52}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"1 through 10","median_amount":18451.5,"10th_percentile":18451.5,"90th_percentile":18451.5,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":11867.29,"10th_percentile":11867.29,"90th_percentile":11867.29,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":15488.27,"10th_percentile":15488.27,"90th_percentile":15488.27,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":12393.56,"10th_percentile":280.08,"90th_percentile":13419.07,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":15824.03,"10th_percentile":15824.03,"90th_percentile":15824.03,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Nontraumatic Stupor And Coma Without Mcc","code_information":[{"code":"081","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":4918.34,"maximum":18424.16,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6557.78,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":13968.67},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16157.52},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15467.01},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14598.28},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6557.78,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9777.27},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11720.72},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6557.78,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6557.78,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4918.34,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6557.78,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":18424.16},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12245.19},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17867.22},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15825.25},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6557.78,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13490.42},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6688.94,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15382.24}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Concussion With Cc","code_information":[{"code":"089","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":6033.14,"maximum":22600.25,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8044.19,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":17134.86},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19819.84},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18972.82},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17907.18},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8044.19,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11993.42},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14377.38},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8044.19,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8044.19,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6033.14,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8044.19,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":22600.25},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15020.73},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21917.07},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19412.26},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8044.19,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16548.21},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8205.07,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18868.84}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Mcc","code_information":[{"code":"097","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":19834.78,"maximum":74301.44,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26446.38,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":56333.24},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":65160.48},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":62375.79},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":58872.34},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26446.38,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":39430.02},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":47267.63},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26446.38,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26446.38,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19834.78,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26446.38,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":74301.44},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":49382.73},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":72055.41},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":63820.51},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26446.38,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":54404.54},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26975.31,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":62033.93}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Orbital Procedures Without Cc/Mcc","code_information":[{"code":"114","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":7430.22,"maximum":27833.73,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9906.96,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":21102.74},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24409.47},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23366.31},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22053.9},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9906.96,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14770.7},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17706.71},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9906.96,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9906.96,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7430.22,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9906.96,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":27833.73},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18499.04},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26992.35},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23907.51},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9906.96,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20380.24},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10105.1,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23238.25}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Disorders Of The Eye Without Mcc","code_information":[{"code":"125","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":4216.5,"maximum":15795.07,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5622.0,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":11975.38},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13851.88},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13259.91},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12515.14},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5622.0,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8382.07},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10048.2},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5622.0,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5622.0,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4216.5,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5622.0,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15795.07},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10497.83},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15317.61},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13567.03},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5622.0,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11565.37},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5734.44,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13187.23}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":6429.27,"10th_percentile":6429.27,"90th_percentile":6429.27,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"1 through 10","median_amount":7659.95,"10th_percentile":7659.95,"90th_percentile":7659.95,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Major Head And Neck Procedures Without Cc/Mcc","code_information":[{"code":"142","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":8766.89,"maximum":32840.92,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11689.19,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":24899.05},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28800.65},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27569.83},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26021.32},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11689.19,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17427.9},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20892.09},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11689.19,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11689.19,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8766.89,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11689.19,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":32840.92},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21826.95},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31848.18},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28208.39},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11689.19,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24046.57},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11922.97,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27418.73}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Epistaxis With Mcc","code_information":[{"code":"150","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":7312.15,"maximum":27391.43,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9749.53,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":20767.41},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24021.59},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22995.01},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21703.45},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9749.53,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14535.99},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17425.34},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9749.53,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9749.53,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7312.15,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9749.53,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":27391.43},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18205.08},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26563.43},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23527.61},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9749.53,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20056.38},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9944.52,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22868.98}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Dental And Oral Diseases With Cc","code_information":[{"code":"158","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":4996.31,"maximum":18716.28,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6661.75,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":14190.15},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16413.7},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15712.25},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14829.74},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6661.75,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9932.29},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11906.55},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6661.75,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6661.75,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4996.31,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6661.75,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":18716.28},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12439.34},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18150.51},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16076.17},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6661.75,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13704.32},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6794.98,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15626.13}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":6706.55,"10th_percentile":6706.55,"90th_percentile":6706.55,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":282.58,"10th_percentile":282.58,"90th_percentile":282.58,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":2418.6,"10th_percentile":2418.6,"90th_percentile":2418.6,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Ultrasound Accelerated And Other Thrombolysis With Principal Diagnosis Pulmonary Embolism","code_information":[{"code":"173","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":16345.38,"maximum":61230.08,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21793.84,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":46422.91},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":53697.23},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":51402.43},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":48515.32},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21793.84,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32493.36},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38952.15},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21793.84,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21793.84,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16345.38,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21793.84,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":61230.08},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":40695.16},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":59379.18},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":52592.99},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21793.84,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":44833.51},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22229.72,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":51120.71}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"1 through 10","median_amount":49244.54,"10th_percentile":49244.54,"90th_percentile":49244.54,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":23619.93,"10th_percentile":23619.93,"90th_percentile":23619.93,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":23645.13,"10th_percentile":23645.13,"90th_percentile":23645.13,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":26107.89,"10th_percentile":26107.89,"90th_percentile":26107.89,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Respiratory Neoplasms Without Cc/Mcc","code_information":[{"code":"182","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":4139.62,"maximum":15507.07,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5519.49,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":11757.02},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13599.31},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13018.13},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12286.94},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5519.49,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8229.23},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9864.98},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5519.49,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5519.49,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4139.62,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5519.49,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15507.07},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10306.41},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15038.31},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13319.65},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5519.49,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11354.49},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5629.88,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12946.78}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Chronic Obstructive Pulmonary Disease With Mcc","code_information":[{"code":"190","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":6083.12,"maximum":22787.45,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8110.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":17276.8},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19984.02},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19129.98},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18055.51},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8110.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12092.76},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14496.47},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8110.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8110.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6083.12,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8110.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":22787.45},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15145.15},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22098.62},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19573.06},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8110.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16685.29},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8273.04,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19025.14}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":7830.1,"10th_percentile":7830.1,"90th_percentile":7830.1,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"1 through 10","median_amount":12259.8,"10th_percentile":12259.8,"90th_percentile":12259.8,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":7066.08,"10th_percentile":6556.1,"90th_percentile":7722.68,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":8662.97,"10th_percentile":8631.48,"90th_percentile":9751.65,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":8644.08,"10th_percentile":6582.61,"90th_percentile":8722.66,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":13040.62,"10th_percentile":13040.62,"90th_percentile":13040.62,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":11715.99,"10th_percentile":11715.99,"90th_percentile":11715.99,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":7293.55,"10th_percentile":7293.55,"90th_percentile":7293.55,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Interstitial Lung Disease Without Cc/Mcc","code_information":[{"code":"198","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":3933.13,"maximum":14733.57,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5244.17,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":11170.57},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12920.96},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12368.77},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11674.06},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5244.17,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7818.76},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9372.91},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5244.17,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5244.17,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3933.13,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5244.17,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":14733.57},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9792.32},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14288.19},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12655.25},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5244.17,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10788.12},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5349.05,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12300.99}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Respiratory System Diagnoses Without Mcc","code_information":[{"code":"206","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":5168.2,"maximum":19360.18,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6890.94,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":14678.34},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16978.39},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16252.8},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15339.93},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6890.94,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10273.99},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12316.18},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6890.94,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6890.94,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5168.2,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6890.94,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":19360.18},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12867.29},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18774.95},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16629.24},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6890.94,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14175.79},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7028.76,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16163.72}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":571.5,"10th_percentile":571.5,"90th_percentile":571.5,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":6474.51,"10th_percentile":6474.51,"90th_percentile":6474.51,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Cc","code_information":[{"code":"217","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":36109.33,"maximum":135266.15,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":48145.77,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":102554.95},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":118624.99},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":113555.43},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":107177.39},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":48145.77,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":71782.55},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":86050.95},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":48145.77,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":48145.77,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":36109.33,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":48145.77,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":135266.15},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":89901.51},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":131177.24},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":116185.55},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":48145.77,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":99043.74},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":49108.69,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":112933.08}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":50020.59,"10th_percentile":50020.59,"90th_percentile":50020.59,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Coronary Bypass With Ptca Without Mcc","code_information":[{"code":"232","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":33293.75,"maximum":124718.96,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":44391.67,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":94558.37},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":109375.37},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":104701.1},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":98820.38},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":44391.67,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":66185.4},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":79341.25},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":44391.67,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":44391.67,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":33293.75,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":44391.67,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":124718.96},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":82891.57},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":120948.87},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":107126.14},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":44391.67,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":91320.94},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":45279.5,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":104127.28}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Permanent Cardiac Pacemaker Implant With Mcc","code_information":[{"code":"242","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":17533.78,"maximum":65681.83,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23378.37,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":49798.1},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":57601.3},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":55139.66},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":52042.64},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23378.37,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34855.8},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":41784.17},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23378.37,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23378.37,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17533.78,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23378.37,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":65681.83},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":43653.91},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":63696.36},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":56416.78},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23378.37,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":48093.15},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23845.94,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":54837.46}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":26288.05,"10th_percentile":26288.05,"90th_percentile":26288.05,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":26125.03,"10th_percentile":16660.51,"90th_percentile":26302.55,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"14","median_amount":26283.95,"10th_percentile":25530.85,"90th_percentile":26304.35,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":28251.23,"10th_percentile":26137.25,"90th_percentile":36322.38,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Vascular Procedures Without Cc/Mcc","code_information":[{"code":"254","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":9784.49,"maximum":36652.88,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13045.99,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":27789.17},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":32143.65},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":30769.96},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":29041.71},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13045.99,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19450.82},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23317.11},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13045.99,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13045.99,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9784.49,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13045.99,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":36652.88},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24360.49},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35544.92},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31482.64},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13045.99,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26837.75},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13306.91,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30601.32}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":11949.38,"10th_percentile":11949.38,"90th_percentile":11949.38,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":15348.76,"10th_percentile":15348.76,"90th_percentile":15348.76,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cardiac Pacemaker Revision Except Device Replacement Without Cc/Mcc","code_information":[{"code":"262","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":8950.86,"maximum":33530.07,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11934.48,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":25421.55},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":29405.03},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28148.37},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26567.37},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11934.48,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17793.62},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21330.5},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11934.48,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11934.48,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8950.86,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11934.48,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":33530.07},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22284.99},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32516.51},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28800.33},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11934.48,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24551.18},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12173.17,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27994.1}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Major Cardiovascular Procedures With Mcc","code_information":[{"code":"270","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":28975.66,"maximum":108543.3,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":38634.21,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":82294.45},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":95189.73},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":91121.7},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":86003.69},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":38634.21,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":57601.37},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":69050.94},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":38634.21,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":38634.21,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":28975.66,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":38634.21,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":108543.3},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":72140.79},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":105262.19},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":93232.22},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":38634.21,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":79476.91},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":39406.89,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":90622.3}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":48539.62,"10th_percentile":48539.62,"90th_percentile":48539.62,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"1 through 10","median_amount":87296.38,"10th_percentile":87296.38,"90th_percentile":87296.38,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":4662.06,"10th_percentile":4662.06,"90th_percentile":4662.06,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":38144.59,"10th_percentile":38144.59,"90th_percentile":53705.56,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":41920.24,"10th_percentile":41920.24,"90th_percentile":41920.24,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":79476.91,"10th_percentile":76653.56,"90th_percentile":88666.38,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures With Mcc","code_information":[{"code":"278","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":30567.69,"maximum":114507.09,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":40756.92,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":86816.02},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":100419.81},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":96128.27},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":90729.06},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":40756.92,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":60766.21},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":72844.86},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":40756.92,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":40756.92,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":30567.69,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":40756.92,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":114507.09},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":76104.48},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":111045.69},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":98354.75},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":40756.92,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":83843.67},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":41572.06,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":95601.43}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":38749.52,"10th_percentile":38749.52,"90th_percentile":38749.52,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Circulatory Disorders Except Ami, With Cardiac Catheterization With Mcc","code_information":[{"code":"286","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":12151.95,"maximum":45521.41,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16202.6,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":34513.04},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":39921.12},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":38215.06},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":36068.64},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16202.6,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24157.14},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28958.91},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16202.6,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16202.6,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12151.95,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16202.6,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":45521.41},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30254.75},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":44145.36},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":39100.18},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16202.6,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33331.41},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16526.65,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38005.61}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":20616.03,"10th_percentile":20616.03,"90th_percentile":20616.03,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":17158.04,"10th_percentile":17036.42,"90th_percentile":19743.71,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"11","median_amount":17152.55,"10th_percentile":16025.65,"90th_percentile":17523.8,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"1 through 10","median_amount":19193.53,"10th_percentile":19193.53,"90th_percentile":19193.53,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":17162.56,"10th_percentile":16406.56,"90th_percentile":19898.13,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":32984.78,"10th_percentile":32984.78,"90th_percentile":32984.78,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":13598.27,"10th_percentile":13598.27,"90th_percentile":13598.27,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cardiac Arrest, Unexplained With Mcc","code_information":[{"code":"296","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":8577.43,"maximum":32131.19,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11436.57,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":24360.95},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28178.24},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26974.01},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25458.97},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11436.57,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17051.26},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20440.59},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11436.57,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11436.57,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8577.43,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11436.57,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":32131.19},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21355.25},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31159.91},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27598.77},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11436.57,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23526.9},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11665.3,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26826.18}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":11140.67,"10th_percentile":11140.67,"90th_percentile":11140.67,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Hypertension With Mcc","code_information":[{"code":"304","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":6535.08,"maximum":24480.51,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8713.44,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":18560.43},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21468.79},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20551.3},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19397.0},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8713.44,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12991.23},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15573.53},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8713.44,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8713.44,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6535.08,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8713.44,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":24480.51},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16270.41},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23740.5},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21027.3},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8713.44,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17924.97},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8887.71,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20438.67}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":7138.58,"10th_percentile":7138.58,"90th_percentile":7138.58,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Syncope And Collapse","code_information":[{"code":"312","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":4786.53,"maximum":17930.43,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6382.04,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":13594.35},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15724.54},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15052.53},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14207.08},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6382.04,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9515.26},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11406.63},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6382.04,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6382.04,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4786.53,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6382.04,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17930.43},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11917.05},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17388.42},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15401.17},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6382.04,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13128.91},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6509.68,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14970.04}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":5481.58,"10th_percentile":5481.58,"90th_percentile":6793.28,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"1 through 10","median_amount":14420.62,"10th_percentile":14420.62,"90th_percentile":14420.62,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":6751.98,"10th_percentile":6751.98,"90th_percentile":6751.98,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"12","median_amount":6753.53,"10th_percentile":125.0,"90th_percentile":6876.98,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":1132.39,"10th_percentile":157.58,"90th_percentile":6838.99,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":6890.5,"10th_percentile":6890.5,"90th_percentile":6890.5,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Endovascular Cardiac Valve Procedures Without Mcc","code_information":[{"code":"320","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":13209.1,"maximum":49481.49,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17612.13,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":37515.46},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43394.02},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":41539.53},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":39206.39},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17612.13,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26258.66},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31478.16},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17612.13,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17612.13,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13209.1,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17612.13,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":49481.49},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32886.73},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":47985.74},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":42501.65},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17612.13,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36231.03},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17964.37,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":41311.87}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Stomach, Esophageal And Duodenal Procedures Without Cc/Mcc","code_information":[{"code":"328","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":8799.29,"maximum":32962.29,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11732.39,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":24991.07},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28907.09},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27671.72},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26117.49},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11732.39,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17492.31},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20969.3},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11732.39,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11732.39,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8799.29,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11732.39,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":32962.29},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21907.62},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31965.89},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28312.64},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11732.39,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24135.44},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11967.04,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27520.06}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Peritoneal Adhesiolysis With Cc","code_information":[{"code":"336","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":11580.27,"maximum":43379.88,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15440.36,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":32889.39},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":38043.06},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":36417.25},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":34371.81},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15440.36,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23020.68},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27596.56},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15440.36,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15440.36,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11580.27,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15440.36,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":43379.88},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28831.43},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":42068.57},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37260.73},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15440.36,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31763.35},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15749.17,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36217.66}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":15019.02,"10th_percentile":15019.02,"90th_percentile":15019.02,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":16504.23,"10th_percentile":16504.23,"90th_percentile":16504.23,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":16359.33,"10th_percentile":16359.33,"90th_percentile":16359.33,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Heart Transplant Or Implant Of Heart Assist System With Mcc","code_information":[{"code":"001","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":153897.78,"maximum":576503.75,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":205197.04,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":437088.77},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":505579.18},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":483972.75},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":456789.57},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":205197.04,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":305936.92},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":366748.78},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":205197.04,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":205197.04,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":153897.78,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":205197.04,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":576503.75},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":383159.86},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":559076.81},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":495182.31},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":205197.04,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":422124.01},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":209300.98,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":481320.29}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Pancreas Or Islet Cell Transplant","code_information":[{"code":"010","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":39406.52,"maximum":147617.5,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":52542.02,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":111919.39},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":129456.8},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":123924.34},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":116963.91},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":52542.02,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":78337.12},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":93908.39},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":52542.02,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":52542.02,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":39406.52,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":52542.02,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":147617.5},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":98110.55},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":143155.22},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":126794.62},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":52542.02,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":108087.57},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":53592.86,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":123245.16}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Inguinal And Femoral Hernia Procedures With Mcc","code_information":[{"code":"350","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":13684.67,"maximum":51263.02,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18246.23,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":38866.16},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":44956.37},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43035.11},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":40617.97},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18246.23,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27204.07},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32611.5},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18246.23,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18246.23,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13684.67,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18246.23,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":51263.02},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34070.78},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":49713.41},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":44031.87},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18246.23,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37535.49},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18611.15,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":42799.25}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":11679.55,"10th_percentile":11679.55,"90th_percentile":11679.55,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":18748.13,"10th_percentile":18748.13,"90th_percentile":18748.13,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Digestive System O.R. Procedures Without Cc/Mcc","code_information":[{"code":"358","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":7676.8,"maximum":28757.4,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10235.73,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":21803.05},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25219.51},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24141.73},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22785.77},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10235.73,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15260.87},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18294.32},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10235.73,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10235.73,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7676.8,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10235.73,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":28757.4},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19112.94},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27888.11},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24700.89},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10235.73,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21056.57},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10440.44,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24009.42}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/Mcc","code_information":[{"code":"373","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":3994.64,"maximum":14963.97,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5326.18,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":11345.26},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13123.02},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12562.2},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11856.62},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5326.18,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7941.03},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9519.48},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5326.18,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5326.18,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3994.64,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5326.18,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":14963.97},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9945.46},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14511.63},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12853.16},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5326.18,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10956.83},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5432.7,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12493.35}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":4240.04,"10th_percentile":4240.04,"90th_percentile":4240.04,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Complicated Peptic Ulcer With Cc","code_information":[{"code":"381","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":5950.22,"maximum":22289.61,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7933.62,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":16899.35},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19547.42},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18712.05},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17661.05},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7933.62,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11828.57},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14179.76},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7933.62,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7933.62,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5950.22,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7933.62,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":22289.61},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14814.27},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21615.83},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19145.45},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7933.62,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16320.76},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8092.29,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18609.49}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":9041.46,"10th_percentile":9041.46,"90th_percentile":9041.46,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":8434.85,"10th_percentile":8434.85,"90th_percentile":8434.85,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":8182.95,"10th_percentile":8182.95,"90th_percentile":8182.95,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":10124.4,"10th_percentile":10124.4,"90th_percentile":10124.4,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Gastrointestinal Obstruction With Cc","code_information":[{"code":"389","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":4337.32,"maximum":16247.66,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5783.09,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":12318.51},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14248.78},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13639.85},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12873.74},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5783.09,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8622.25},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10336.11},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5783.09,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5783.09,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4337.32,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5783.09,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":16247.66},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10798.63},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15756.51},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13955.77},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5783.09,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11896.76},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5898.75,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13565.09}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":4600.49,"10th_percentile":4600.49,"90th_percentile":4600.49,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":6471.81,"10th_percentile":6471.81,"90th_percentile":6471.81,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"1 through 10","median_amount":12502.56,"10th_percentile":12502.56,"90th_percentile":13067.24,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":6230.23,"10th_percentile":6230.23,"90th_percentile":6230.23,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":6264.21,"10th_percentile":6264.21,"90th_percentile":6264.21,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"1 through 10","median_amount":17872.34,"10th_percentile":17872.34,"90th_percentile":17872.34},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":6315.0,"10th_percentile":6050.59,"90th_percentile":7039.11,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":6302.41,"10th_percentile":6234.6,"90th_percentile":12112.43,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":11857.83,"10th_percentile":11857.83,"90th_percentile":11896.76,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":128.35,"10th_percentile":128.35,"90th_percentile":128.35,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":5234.13,"10th_percentile":5234.13,"90th_percentile":5234.13,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Appendix Procedures With Cc","code_information":[{"code":"398","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":8312.18,"maximum":31137.57,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11082.91,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":23607.62},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27306.86},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26139.87},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24671.68},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11082.91,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16523.97},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19808.48},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11082.91,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11082.91,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8312.18,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11082.91,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":31137.57},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20694.86},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30196.32},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26745.31},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11082.91,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22799.36},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11304.57,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25996.61}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"1 through 10","median_amount":15976.37,"10th_percentile":15976.37,"90th_percentile":15976.37,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":10076.94,"10th_percentile":10076.94,"90th_percentile":10076.94,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":10165.56,"10th_percentile":10165.56,"90th_percentile":10165.56,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":11682.56,"10th_percentile":11682.56,"90th_percentile":11682.56,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. Without Cc/Mcc","code_information":[{"code":"410","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":8719.11,"maximum":32661.94,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11625.48,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":24763.36},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28643.7},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27419.58},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25879.51},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11625.48,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17332.92},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20778.23},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11625.48,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11625.48,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8719.11,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11625.48,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":32661.94},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21708.0},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31674.62},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28054.66},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11625.48,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23915.53},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11857.99,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27269.3}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":5291.07,"10th_percentile":5291.07,"90th_percentile":5291.07,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Laparoscopic Cholecystectomy Without C.D.E. With Cc","code_information":[{"code":"418","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":9289.7,"maximum":34799.36,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12386.26,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":26383.89},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":30518.16},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":29213.93},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27573.08},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12386.26,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18467.2},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22137.97},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12386.26,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12386.26,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9289.7,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12386.26,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":34799.36},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23128.59},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33747.42},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29890.57},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12386.26,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25480.57},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12633.99,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29053.82}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"1 through 10","median_amount":25866.06,"10th_percentile":25866.06,"90th_percentile":25866.06,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":13439.78,"10th_percentile":13439.78,"90th_percentile":13439.78,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":13355.47,"10th_percentile":12270.56,"90th_percentile":13445.28,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":10335.55,"10th_percentile":10335.55,"90th_percentile":10335.55,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":13471.48,"10th_percentile":13471.48,"90th_percentile":13471.48,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":24733.38,"10th_percentile":22502.81,"90th_percentile":24967.98,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":91.96,"10th_percentile":91.96,"90th_percentile":91.96,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Mcc","code_information":[{"code":"426","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":60524.71,"maximum":226726.58,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":80699.61,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":171897.66},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":198833.47},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":190336.12},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":179645.56},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":80699.61,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":120318.44},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":144234.44},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":80699.61,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":80699.61,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":60524.71,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":80699.61,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":226726.58},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":150688.57},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":219872.94},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":194744.6},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":80699.61,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":166012.34},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":82313.6,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":189292.97}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Malignancy Of Hepatobiliary System Or Pancreas With Mcc","code_information":[{"code":"435","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":10086.53,"maximum":37784.34,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13448.71,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":28647.01},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":33135.9},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":31719.81},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":29938.21},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13448.71,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20051.25},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24036.89},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13448.71,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13448.71,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10086.53,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13448.71,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":37784.34},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25112.48},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36642.17},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32454.49},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13448.71,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27666.21},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13717.68,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31545.97}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":14136.65,"10th_percentile":14136.65,"90th_percentile":14136.65,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":12911.05,"10th_percentile":12911.05,"90th_percentile":14127.68,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis Without Cc/Mcc","code_information":[{"code":"443","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":3842.51,"maximum":14394.13,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5123.35,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":10913.22},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12623.29},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12083.82},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11405.11},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5123.35,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7638.62},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9156.97},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5123.35,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5123.35,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3842.51,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5123.35,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":14394.13},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9566.73},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13959.02},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12363.7},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5123.35,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10539.58},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5225.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12017.59}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":5459.47,"10th_percentile":5459.47,"90th_percentile":5459.47,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Or Infection With Mcc","code_information":[{"code":"456","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":46148.63,"maximum":172873.57,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":61531.51,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":131067.83},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":151605.74},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":145126.72},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":136975.42},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":61531.51,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":91739.92},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":109975.3},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":61531.51,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":61531.51,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":46148.63,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":61531.51,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":172873.57},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":114896.41},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":167647.83},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":148488.08},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":61531.51,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":126580.41},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":62762.14,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":144331.34}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Revision Of Hip Or Knee Replacement With Mcc","code_information":[{"code":"466","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":28586.3,"maximum":107084.76,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":38115.06,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":81188.62},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":93910.62},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":89897.26},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":84848.02},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":38115.06,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":56827.35},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":68123.07},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":38115.06,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":38115.06,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":28586.3,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":38115.06,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":107084.76},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":71171.4},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":103847.73},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":91979.42},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":38115.06,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":78408.94},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":38877.36,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":89404.57}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Amputation For Musculoskeletal System And Connective Tissue Disorders With Mcc Or Insertion Of Antib","code_information":[{"code":"474","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":23575.16,"maximum":88312.94,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":31433.54,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":66956.36},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":77448.21},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":74138.38},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":69974.27},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":31433.54,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":46865.59},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":56181.18},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":31433.54,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":31433.54,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23575.16,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":31433.54,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":88312.94},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":58695.15},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":85643.36},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":75855.54},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":31433.54,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":64663.95},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":32062.21,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":73732.06}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Hip And Femur Procedures Except Major Joint Without Cc/Mcc","code_information":[{"code":"482","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":8956.9,"maximum":33552.7,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11942.53,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":25438.71},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":29424.87},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28167.37},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26585.3},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11942.53,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17805.63},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21344.9},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11942.53,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11942.53,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8956.9,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11942.53,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":33552.7},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22300.03},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32538.45},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28819.77},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11942.53,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24567.75},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12181.38,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28013.0}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":12302.84,"10th_percentile":12302.84,"90th_percentile":12302.84,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":15195.82,"10th_percentile":15195.82,"90th_percentile":15195.82,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":11668.24,"10th_percentile":11668.24,"90th_percentile":11668.24,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":10906.81,"10th_percentile":10906.81,"90th_percentile":10906.81,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc","code_information":[{"code":"493","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":13927.4,"maximum":52172.29,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18569.87,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":39555.55},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":45753.78},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43798.45},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":41338.43},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18569.87,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27686.6},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33189.94},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18569.87,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18569.87,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13927.4,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18569.87,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":52172.29},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34675.11},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":50595.2},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":44812.89},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18569.87,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38201.27},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18941.27,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":43558.41}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":13139.81,"10th_percentile":13139.81,"90th_percentile":13139.81,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":18407.22,"10th_percentile":18407.22,"90th_percentile":18407.22,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":13139.81,"10th_percentile":13139.81,"90th_percentile":13139.81,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":17664.79,"10th_percentile":17664.79,"90th_percentile":17664.79,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Soft Tissue Procedures With Cc","code_information":[{"code":"501","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":9599.98,"maximum":35961.67,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12799.97,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":27265.12},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":31537.47},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":30189.69},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28494.03},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12799.97,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19084.01},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22877.38},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12799.97,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12799.97,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9599.98,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12799.97,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":35961.67},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23901.09},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34874.6},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30888.93},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12799.97,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26331.63},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13055.97,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30024.23}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"1 through 10","median_amount":25349.31,"10th_percentile":25349.31,"90th_percentile":25349.31,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":13561.44,"10th_percentile":13561.44,"90th_percentile":13561.44,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"1 through 10","median_amount":22256.75,"10th_percentile":22256.75,"90th_percentile":22256.75,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":13759.38,"10th_percentile":13759.38,"90th_percentile":13759.38,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Mcc","code_information":[{"code":"510","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":16587.56,"maximum":62137.3,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22116.75,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":47110.74},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":54492.84},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":52164.04},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":49234.15},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22116.75,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32974.8},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":39529.28},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22116.75,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22116.75,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16587.56,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22116.75,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":62137.3},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":41298.12},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":60258.98},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":53372.24},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22116.75,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":45497.79},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22559.08,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":51878.14}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":21008.7,"10th_percentile":21008.7,"90th_percentile":21008.7,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Back And Neck Procedures Except Spinal Fusion With Mcc Or Disc Device Or Neurostimulator","code_information":[{"code":"518","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":20523.99,"maximum":76883.21,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27365.32,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":58290.67},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":67424.63},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":64543.17},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":60917.99},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27365.32,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":40800.1},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":48910.05},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27365.32,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27365.32,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20523.99,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27365.32,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":76883.21},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":51098.65},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":74559.14},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":66038.09},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27365.32,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":56294.95},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27912.63,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":64189.44}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":29725.86,"10th_percentile":29725.86,"90th_percentile":34813.64,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"1 through 10","median_amount":74315.11,"10th_percentile":74315.11,"90th_percentile":74315.11,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Fractures Of Hip And Pelvis Without Mcc","code_information":[{"code":"536","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":4435.06,"maximum":16613.83,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5913.42,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":12596.14},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14569.91},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13947.25},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13163.88},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5913.42,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8816.57},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10569.06},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5913.42,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5913.42,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4435.06,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5913.42,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":16613.83},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11042.0},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16111.62},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14270.29},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5913.42,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12164.88},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6031.69,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13870.81}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":6152.13,"10th_percentile":6152.13,"90th_percentile":6152.13,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":5886.63,"10th_percentile":5886.63,"90th_percentile":6331.84,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy Without Cc/Mcc","code_information":[{"code":"544","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":4144.0,"maximum":15523.53,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5525.34,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":11769.5},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13613.74},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13031.94},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12299.98},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5525.34,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8237.97},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9875.45},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5525.34,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5525.34,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4144.0,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5525.34,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15523.53},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10317.35},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15054.27},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13333.78},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5525.34,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11366.54},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5635.85,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12960.52}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Medical Back Problems Without Mcc","code_information":[{"code":"552","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":5279.14,"maximum":19775.73,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7038.85,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":14993.4},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17342.81},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16601.65},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15669.19},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7038.85,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10494.51},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12580.53},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7038.85,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7038.85,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5279.14,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7038.85,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":19775.73},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13143.48},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19177.94},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16986.17},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7038.85,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14480.06},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7179.63,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16510.66}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":138.2,"10th_percentile":138.2,"90th_percentile":138.2,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":6810.95,"10th_percentile":6810.95,"90th_percentile":6810.95,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":7533.67,"10th_percentile":7533.67,"90th_percentile":7533.67,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":5481.98,"10th_percentile":5481.98,"90th_percentile":5481.98,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":7478.04,"10th_percentile":7478.04,"90th_percentile":7545.63,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"1 through 10","median_amount":10091.15,"10th_percentile":10091.15,"90th_percentile":10091.15,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":6767.45,"10th_percentile":1317.34,"90th_percentile":7493.65,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":13041.2,"10th_percentile":13041.2,"90th_percentile":14480.06,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":6309.95,"10th_percentile":6309.95,"90th_percentile":6309.95,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":6361.23,"10th_percentile":6361.23,"90th_percentile":6361.23,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Aftercare, Musculoskeletal System And Connective Tissue With Cc","code_information":[{"code":"560","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":6184.16,"maximum":23165.97,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8245.55,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":17563.78},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20315.97},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19447.75},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18355.43},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8245.55,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12293.63},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14737.27},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8245.55,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8245.55,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6184.16,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8245.55,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":23165.97},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15396.73},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22465.7},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19898.19},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8245.55,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16962.44},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8410.46,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19341.16}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":8837.89,"10th_percentile":8837.89,"90th_percentile":8837.89,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Skin Debridement With Cc","code_information":[{"code":"571","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":9278.16,"maximum":34756.16,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12370.88,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":26351.13},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":30480.27},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":29177.67},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27538.85},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12370.88,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18444.27},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22110.49},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12370.88,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12370.88,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9278.16,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12370.88,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":34756.16},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23099.87},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33705.53},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29853.47},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12370.88,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25448.94},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12618.3,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29017.75}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":12099.81,"10th_percentile":12099.81,"90th_percentile":12099.81,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":12808.38,"10th_percentile":12808.38,"90th_percentile":12808.38,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Skin, Subcutaneous Tissue And Breast Procedures With Mcc","code_information":[{"code":"579","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":17784.75,"maximum":66621.97,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23713.0,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":50510.88},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":58425.78},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":55928.9},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":52787.55},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23713.0,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35354.7},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":42382.25},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23713.0,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23713.0,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17784.75,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23713.0,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":66621.97},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":44278.75},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":64608.08},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":57224.3},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23713.0,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":48781.53},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":24187.26,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":55622.37}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":23353.98,"10th_percentile":23353.98,"90th_percentile":23353.98,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":25283.39,"10th_percentile":25283.39,"90th_percentile":25283.39,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Skin Ulcers With Cc","code_information":[{"code":"593","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":6514.76,"maximum":24404.4,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8686.34,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":18502.72},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21402.04},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20487.4},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19336.69},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8686.34,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12950.84},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15525.11},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8686.34,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8686.34,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6514.76,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8686.34,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":24404.4},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16219.82},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23666.69},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20961.92},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8686.34,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17869.24},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8860.07,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20375.12}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Non-Malignant Breast Disorders Without Cc/Mcc","code_information":[{"code":"601","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":3322.46,"maximum":12445.98,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4429.94,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":9436.19},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10914.81},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10448.35},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":9861.5},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4429.94,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6604.79},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7917.64},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4429.94,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4429.94,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3322.46,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4429.94,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":12445.98},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8271.93},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12069.75},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10690.35},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4429.94,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9113.12},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4518.54,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10391.09}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Adrenal And Pituitary Procedures Without Cc/Mcc","code_information":[{"code":"615","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":7684.48,"maximum":28786.2,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10245.98,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":21824.88},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25244.77},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24165.91},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22808.59},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10245.98,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15276.16},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18312.64},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10245.98,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10245.98,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7684.48,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10245.98,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":28786.2},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19132.08},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27916.04},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24725.63},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10245.98,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21077.66},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10450.9,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24033.47}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Cc","code_information":[{"code":"623","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":9851.49,"maximum":36903.86,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13135.32,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":27979.46},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":32363.75},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":30980.65},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":29240.57},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13135.32,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19584.01},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23476.77},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13135.32,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13135.32,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9851.49,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13135.32,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":36903.86},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24527.3},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35788.31},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31698.21},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13135.32,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27021.52},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13398.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30810.86}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":16647.39,"10th_percentile":16647.39,"90th_percentile":16647.39,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":14760.9,"10th_percentile":14760.9,"90th_percentile":14760.9,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":16486.5,"10th_percentile":16486.5,"90th_percentile":27446.75,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Diabetes With Mcc","code_information":[{"code":"637","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":7889.87,"maximum":29555.59,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10519.83,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":22408.21},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25919.5},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24811.81},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23418.21},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10519.83,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15684.45},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18802.09},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10519.83,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10519.83,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7889.87,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10519.83,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":29555.59},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19643.44},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28662.17},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25386.49},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10519.83,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21641.01},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10730.23,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24675.83}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":10958.22,"10th_percentile":10958.22,"90th_percentile":11312.26,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"1 through 10","median_amount":22713.91,"10th_percentile":22713.91,"90th_percentile":22713.91,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":10594.19,"10th_percentile":10594.19,"90th_percentile":10594.19,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":4238.93,"10th_percentile":4238.93,"90th_percentile":4238.93,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":6942.82,"10th_percentile":6942.82,"90th_percentile":6942.82,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":10879.28,"10th_percentile":10111.57,"90th_percentile":11311.74,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":21719.0,"10th_percentile":21719.0,"90th_percentile":21936.25,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":4238.93,"10th_percentile":4238.93,"90th_percentile":4238.93,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":9926.52,"10th_percentile":9926.52,"90th_percentile":9926.52,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Endocrine Disorders Without Cc/Mcc","code_information":[{"code":"645","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":4219.24,"maximum":15805.36,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5625.66,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":11983.18},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13860.9},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13268.54},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12523.29},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5625.66,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8387.53},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10054.74},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5625.66,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5625.66,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4219.24,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5625.66,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15805.36},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10504.67},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15327.59},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13575.86},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5625.66,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11572.9},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5738.17,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13195.82}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":5872.55,"10th_percentile":5872.55,"90th_percentile":5872.55,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Kidney And Ureter Procedures For Neoplasm With Cc","code_information":[{"code":"657","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":10049.74,"maximum":37646.5,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13399.65,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":28542.51},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":33015.03},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":31604.1},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":29829.0},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13399.65,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19978.11},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23949.21},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13399.65,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13399.65,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10049.74,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13399.65,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":37646.5},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25020.88},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36508.5},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32336.1},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13399.65,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27565.29},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13667.64,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31430.89}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":10922.96,"10th_percentile":10922.96,"90th_percentile":10922.96,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":14185.76,"10th_percentile":14185.76,"90th_percentile":14185.76,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":14175.76,"10th_percentile":14175.76,"90th_percentile":14175.76,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":6345.38,"10th_percentile":6345.38,"90th_percentile":6345.38,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Prostatectomy With Mcc","code_information":[{"code":"665","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":17140.58,"maximum":64208.89,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22854.1,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":48681.36},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":56309.57},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":53903.12},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":50875.56},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22854.1,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34074.14},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":40847.14},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22854.1,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22854.1,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17140.58,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22854.1,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":64208.89},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":42674.95},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":62267.94},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":55151.6},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22854.1,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":47014.64},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23311.18,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":53607.7}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Kidney And Urinary Tract Procedures With Mcc","code_information":[{"code":"673","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":23073.76,"maximum":86434.73,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":30765.02,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":65532.36},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":75801.07},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":72561.63},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":68486.08},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":30765.02,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":45868.87},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":54986.34},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":30765.02,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":30765.02,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23073.76,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":30765.02,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":86434.73},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":57446.84},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":83821.92},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":74242.27},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":30765.02,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":63288.7},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":31380.32,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":72163.95}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"1 through 10","median_amount":33629.62,"10th_percentile":33629.62,"90th_percentile":33629.62,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":32480.58,"10th_percentile":32480.58,"90th_percentile":32480.58,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":62359.58,"10th_percentile":62359.58,"90th_percentile":62359.58,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Simultaneous Pancreas, Islet Cell And Kidney Transplant With Hemodialysis","code_information":[{"code":"019","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":39180.81,"maximum":146771.99,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":52241.08,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":111278.36},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":128715.32},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":123214.54},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":116293.98},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":52241.08,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":77888.43},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":93370.51},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":52241.08,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":52241.08,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":39180.81,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":52241.08,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":146771.99},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":97548.6},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":142335.27},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":126068.38},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":52241.08,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":107468.48},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":53285.9,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":122539.25}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Craniotomy And Endovascular Intracranial Procedures Without Cc/Mcc","code_information":[{"code":"027","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":13854.92,"maximum":51900.75,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18473.22,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":39349.67},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":45515.64},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43570.48},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":41123.27},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18473.22,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27542.5},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33017.19},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18473.22,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18473.22,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13854.92,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18473.22,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":51900.75},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34494.63},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":50331.86},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":44579.64},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18473.22,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38002.44},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18842.68,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":43331.69}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"1 through 10","median_amount":42381.89,"10th_percentile":42381.89,"90th_percentile":42381.89,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."}]}]},{"description":"Carotid Artery Stent Procedures With Cc","code_information":[{"code":"035","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":13127.82,"maximum":49177.03,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17503.76,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":37284.63},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43127.01},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":41283.94},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":38965.15},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17503.76,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26097.09},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31284.47},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17503.76,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17503.76,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13127.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17503.76,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":49177.03},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32684.37},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":47690.48},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":42240.14},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17503.76,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36008.1},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17853.84,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":41057.67}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":17623.36,"10th_percentile":17623.36,"90th_percentile":17623.36,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Spinal Disorders And Injuries With Cc/Mcc","code_information":[{"code":"052","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":9947.05,"maximum":37261.81,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13262.73,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":28250.85},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":32677.66},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":31281.15},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":29524.19},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13262.73,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19773.96},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23704.48},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13262.73,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13262.73,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9947.05,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13262.73,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":37261.81},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24765.2},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36135.44},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32005.67},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13262.73,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27283.61},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13527.98,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31109.71}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"1 through 10","median_amount":2313.69,"10th_percentile":2313.69,"90th_percentile":2313.69},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Multiple Sclerosis And Cerebellar Ataxia Without Cc/Mcc","code_information":[{"code":"060","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":5051.23,"maximum":18922.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6734.97,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":14346.12},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16594.11},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15884.95},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14992.74},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6734.97,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10041.46},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12037.42},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6734.97,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6734.97,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5051.23,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6734.97,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":18922.0},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12576.07},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18350.01},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16252.87},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6734.97,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13854.95},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6869.67,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15797.89}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"1 through 10","median_amount":13918.76,"10th_percentile":13918.76,"90th_percentile":13918.76,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":9609.54,"10th_percentile":9609.54,"90th_percentile":9609.54,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Precerebral Occlusion Without Infarction Without Mcc","code_information":[{"code":"068","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":4746.99,"maximum":17782.32,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6329.32,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":13482.05},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15594.64},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14928.19},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14089.72},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6329.32,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9436.65},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11312.4},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6329.32,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6329.32,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4746.99,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6329.32,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17782.32},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11818.6},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17244.78},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15273.95},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6329.32,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13020.46},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6455.91,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14846.37}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":6832.53,"10th_percentile":6832.53,"90th_percentile":6832.53,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":280.07,"10th_percentile":280.07,"90th_percentile":280.07,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Viral Meningitis Without Cc/Mcc","code_information":[{"code":"076","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":4531.72,"maximum":16975.9,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6042.29,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":12870.64},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14887.43},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14251.2},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13450.76},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6042.29,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9008.71},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10799.39},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6042.29,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6042.29,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4531.72,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6042.29,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":16975.9},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11282.64},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16462.74},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14581.28},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6042.29,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12429.99},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6163.14,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14173.1}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Traumatic Stupor And Coma <1 Hour Without Cc/Mcc","code_information":[{"code":"087","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":5023.22,"maximum":18817.08,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6697.63,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":14266.58},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16502.1},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15796.87},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14909.61},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6697.63,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9985.78},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11970.68},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6697.63,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6697.63,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5023.22,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6697.63,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":18817.08},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12506.34},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18248.27},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16162.75},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6697.63,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13778.13},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6831.58,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15710.29}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Bacterial And Tuberculous Infections Of Nervous System With Cc","code_information":[{"code":"095","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":14164.1,"maximum":53058.94,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18885.46,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":40227.78},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":46531.35},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":44542.78},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":42040.96},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18885.46,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28157.13},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33753.99},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18885.46,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18885.46,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14164.1,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18885.46,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":53058.94},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35264.4},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":51455.04},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":45574.46},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18885.46,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38850.49},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19263.17,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":44298.66}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Headaches Without Mcc","code_information":[{"code":"103","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":4592.68,"maximum":17204.25,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6123.57,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":13043.77},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15087.69},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14442.9},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13631.69},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6123.57,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9129.89},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10944.66},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6123.57,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6123.57,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4592.68,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6123.57,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17204.25},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11434.4},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16684.19},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14777.42},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6123.57,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12597.19},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6246.04,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14363.75}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":6241.62,"10th_percentile":6241.62,"90th_percentile":6241.62,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":12679.88,"10th_percentile":12679.88,"90th_percentile":12679.88,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Neurological Eye Disorders","code_information":[{"code":"123","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":4385.64,"maximum":16428.69,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5847.52,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":12455.76},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14407.54},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13791.82},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13017.18},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5847.52,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8718.32},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10451.28},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5847.52,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5847.52,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4385.64,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5847.52,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":16428.69},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10918.95},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15932.07},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14111.26},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5847.52,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12029.31},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5964.47,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13716.23}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":20075.44,"10th_percentile":20075.44,"90th_percentile":20075.44,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Major Head And Neck Procedures With Mcc","code_information":[{"code":"140","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":23423.59,"maximum":87745.15,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":31231.45,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":66525.88},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":76950.28},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":73661.73},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":69524.39},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":31231.45,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":46564.28},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":55819.98},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":31231.45,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":31231.45,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23423.59,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":31231.45,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":87745.15},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":58317.78},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":85092.74},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":75367.85},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":31231.45,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":64248.21},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":31856.08,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":73258.02}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Ear, Nose, Mouth And Throat Malignancy Without Cc/Mcc","code_information":[{"code":"148","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":4377.4,"maximum":16397.83,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5836.54,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":12432.37},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14380.48},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13765.92},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12992.73},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5836.54,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8701.94},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10431.65},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5836.54,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5836.54,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4377.4,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5836.54,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":16397.83},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10898.44},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15902.15},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14084.76},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5836.54,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12006.72},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5953.27,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13690.47}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Ear, Nose, Mouth And Throat Diagnoses Without Cc/Mcc","code_information":[{"code":"156","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":3795.28,"maximum":14217.21,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5060.38,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":10779.09},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12468.14},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11935.3},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11264.93},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5060.38,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7544.74},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9044.43},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5060.38,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5060.38,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3795.28,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5060.38,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":14217.21},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9449.14},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13787.45},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12211.74},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5060.38,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10410.04},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5161.59,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11869.88}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":1476.89,"10th_percentile":1476.89,"90th_percentile":1476.89,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Respiratory System O.R. Procedures With Cc","code_information":[{"code":"167","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":9903.66,"maximum":37099.29,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13204.88,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":28127.63},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":32535.14},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":31144.72},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":29395.42},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13204.88,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19687.72},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23601.1},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13204.88,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13204.88,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9903.66,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13204.88,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":37099.29},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24657.18},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35977.83},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31866.08},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13204.88,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27164.61},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13468.98,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30974.03}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":12534.28,"10th_percentile":12534.28,"90th_percentile":12534.28,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Respiratory Neoplasms With Mcc","code_information":[{"code":"180","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":9698.27,"maximum":36329.9,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12931.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":27544.3},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":31860.41},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":30498.82},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28785.8},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12931.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19279.42},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23111.64},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12931.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12931.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9698.27,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12931.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":36329.9},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24145.83},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35231.7},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31205.22},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12931.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26601.26},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13189.65,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30331.67}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":13453.34,"10th_percentile":13453.34,"90th_percentile":13453.34,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":12044.35,"10th_percentile":12044.35,"90th_percentile":12044.35,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Pleural Effusion Without Cc/Mcc","code_information":[{"code":"188","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":3938.62,"maximum":14754.14,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5251.49,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":11186.17},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12939.01},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12386.04},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11690.36},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5251.49,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7829.67},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9386.0},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5251.49,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5251.49,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3938.62,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5251.49,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":14754.14},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9806.0},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14308.14},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12672.92},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5251.49,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10803.18},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5356.52,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12318.16}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Interstitial Lung Disease With Mcc","code_information":[{"code":"196","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":10363.87,"maximum":38823.21,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13818.49,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":29434.66},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":34046.98},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":32591.94},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":30761.36},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13818.49,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20602.56},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24697.79},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13818.49,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13818.49,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10363.87,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13818.49,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":38823.21},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25802.95},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37649.64},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33346.82},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13818.49,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28426.89},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14094.86,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32413.32}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":17082.05,"10th_percentile":17082.05,"90th_percentile":17082.05,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":12803.47,"10th_percentile":12803.47,"90th_percentile":12803.47,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Respiratory Signs And Symptoms","code_information":[{"code":"204","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":4433.97,"maximum":16609.72,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5911.96,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":12593.02},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14566.3},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13943.8},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13160.62},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5911.96,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8814.39},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10566.44},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5911.96,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5911.96,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4433.97,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5911.96,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":16609.72},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11039.27},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16107.63},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14266.76},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5911.96,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12161.87},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6030.2,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13867.38}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":586.89,"10th_percentile":586.89,"90th_percentile":586.89,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Heart Assist System Implant","code_information":[{"code":"215","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":54680.48,"maximum":204834.01,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":72907.3,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":155299.33},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":179634.24},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":171957.39},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":162299.1},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":72907.3,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":108700.57},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":130307.26},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":72907.3,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":72907.3,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":54680.48,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":72907.3,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":204834.01},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":136138.18},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":198642.15},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":175940.19},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":72907.3,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":149982.29},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":74365.45,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":171014.96}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":135201.36,"10th_percentile":135201.36,"90th_percentile":135201.36,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":78656.5,"10th_percentile":78656.5,"90th_percentile":78656.5,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":159589.47,"10th_percentile":159589.47,"90th_percentile":159589.47,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Cardiothoracic Procedures Without Mcc","code_information":[{"code":"229","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":17295.99,"maximum":64791.07,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23061.32,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":49122.75},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":56820.13},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":54391.87},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":51336.85},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23061.32,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34383.09},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":41217.51},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23061.32,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23061.32,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17295.99,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23061.32,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":64791.07},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":43061.89},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":62832.53},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":55651.67},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23061.32,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":47440.92},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23522.55,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":54093.76}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":24063.55,"10th_percentile":24063.55,"90th_percentile":24063.55,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"1 through 10","median_amount":107461.25,"10th_percentile":107461.25,"90th_percentile":107461.25,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":23926.61,"10th_percentile":23926.61,"90th_percentile":23926.61,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":24071.65,"10th_percentile":24071.65,"90th_percentile":24071.65,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":24064.65,"10th_percentile":24064.65,"90th_percentile":24064.65,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Amputation For Circulatory System Disorders Except Upper Limb And Toe With Cc","code_information":[{"code":"240","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":15653.98,"maximum":58640.09,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20871.98,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":44459.25},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":51425.87},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":49228.14},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":46463.15},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20871.98,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31118.91},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37304.49},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20871.98,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20871.98,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15653.98,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20871.98,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":58640.09},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38973.77},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":56867.48},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":50368.34},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20871.98,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":42937.08},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21289.42,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":48958.34}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":21905.62,"10th_percentile":21905.62,"90th_percentile":21905.62,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Vascular Procedures With Mcc","code_information":[{"code":"252","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":19156.57,"maximum":71760.82,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25542.09,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":54407.02},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":62932.42},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":60242.94},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":56859.29},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25542.09,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38081.77},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":45651.38},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25542.09,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25542.09,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19156.57,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25542.09,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":71760.82},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":47694.17},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":69591.59},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":61638.26},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25542.09,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":52544.26},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26052.93,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":59912.77}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":26567.74,"10th_percentile":26567.74,"90th_percentile":26567.74,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":26586.14,"10th_percentile":26586.14,"90th_percentile":26586.14,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":26585.82,"10th_percentile":26585.82,"90th_percentile":26585.82,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":26567.74,"10th_percentile":26567.74,"90th_percentile":26567.74,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cardiac Pacemaker Revision Except Device Replacement With Mcc","code_information":[{"code":"260","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":17863.28,"maximum":66916.15,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23817.7,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":50733.92},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":58683.76},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":56175.86},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":53020.64},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23817.7,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35510.82},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":42569.39},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23817.7,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23817.7,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17863.28,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23817.7,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":66916.15},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":44474.27},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":64893.36},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":57476.98},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23817.7,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":48996.93},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":24294.05,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":55867.98}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Aortic And Heart Assist Procedures Except Pulsation Balloon With Mcc","code_information":[{"code":"268","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":37771.1,"maximum":141491.2,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":50361.47,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":107274.61},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":124084.19},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":118781.33},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":112109.77},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":50361.47,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":75086.03},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":90011.08},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":50361.47,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":50361.47,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":37771.1,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":50361.47,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":141491.2},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":94038.84},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":137214.11},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":121532.49},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":50361.47,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":103601.81},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":51368.7,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":118130.34}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":51322.52,"10th_percentile":51322.52,"90th_percentile":51322.52,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cardiac Defibrillator Implant With Mcc Or Carotid Sinus Neurostimulator","code_information":[{"code":"276","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":32986.22,"maximum":123566.93,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":43981.62,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":93684.94},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":108365.07},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":103733.98},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":97907.58},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":43981.62,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":65574.05},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":78608.37},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":43981.62,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":43981.62,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":32986.22,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":43981.62,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":123566.93},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":82125.9},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":119831.67},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":106136.62},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":43981.62,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":90477.42},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":44861.25,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":103165.46}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Acute Myocardial Infarction, Expired With Cc","code_information":[{"code":"284","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":3801.33,"maximum":14239.84,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5068.44,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":10796.24},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12487.98},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11954.29},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11282.86},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5068.44,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7556.75},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9058.82},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5068.44,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5068.44,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3801.33,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5068.44,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":14239.84},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9464.18},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13809.39},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12231.17},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5068.44,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10426.61},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5169.81,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11888.78}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Heart Failure And Shock With Cc","code_information":[{"code":"292","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":4662.42,"maximum":17465.51,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6216.56,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":13241.85},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15316.81},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14662.23},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13838.7},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6216.56,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9268.53},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11110.86},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6216.56,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6216.56,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4662.42,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6216.56,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17465.51},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11608.05},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16937.55},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15001.83},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6216.56,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12788.49},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6340.89,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14581.87}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":6351.31,"10th_percentile":6351.31,"90th_percentile":6351.31,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":6159.65,"10th_percentile":6159.65,"90th_percentile":6628.93,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":6701.18,"10th_percentile":6701.18,"90th_percentile":6701.18,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":420.08,"10th_percentile":420.08,"90th_percentile":420.08,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Atherosclerosis With Mcc","code_information":[{"code":"302","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":6571.32,"maximum":24616.29,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8761.76,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":18663.37},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21587.86},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20665.28},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19504.58},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8761.76,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13063.28},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15659.9},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8761.76,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8761.76,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6571.32,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8761.76,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":24616.29},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16360.65},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23872.17},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21143.92},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8761.76,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18024.39},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8937.0,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20552.02}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":6266.56,"10th_percentile":6266.56,"90th_percentile":6266.56,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cardiac Arrhythmia And Conduction Disorders Without Cc/Mcc","code_information":[{"code":"310","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":3108.83,"maximum":11645.73,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4145.11,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":8829.46},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10213.01},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":9776.55},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":9227.43},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4145.11,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6180.11},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7408.55},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4145.11,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4145.11,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3108.83,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4145.11,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":11645.73},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7740.06},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11293.7},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10002.99},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4145.11,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8527.16},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4228.01,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9722.97}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":4631.45,"10th_percentile":4631.45,"90th_percentile":4631.45,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"1 through 10","median_amount":8740.09,"10th_percentile":8740.09,"90th_percentile":8740.09,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"1 through 10","median_amount":26265.75,"10th_percentile":26265.75,"90th_percentile":26265.75},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":4982.44,"10th_percentile":4982.44,"90th_percentile":4982.44,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":4649.25,"10th_percentile":4554.64,"90th_percentile":5391.65,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":3397.94,"10th_percentile":3397.94,"90th_percentile":3397.94,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":4842.53,"10th_percentile":4842.53,"90th_percentile":4842.53,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":8344.38,"10th_percentile":8344.38,"90th_percentile":8344.38,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Percutaneous Coronary Atherectomy Without Intraluminal Device","code_information":[{"code":"318","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":13301.9,"maximum":49829.16,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17735.87,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":37779.05},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43698.91},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":41831.39},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":39481.86},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17735.87,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26443.16},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31699.33},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17735.87,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17735.87,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13301.9,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17735.87,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":49829.16},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33117.8},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":48322.89},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":42800.27},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17735.87,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36485.6},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18090.59,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":41602.13}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Stomach, Esophageal And Duodenal Procedures With Mcc","code_information":[{"code":"326","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":27389.12,"maximum":102600.09,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":36518.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":77788.48},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":89977.68},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":86132.4},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":81294.62},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":36518.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":54447.45},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":65270.1},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":36518.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":36518.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27389.12,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":36518.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":102600.09},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":68190.78},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":99498.63},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":88127.36},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":36518.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":75125.21},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":37249.2,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":85660.34}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":39040.17,"10th_percentile":39040.17,"90th_percentile":39040.17,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Rectal Resection Without Cc/Mcc","code_information":[{"code":"334","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":8994.8,"maximum":33694.65,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11993.06,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":25546.33},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":29549.35},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28286.53},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26697.77},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11993.06,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17880.95},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21435.2},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11993.06,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11993.06,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8994.8,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11993.06,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":33694.65},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22394.37},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32676.11},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28941.69},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11993.06,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24671.69},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12232.92,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28131.51}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Anal And Stomal Procedures With Cc","code_information":[{"code":"348","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":7187.49,"maximum":26924.45,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9583.32,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":20413.35},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23612.06},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22602.98},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21333.44},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9583.32,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14288.17},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17128.27},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9583.32,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9583.32,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7187.49,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9583.32,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":26924.45},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17894.71},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26110.56},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23126.5},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9583.32,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19714.45},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9774.99,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22479.1}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":9761.9,"10th_percentile":9761.9,"90th_percentile":9761.9,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Digestive System O.R. Procedures With Mcc","code_information":[{"code":"356","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":24123.77,"maximum":90368.07,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":32165.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":68514.5},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":79250.5},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":75863.66},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":71602.64},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":32165.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":47956.2},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":57488.57},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":32165.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":32165.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":24123.77,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":32165.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":90368.07},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":60061.04},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":87636.36},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":77620.78},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":32165.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":66168.75},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":32808.33,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":75447.88}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":9657.84,"10th_percentile":9657.84,"90th_percentile":9657.84,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":17023.94,"10th_percentile":17023.94,"90th_percentile":17023.94,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Major Gastrointestinal Disorders And Peritoneal Infections With Mcc","code_information":[{"code":"371","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":9737.26,"maximum":36475.96,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12983.02,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":27655.04},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":31988.5},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":30621.44},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28901.53},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12983.02,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19356.93},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23204.56},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12983.02,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12983.02,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9737.26,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12983.02,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":36475.96},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24242.9},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35373.35},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31330.68},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12983.02,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26708.21},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13242.68,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30453.61}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":652.3,"10th_percentile":652.3,"90th_percentile":652.3,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"1 through 10","median_amount":119593.14,"10th_percentile":119593.14,"90th_percentile":119593.14,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":13551.9,"10th_percentile":13551.9,"90th_percentile":13551.9,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":16495.85,"10th_percentile":16495.85,"90th_percentile":16495.85,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":16114.96,"10th_percentile":16114.96,"90th_percentile":16114.96,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":12230.85,"10th_percentile":12230.85,"90th_percentile":12230.85,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Gastrointestinal Hemorrhage Without Cc/Mcc","code_information":[{"code":"379","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":3461.94,"maximum":12968.5,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4615.92,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":9832.35},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11373.05},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10887.01},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10275.52},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4615.92,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6882.08},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8250.04},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4615.92,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4615.92,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3461.94,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4615.92,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":12968.5},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8619.21},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12576.48},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11139.17},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4615.92,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9495.72},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4708.24,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10827.34}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":5110.43,"10th_percentile":5110.43,"90th_percentile":5110.43,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Inflammatory Bowel Disease Without Cc/Mcc","code_information":[{"code":"387","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":3741.47,"maximum":14015.61,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4988.63,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":10626.24},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12291.33},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11766.05},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11105.19},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4988.63,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7437.75},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8916.17},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4988.63,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4988.63,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3741.47,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4988.63,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":14015.61},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9315.15},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13591.94},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12038.57},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4988.63,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10262.42},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5088.4,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11701.57}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"1 through 10","median_amount":8810.92,"10th_percentile":8810.92,"90th_percentile":8810.92,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Digestive System Diagnoses Without Cc/Mcc","code_information":[{"code":"395","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":3564.09,"maximum":13351.14,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4752.12,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":10122.45},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11708.61},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11208.23},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10578.7},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4752.12,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7085.13},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8493.46},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4752.12,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4752.12,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3564.09,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4752.12,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":13351.14},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8873.52},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12947.55},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11467.83},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4752.12,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9775.89},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4847.16,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11146.8}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Mcc","code_information":[{"code":"408","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":19581.07,"maximum":73351.02,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26108.09,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":55612.66},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":64326.99},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":61577.91},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":58119.28},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26108.09,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38925.66},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":46663.01},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26108.09,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26108.09,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19581.07,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26108.09,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":73351.02},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":48751.06},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":71133.72},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":63004.15},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26108.09,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":53708.63},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26630.25,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":61240.43}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cholecystectomy Except By Laparoscope Without C.D.E. Without Cc/Mcc","code_information":[{"code":"416","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":7486.78,"maximum":28045.62,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9982.38,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":21263.39},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24595.3},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23544.19},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22221.79},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9982.38,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14883.15},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17841.51},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9982.38,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9982.38,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7486.78,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9982.38,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":28045.62},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18639.87},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27197.84},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24089.51},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9982.38,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20535.39},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10182.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23415.15}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Hepatobiliary Or Pancreas O.R. Procedures With Cc","code_information":[{"code":"424","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":12015.21,"maximum":45009.17,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16020.28,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":34124.68},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":39471.9},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":37785.03},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":35662.77},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16020.28,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23885.3},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28633.05},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16020.28,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16020.28,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12015.21,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16020.28,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":45009.17},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29914.3},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":43648.61},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38660.19},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16020.28,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32956.34},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16340.69,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37577.95}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":17683.69,"10th_percentile":17683.69,"90th_percentile":17683.69,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cirrhosis And Alcoholic Hepatitis With Cc","code_information":[{"code":"433","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":5800.29,"maximum":21728.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7733.72,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":16473.55},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19054.9},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18240.57},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17216.06},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7733.72,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11530.54},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13822.49},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7733.72,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7733.72,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5800.29,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7733.72,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":21728.0},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14441.01},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21071.19},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18663.05},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7733.72,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15909.54},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7888.39,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18140.6}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":5187.57,"10th_percentile":5187.57,"90th_percentile":5187.57,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":8045.06,"10th_percentile":8045.06,"90th_percentile":8045.06,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":8490.01,"10th_percentile":8490.01,"90th_percentile":8490.01,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":8301.87,"10th_percentile":8301.87,"90th_percentile":8301.87,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"1 through 10","median_amount":11519.86,"10th_percentile":11519.86,"90th_percentile":11519.86,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":12123.4,"10th_percentile":12123.4,"90th_percentile":12123.4,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":8357.1,"10th_percentile":8357.1,"90th_percentile":8357.1,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Mcc","code_information":[{"code":"441","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":9855.88,"maximum":36920.32,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13141.18,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":27991.94},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":32378.18},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":30994.47},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":29253.61},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13141.18,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19592.74},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23487.24},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13141.18,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13141.18,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9855.88,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13141.18,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":36920.32},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24538.23},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35804.27},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31712.35},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13141.18,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27033.57},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13404.0,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30824.6}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"1 through 10","median_amount":25028.48,"10th_percentile":25028.48,"90th_percentile":25028.48,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":15481.5,"10th_percentile":15481.5,"90th_percentile":15481.5,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":13414.82,"10th_percentile":13414.82,"90th_percentile":13414.82,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Single Level Spinal Fusion Except Cervical With Mcc","code_information":[{"code":"450","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":29268.36,"maximum":109639.79,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":39024.48,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":83125.77},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":96151.31},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":92042.19},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":86872.48},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":39024.48,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":58183.24},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":69748.48},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":39024.48,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":39024.48,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":29268.36,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":39024.48,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":109639.79},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":72869.54},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":106325.52},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":94174.03},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":39024.48,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":80279.76},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":39804.97,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":91537.75}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Wound Debridement Or Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders With","code_information":[{"code":"464","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":17104.88,"maximum":64075.17,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22806.51,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":48579.98},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":56192.3},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":53790.87},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":50769.61},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22806.51,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34003.18},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":40762.08},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22806.51,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22806.51,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17104.88,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22806.51,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":64075.17},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":42586.08},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":62138.27},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":55036.75},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22806.51,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":46916.73},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23262.64,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":53496.06}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cervical Spinal Fusion With Cc","code_information":[{"code":"472","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":16178.98,"maximum":60606.76,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21571.98,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":45950.32},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":53150.59},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":50879.15},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":48021.43},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21571.98,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32162.57},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38555.61},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21571.98,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21571.98,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16178.98,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21571.98,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":60606.76},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":40280.88},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":58774.7},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":52057.59},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21571.98,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":44377.1},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22003.42,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":50600.3}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":22438.21,"10th_percentile":22438.21,"90th_percentile":22438.21,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":26487.52,"10th_percentile":26487.52,"90th_percentile":26487.52,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":27346.58,"10th_percentile":27346.58,"90th_percentile":27346.58,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Hip And Femur Procedures Except Major Joint With Mcc Or Insertion Of Antibiotic-Eluting Bone Void Fi","code_information":[{"code":"480","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":15993.37,"maximum":59911.43,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21324.49,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":45423.14},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":52540.8},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":50295.42},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":47470.49},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21324.49,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31793.58},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38113.27},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21324.49,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21324.49,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15993.37,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21324.49,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":59911.43},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":39818.74},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":58100.39},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":51460.34},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21324.49,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":43867.97},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21750.98,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":50019.77}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":22100.43,"10th_percentile":22100.43,"90th_percentile":22100.43,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":21571.67,"10th_percentile":20973.88,"90th_percentile":25958.64,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Knee Procedures Without Principal Diagnosis Of Infection Without Cc/Mcc","code_information":[{"code":"489","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":6133.09,"maximum":22974.65,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8177.45,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":17418.73},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20148.19},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19287.14},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18203.84},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8177.45,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12192.11},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14615.56},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8177.45,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8177.45,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6133.09,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8177.45,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":22974.65},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15269.57},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22280.16},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19733.86},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8177.45,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16822.36},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8341.0,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19181.43}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur Without Cc/Mcc","code_information":[{"code":"499","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":11064.6,"maximum":41448.18,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14752.8,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":31424.84},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":36349.01},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":34795.6},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":32841.24},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14752.8,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21995.57},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26367.69},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14752.8,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14752.8,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11064.6,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14752.8,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":41448.18},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27547.57},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":40195.26},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35601.52},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14752.8,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30348.93},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15047.86,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34604.9}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Major Shoulder Or Elbow Joint Procedures With Cc/Mcc","code_information":[{"code":"507","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":9920.14,"maximum":37161.01,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13226.85,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":28174.42},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":32589.26},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":31196.53},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":29444.32},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13226.85,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19720.47},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23640.36},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13226.85,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13226.85,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9920.14,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13226.85,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":37161.01},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24698.2},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36037.68},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31919.09},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13226.85,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27209.8},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13491.39,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31025.55}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc","code_information":[{"code":"516","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":11412.22,"maximum":42750.38,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15216.3,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":32412.13},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":37491.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":35888.79},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":33873.03},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15216.3,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22686.62},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27196.09},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15216.3,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15216.3,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11412.22,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15216.3,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":42750.38},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28413.05},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":41458.1},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36720.03},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15216.3,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31302.42},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15520.63,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35692.09}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":18909.31,"10th_percentile":18909.31,"90th_percentile":18909.31,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":15613.2,"10th_percentile":15613.2,"90th_percentile":15613.2,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Fractures Of Femur Without Mcc","code_information":[{"code":"534","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":4426.83,"maximum":16582.98,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5902.44,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":12572.74},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14542.85},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13921.35},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13139.43},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5902.44,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8800.19},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10549.43},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5902.44,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5902.44,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4426.83,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5902.44,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":16582.98},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11021.49},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16081.7},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14243.79},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5902.44,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12142.28},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6020.49,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13845.05}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Mcc","code_information":[{"code":"542","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":9701.02,"maximum":36340.19,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12934.69,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":27552.1},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":31869.43},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":30507.46},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28793.95},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12934.69,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19284.88},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23118.19},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12934.69,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12934.69,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9701.02,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12934.69,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":36340.19},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24152.67},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35241.68},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31214.06},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12934.69,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26608.79},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13193.38,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30340.26}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"1 through 10","median_amount":29089.96,"10th_percentile":29089.96,"90th_percentile":29089.96,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"1 through 10","median_amount":11520.3,"10th_percentile":11520.3,"90th_percentile":11520.3,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":12798.5,"10th_percentile":12798.5,"90th_percentile":12798.5,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":14444.82,"10th_percentile":14444.82,"90th_percentile":14444.82,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":14455.82,"10th_percentile":14455.82,"90th_percentile":14455.82,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":26608.79,"10th_percentile":26608.79,"90th_percentile":26608.79,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Septic Arthritis Without Cc/Mcc","code_information":[{"code":"550","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":4800.26,"maximum":17981.86,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6400.35,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":13633.34},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15769.64},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15095.71},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14247.83},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6400.35,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9542.55},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11439.35},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6400.35,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6400.35,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4800.26,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6400.35,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17981.86},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11951.23},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17438.3},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15445.35},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6400.35,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13166.57},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6528.36,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15012.97}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Tendonitis, Myositis And Bursitis Without Mcc","code_information":[{"code":"558","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":4905.15,"maximum":18374.79,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6540.2,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":13931.24},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16114.22},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15425.56},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14559.16},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6540.2,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9751.06},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11689.31},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6540.2,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6540.2,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4905.15,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6540.2,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":18374.79},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12212.38},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17819.34},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15782.84},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6540.2,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13454.27},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6671.0,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15341.02}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":6689.94,"10th_percentile":6689.94,"90th_percentile":6689.94,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":5100.08,"10th_percentile":5100.08,"90th_percentile":5100.08,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"1 through 10","median_amount":17769.97,"10th_percentile":17769.97,"90th_percentile":17769.97,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":6050.31,"10th_percentile":6050.31,"90th_percentile":6742.88,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Musculoskeletal System And Connective Tissue Diagnoses Without Cc/Mcc","code_information":[{"code":"566","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":4114.9,"maximum":15414.49,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5486.54,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":11686.83},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13518.12},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12940.41},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12213.59},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5486.54,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8180.11},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9806.09},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5486.54,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5486.54,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4114.9,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5486.54,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15414.49},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10244.89},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14948.54},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13240.13},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5486.54,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11286.71},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5596.27,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12869.49}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":5058.15,"10th_percentile":5058.15,"90th_percentile":5058.15,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":5779.36,"10th_percentile":5779.36,"90th_percentile":5779.36,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":825.0,"10th_percentile":825.0,"90th_percentile":825.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Skin Graft Except For Skin Ulcer Or Cellulitis With Cc","code_information":[{"code":"577","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":14556.75,"maximum":54529.83,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19409.0,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":41342.97},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":47821.28},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":45777.59},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43206.41},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19409.0,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28937.69},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34689.71},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19409.0,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19409.0,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14556.75,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19409.0,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":54529.83},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36241.99},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":52881.47},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":46837.87},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19409.0,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":39927.49},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19797.18,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":45526.7}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":33138.0,"10th_percentile":33138.0,"90th_percentile":33138.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Breast Biopsy, Local Excision And Other Breast Procedures Without Cc/Mcc","code_information":[{"code":"585","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":10593.97,"maximum":39685.18,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14125.29,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":30088.17},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":34802.89},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":33315.56},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":31444.33},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14125.29,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21059.98},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25246.13},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14125.29,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14125.29,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10593.97,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14125.29,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":39685.18},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26375.83},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38485.55},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34087.2},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14125.29,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29058.03},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14407.8,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33132.97}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":13731.71,"10th_percentile":13731.71,"90th_percentile":13731.71,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"1 through 10","median_amount":30960.05,"10th_percentile":30960.05,"90th_percentile":30960.05,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":15413.59,"10th_percentile":15413.59,"90th_percentile":15413.59,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Malignant Breast Disorders Without Cc/Mcc","code_information":[{"code":"599","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":4225.28,"maximum":15827.99,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5633.71,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":12000.33},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13880.75},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13287.54},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12541.22},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5633.71,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8399.54},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10069.14},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5633.71,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5633.71,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4225.28,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5633.71,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15827.99},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10519.71},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15349.53},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13595.3},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5633.71,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11589.47},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5746.38,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13214.71}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Minor Skin Disorders Without Mcc","code_information":[{"code":"607","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":4977.64,"maximum":18646.33,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6636.86,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":14137.12},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16352.36},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15653.53},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14774.32},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6636.86,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9895.17},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11862.06},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6636.86,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6636.86,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4977.64,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6636.86,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":18646.33},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12392.85},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18082.68},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16016.09},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6636.86,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13653.1},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6769.6,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15567.74}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"O.R. Procedures For Obesity Without Cc/Mcc","code_information":[{"code":"621","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":8283.62,"maximum":31030.59,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11044.83,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":23526.51},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27213.04},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26050.07},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24586.92},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11044.83,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16467.2},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19740.43},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11044.83,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11044.83,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8283.62,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11044.83,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":31030.59},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20623.76},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30092.58},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26653.43},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11044.83,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22721.03},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11265.73,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25907.3}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Cc","code_information":[{"code":"629","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":11965.23,"maximum":44821.97,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15953.64,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":33982.74},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":39307.73},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":37627.88},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":35514.44},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15953.64,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23785.96},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28513.96},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15953.64,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15953.64,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11965.23,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15953.64,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":44821.97},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29789.88},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":43467.06},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38499.4},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15953.64,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32819.26},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16272.71,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37421.65}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":15801.81,"10th_percentile":15801.81,"90th_percentile":15801.81,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":17376.51,"10th_percentile":17376.51,"90th_percentile":17376.51,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":18688.72,"10th_percentile":18688.72,"90th_percentile":18688.72,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Endocrine Disorders With Mcc","code_information":[{"code":"643","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":9039.82,"maximum":33863.34,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12053.1,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":25674.22},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":29697.29},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28428.15},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26831.43},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12053.1,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17970.47},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21542.51},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12053.1,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12053.1,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9039.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12053.1,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":33863.34},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22506.48},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32839.7},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29086.59},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12053.1,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24795.2},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12294.16,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28272.34}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":11157.38,"10th_percentile":11157.38,"90th_percentile":11157.38,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":12849.45,"10th_percentile":12849.45,"90th_percentile":12849.45,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Major Bladder Procedures Without Cc/Mcc","code_information":[{"code":"655","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":11623.65,"maximum":43542.4,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15498.2,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":33012.61},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":38185.58},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":36553.68},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":34500.58},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15498.2,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23106.92},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27699.94},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15498.2,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15498.2,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11623.65,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15498.2,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":43542.4},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28939.45},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":42226.17},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37400.32},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15498.2,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31882.35},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15808.16,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36353.35}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":30996.26,"10th_percentile":30996.26,"90th_percentile":30996.26,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"1 through 10","median_amount":39466.8,"10th_percentile":39466.8,"90th_percentile":39466.8,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Minor Bladder Procedures With Cc","code_information":[{"code":"663","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":8348.42,"maximum":31273.34,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11131.23,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":23710.56},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27425.93},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26253.85},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24779.26},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11131.23,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16596.02},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19894.86},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11131.23,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11131.23,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8348.42,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11131.23,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":31273.34},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20785.1},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30327.99},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26861.93},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11131.23,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22898.77},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11353.85,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26109.97}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":11657.89,"10th_percentile":11657.89,"90th_percentile":11657.89,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":11845.2,"10th_percentile":11845.2,"90th_percentile":11845.2,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Urethral Procedures With Cc/Mcc","code_information":[{"code":"671","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":9857.54,"maximum":36926.49,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13143.38,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":27996.62},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":32383.6},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":30999.65},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":29258.5},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13143.38,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19596.02},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23491.17},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13143.38,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13143.38,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9857.54,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13143.38,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":36926.49},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24542.33},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35810.25},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31717.65},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13143.38,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27038.09},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13406.25,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30829.75}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Kidney And Urinary Tract Neoplasms With Mcc","code_information":[{"code":"686","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":9905.31,"maximum":37105.46,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13207.08,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":28132.31},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":32540.55},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":31149.9},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":29400.31},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13207.08,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19690.99},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23605.02},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13207.08,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13207.08,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9905.31,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13207.08,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":37105.46},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24661.29},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35983.82},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31871.38},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13207.08,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27169.13},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13471.22,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30979.18}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Kidney And Urinary Tract Signs And Symptoms Without Mcc","code_information":[{"code":"696","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":3783.76,"maximum":14174.01,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5045.01,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":10746.33},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12430.25},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11899.03},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11230.7},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5045.01,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7521.81},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9016.94},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5045.01,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5045.01,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3783.76,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5045.01,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":14174.01},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9420.43},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13745.55},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12174.63},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5045.01,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10378.41},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5145.91,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11833.82}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":5463.11,"10th_percentile":5463.11,"90th_percentile":5463.11,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Penis Procedures Without Cc/Mcc","code_information":[{"code":"710","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":7694.92,"maximum":28825.29,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10259.89,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":21854.52},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25279.05},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24198.72},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22839.56},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10259.89,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15296.9},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18337.5},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10259.89,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10259.89,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7694.92,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10259.89,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":28825.29},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19158.06},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27953.94},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24759.2},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10259.89,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21106.28},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10465.09,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24066.1}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Male Reproductive System O.R. Procedures Without Cc/Mcc","code_information":[{"code":"718","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":7375.85,"maximum":27630.07,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9834.47,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":20948.33},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24230.87},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23195.34},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21892.53},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9834.47,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14662.62},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17577.15},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9834.47,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9834.47,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7375.85,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9834.47,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":27630.07},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18363.68},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26794.85},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23732.58},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9834.47,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20231.12},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10031.16,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23068.21}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":17638.27,"10th_percentile":17638.27,"90th_percentile":17638.27,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Male Reproductive System Diagnoses With Cc/Mcc","code_information":[{"code":"729","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":5814.02,"maximum":21779.43,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7752.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":16512.54},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19100.01},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18283.75},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17256.81},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7752.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11557.83},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13855.21},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7752.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7752.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5814.02,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7752.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":21779.43},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14475.19},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21121.07},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18707.23},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7752.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15947.2},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7907.07,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18183.54}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Cc","code_information":[{"code":"740","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":9937.71,"maximum":37226.84,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13250.28,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":28224.33},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":32646.99},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":31251.79},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":29496.48},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13250.28,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19755.4},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23682.24},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13250.28,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13250.28,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9937.71,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13250.28,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":37226.84},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24741.96},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36101.52},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31975.63},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13250.28,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27258.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13515.29,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31080.51}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Female Reproductive System Reconstructive Procedures","code_information":[{"code":"748","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":7618.58,"maximum":28539.34,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10158.11,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":21637.72},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25028.28},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23958.67},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22612.99},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10158.11,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15145.15},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18155.6},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10158.11,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10158.11,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7618.58,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10158.11,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":28539.34},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18968.01},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27676.64},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24513.59},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10158.11,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20896.9},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10361.27,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23827.36}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Infections, Female Reproductive System Without Cc/Mcc","code_information":[{"code":"759","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":3644.26,"maximum":13651.49,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4859.02,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":10350.17},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11972.01},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11460.37},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10816.68},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4859.02,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7244.52},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8684.53},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4859.02,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4859.02,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3644.26,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4859.02,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":13651.49},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9073.14},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13238.82},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11725.81},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4859.02,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9995.81},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4956.2,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11397.56}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cesarean Section With Sterilization With Mcc","code_information":[{"code":"783","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":13482.58,"maximum":50505.97,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17976.77,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":38292.19},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":44292.46},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":42399.58},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":40018.13},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17976.77,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26802.33},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32129.89},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17976.77,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17976.77,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13482.58,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17976.77,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":50505.97},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33567.62},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":48979.25},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":43381.62},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17976.77,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36981.17},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18336.31,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":42167.2}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"1 through 10","median_amount":17524.98,"10th_percentile":17524.98,"90th_percentile":17524.98,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Prematurity With Major Problems","code_information":[{"code":"791","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":22290.65,"maximum":83501.18,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":29720.87,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":63308.22},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":73228.42},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":70098.93},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":66161.7},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":29720.87,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":44312.1},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":53120.13},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":29720.87,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":29720.87,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22290.65,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":29720.87,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":83501.18},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":55497.12},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":80977.05},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":71722.53},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":29720.87,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":61140.72},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":30315.29,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":69714.75}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":4763.91,"10th_percentile":4763.91,"90th_percentile":13496.76,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"1 through 10","median_amount":4765.7,"10th_percentile":4765.7,"90th_percentile":4765.7,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"1 through 10","median_amount":4954.0,"10th_percentile":4954.0,"90th_percentile":4954.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":6729.0,"10th_percentile":6729.0,"90th_percentile":6729.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":5641.7,"10th_percentile":5641.7,"90th_percentile":5641.7,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Splenic Procedures With Mcc","code_information":[{"code":"799","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":24871.18,"maximum":93167.9,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":33161.58,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":70637.25},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":81705.88},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":78214.1},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":73821.07},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":33161.58,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":49442.0},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":59269.71},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":33161.58,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":33161.58,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":24871.18,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":33161.58,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":93167.9},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":61921.88},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":90351.56},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":80025.66},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":33161.58,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":68218.82},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":33824.81,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":77785.44}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Vaginal Delivery Without Sterilization Or D&C Without Cc/Mcc","code_information":[{"code":"807","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":3702.48,"maximum":13869.55,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4936.64,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":10515.5},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12163.24},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11643.43},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10989.46},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4936.64,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7360.24},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8823.26},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4936.64,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4936.64,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3702.48,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4936.64,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":13869.55},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9218.07},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13450.29},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11913.11},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4936.64,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10155.47},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5035.37,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11579.62}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"15","median_amount":2783.78,"10th_percentile":2503.44,"90th_percentile":2838.97,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"13","median_amount":6328.77,"10th_percentile":4788.75,"90th_percentile":9045.13,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"46","median_amount":6811.0,"10th_percentile":4840.4,"90th_percentile":7602.35,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"1 through 10","median_amount":623.43,"10th_percentile":623.43,"90th_percentile":623.43,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":2922.97,"10th_percentile":2628.61,"90th_percentile":3154.34,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"1 through 10","median_amount":6535.0,"10th_percentile":5931.0,"90th_percentile":6731.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":2980.92,"10th_percentile":2628.61,"90th_percentile":4248.15,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"1 through 10","median_amount":6806.61,"10th_percentile":4865.96,"90th_percentile":9091.61},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":2503.44,"10th_percentile":2457.35,"90th_percentile":2783.78,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"1 through 10","median_amount":4908.0,"10th_percentile":3609.95,"90th_percentile":7535.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":5075.01,"10th_percentile":5075.01,"90th_percentile":5075.01,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":2503.44,"10th_percentile":2503.44,"90th_percentile":2838.97,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"1 through 10","median_amount":13891.08,"10th_percentile":9491.76,"90th_percentile":14597.65},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"1 through 10","median_amount":4370.25,"10th_percentile":4370.25,"90th_percentile":4370.25},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"12","median_amount":2628.61,"10th_percentile":2628.61,"90th_percentile":2980.92,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"1 through 10","median_amount":7489.46,"10th_percentile":6343.96,"90th_percentile":10285.94,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":8660.2,"10th_percentile":7534.02,"90th_percentile":10086.24,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":2503.44,"10th_percentile":2457.35,"90th_percentile":2838.97,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"1 through 10","median_amount":7293.8,"10th_percentile":7293.8,"90th_percentile":7765.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"102","median_amount":7130.0,"10th_percentile":5701.27,"90th_percentile":7201.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"37","median_amount":2503.44,"10th_percentile":2457.35,"90th_percentile":2838.97,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Reticuloendothelial And Immunity Disorders With Cc","code_information":[{"code":"815","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":5568.55,"maximum":20859.87,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7424.73,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":15815.36},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18293.57},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17511.78},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16528.2},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7424.73,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11069.84},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13270.22},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7424.73,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7424.73,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5568.55,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7424.73,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":20859.87},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13864.03},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20229.3},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17917.38},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7424.73,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15273.88},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7573.22,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17415.8}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Lymphoma And Non-Acute Leukemia With Other Procedures With Mcc","code_information":[{"code":"823","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":25178.18,"maximum":94317.86,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":33570.9,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":71509.13},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":82714.38},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":79179.5},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":74732.24},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":33570.9,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":50052.26},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":60001.28},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":33570.9,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":33570.9,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25178.18,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":33570.9,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":94317.86},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":62686.18},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":91466.76},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":81013.42},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":33570.9,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":69060.84},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":34242.32,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":78745.54}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"1 through 10","median_amount":218452.19,"10th_percentile":218452.19,"90th_percentile":218452.19,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":36253.78,"10th_percentile":36253.78,"90th_percentile":36253.78,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":36241.77,"10th_percentile":36241.77,"90th_percentile":36241.77,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Antepartum Diagnoses Without O.R. Procedures With Mcc","code_information":[{"code":"831","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":6603.72,"maximum":24737.66,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8804.96,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":18755.39},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21694.3},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20767.18},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19600.75},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8804.96,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13127.69},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15737.12},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8804.96,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8804.96,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6603.72,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8804.96,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":24737.66},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16441.31},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23989.88},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21248.18},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8804.96,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18113.26},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8981.06,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20653.36}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":12265.02,"10th_percentile":12265.02,"90th_percentile":12265.02,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Chemotherapy With Acute Leukemia As Secondary Diagnosis Without Cc/Mcc","code_information":[{"code":"839","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":7929.41,"maximum":29703.71,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10572.55,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":22520.51},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26049.4},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24936.15},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23535.57},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10572.55,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15763.06},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18896.32},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10572.55,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10572.55,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7929.41,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10572.55,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":29703.71},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19741.88},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28805.81},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25513.71},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10572.55,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21749.47},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10784.0,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24799.49}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Cc","code_information":[{"code":"847","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":7184.19,"maximum":26912.11,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9578.92,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":20404.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23601.24},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22592.61},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21323.66},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9578.92,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14281.62},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17120.41},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9578.92,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9578.92,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7184.19,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9578.92,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":26912.11},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17886.51},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26098.59},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23115.89},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9578.92,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19705.42},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9770.5,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22468.79}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc","code_information":[{"code":"857","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":11760.4,"maximum":44054.64,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15680.53,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":33400.98},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":38634.8},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":36983.71},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":34906.45},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15680.53,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23378.76},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28025.81},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15680.53,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15680.53,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11760.4,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15680.53,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":44054.64},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29279.89},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":42722.93},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37840.31},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15680.53,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32257.41},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15994.14,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36781.01}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":18718.5,"10th_percentile":18718.5,"90th_percentile":18718.5,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":19923.19,"10th_percentile":19923.19,"90th_percentile":19923.19,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":16771.66,"10th_percentile":16771.66,"90th_percentile":16771.66,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":32820.77,"10th_percentile":32820.77,"90th_percentile":32820.77,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Infectious And Parasitic Diseases Diagnoses With Cc","code_information":[{"code":"868","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":5662.46,"maximum":21211.64,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7549.94,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":16082.07},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18602.08},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17807.1},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16806.93},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7549.94,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11256.52},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13494.01},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7549.94,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7549.94,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5662.46,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7549.94,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":21211.64},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14097.83},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20570.45},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18219.54},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7549.94,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15531.46},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7700.94,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17709.5}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":8625.14,"10th_percentile":8625.14,"90th_percentile":8625.14,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":6172.81,"10th_percentile":6172.81,"90th_percentile":6172.81,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Neuroses Except Depressive","code_information":[{"code":"882","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":5896.95,"maximum":22090.06,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7862.6,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":16748.06},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19372.43},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18544.53},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17502.94},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7862.6,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11722.67},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14052.82},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7862.6,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7862.6,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5896.95,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7862.6,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":22090.06},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14681.65},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21422.31},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18974.05},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7862.6,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16174.65},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8019.85,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18442.89}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":3873.25,"10th_percentile":3873.25,"90th_percentile":3873.25,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"1 through 10","median_amount":1905.0,"10th_percentile":1905.0,"90th_percentile":1966.66,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":6096.51,"10th_percentile":6096.51,"90th_percentile":6096.51,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":7274.9,"10th_percentile":7274.9,"90th_percentile":7274.9,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":7650.25,"10th_percentile":7650.25,"90th_percentile":7650.25,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":142.88,"10th_percentile":142.88,"90th_percentile":142.88,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":6203.5,"10th_percentile":6203.5,"90th_percentile":6203.5,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With Mcc","code_information":[{"code":"896","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":9583.5,"maximum":35899.95,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12778.0,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":27218.32},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":31483.35},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":30137.88},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28445.13},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12778.0,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19051.26},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22838.12},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12778.0,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12778.0,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9583.5,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12778.0,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":35899.95},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23860.07},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34814.75},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30835.92},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12778.0,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26286.44},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13033.56,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29972.7}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":13143.72,"10th_percentile":13143.72,"90th_percentile":13143.72,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"1 through 10","median_amount":8555.8,"10th_percentile":8555.8,"90th_percentile":8555.8,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":13800.91,"10th_percentile":13800.91,"90th_percentile":13800.91,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":13800.91,"10th_percentile":13800.91,"90th_percentile":13800.91,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":7302.07,"10th_percentile":7302.07,"90th_percentile":7302.07,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":7610.41,"10th_percentile":7610.41,"90th_percentile":7610.41,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":11430.79,"10th_percentile":11430.79,"90th_percentile":11430.79,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"1 through 10","median_amount":2093.74,"10th_percentile":2093.74,"90th_percentile":2093.74,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":7303.37,"10th_percentile":7303.37,"90th_percentile":7303.37,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other O.R. Procedures For Injuries With Mcc","code_information":[{"code":"907","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":21084.14,"maximum":78981.54,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":28112.18,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":59881.56},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":69264.81},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":66304.71},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":62580.59},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":28112.18,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":41913.64},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":50244.92},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":28112.18,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":28112.18,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21084.14,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":28112.18,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":78981.54},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":52493.25},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":76594.04},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":67840.43},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":28112.18,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":57831.38},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":28674.42,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":65941.32}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":28892.94,"10th_percentile":28892.94,"90th_percentile":28892.94,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Poisoning And Toxic Effects Of Drugs Without Mcc","code_information":[{"code":"918","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":4706.9,"maximum":17632.14,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6275.87,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":13368.19},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15462.94},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14802.12},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13970.73},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6275.87,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9356.96},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11216.87},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6275.87,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6275.87,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4706.9,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6275.87,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17632.14},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11718.79},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17099.15},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15144.96},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6275.87,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12910.5},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6401.39,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14720.99}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":6851.04,"10th_percentile":6851.04,"90th_percentile":6851.04,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"1 through 10","median_amount":14180.72,"10th_percentile":14180.72,"90th_percentile":14180.72,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":2864.13,"10th_percentile":2864.13,"90th_percentile":2864.13,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":3731.26,"10th_percentile":3731.26,"90th_percentile":3731.26,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":3713.1,"10th_percentile":3713.1,"90th_percentile":3713.1,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":4788.01,"10th_percentile":4788.01,"90th_percentile":4891.04,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":11725.26,"10th_percentile":11725.26,"90th_percentile":11725.26,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":6990.86,"10th_percentile":6990.86,"90th_percentile":6990.86,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Full Thickness Burn With Skin Graft Or Inhalation Injury Without Cc/Mcc","code_information":[{"code":"929","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":17687.54,"maximum":66257.85,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23583.39,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":50234.82},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":58106.45},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":55623.22},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":52499.04},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23583.39,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35161.47},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":42150.61},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23583.39,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23583.39,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17687.54,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23583.39,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":66257.85},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":44036.74},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":64254.96},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":56911.54},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23583.39,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":48514.91},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":24055.06,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":55318.37}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Rehabilitation Without Cc/Mcc","code_information":[{"code":"946","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":6297.84,"maximum":23591.81,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8397.12,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":17886.64},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20689.42},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19805.24},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18692.84},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8397.12,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12519.62},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15008.17},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8397.12,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8397.12,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6297.84,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8397.12,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":23591.81},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15679.75},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22878.66},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20263.96},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8397.12,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17274.25},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8565.06,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19696.69}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other O.R. Procedures For Multiple Significant Trauma With Mcc","code_information":[{"code":"957","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":41845.91,"maximum":156755.52,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":55794.55,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":118847.58},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":137470.62},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":131595.67},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":124204.37},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":55794.55,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":83186.45},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":99721.63},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":55794.55,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":55794.55,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":41845.91,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":55794.55,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":156755.52},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":104183.92},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":152017.01},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":134643.63},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":55794.55,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":114778.55},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":56910.44,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":130874.45}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Hiv With Major Related Condition With Mcc","code_information":[{"code":"974","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":15848.93,"maximum":59370.39,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21131.91,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":45012.94},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":52066.33},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":49841.22},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":47041.8},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21131.91,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31506.46},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37769.08},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21131.91,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21131.91,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15848.93,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21131.91,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":59370.39},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":39459.15},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":57575.7},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":50995.62},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21131.91,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":43471.82},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21554.55,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":49568.06}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":23167.5,"10th_percentile":23167.5,"90th_percentile":23167.5,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc","code_information":[{"code":"988","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":9026.09,"maximum":33811.91,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12034.79,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":25635.23},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":29652.19},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28384.97},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26790.68},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12034.79,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17943.18},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21509.79},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12034.79,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12034.79,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9026.09,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12034.79,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":33811.91},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22472.3},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32789.82},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29042.41},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12034.79,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24757.55},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12275.49,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28229.41}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":12862.51,"10th_percentile":12862.51,"90th_percentile":12862.51,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Liver Transplant With Mcc Or Intestinal Transplant","code_information":[{"code":"005","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":56621.78,"maximum":212106.16,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":75495.71,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":160812.87},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":186011.73},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":178062.34},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":168061.15},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":75495.71,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":112559.73},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":134933.51},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":75495.71,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":75495.71,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":56621.78,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":75495.71,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":212106.16},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":140971.45},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":205694.48},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":182186.54},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":75495.71,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":155307.06},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":77005.62,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":177086.45}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Allogeneic Bone Marrow Transplant","code_information":[{"code":"014","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":65998.24,"maximum":247230.56,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":87997.66,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":187443.19},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":216814.93},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":207549.13},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":195891.77},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":87997.66,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":131199.41},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":157278.26},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":87997.66,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":87997.66,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":65998.24,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":87997.66,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":247230.56},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":164316.06},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":239757.11},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":212356.29},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":87997.66,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":181025.63},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":89757.61,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":206411.64}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis With Mcc Or Antineopla","code_information":[{"code":"023","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":31468.87,"maximum":117882.93,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":41958.49,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":89375.49},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":103380.34},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":98962.28},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":93403.89},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":41958.49,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":62557.69},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":74992.44},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":41958.49,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":41958.49,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":31468.87,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":41958.49,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":117882.93},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":78348.16},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":114319.49},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":101254.4},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":41958.49,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":86315.51},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":42797.66,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":98419.91}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":63571.61,"10th_percentile":63571.61,"90th_percentile":63571.61,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Ventricular Shunt Procedures With Mcc","code_information":[{"code":"031","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":24605.39,"maximum":92172.22,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":32807.19,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":69882.36},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":80832.7},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":77378.24},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":73032.15},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":32807.19,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":48913.62},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":58636.3},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":32807.19,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":32807.19,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":24605.39,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":32807.19,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":92172.22},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":61260.13},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":89385.98},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":79170.44},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":32807.19,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":67489.77},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":33463.33,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":76954.16}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Extracranial Procedures Without Cc/Mcc","code_information":[{"code":"039","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":6455.44,"maximum":24182.22,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8607.26,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":18334.27},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21207.2},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20300.89},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19160.65},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8607.26,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12832.93},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15383.77},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8607.26,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8607.26,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6455.44,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8607.26,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":24182.22},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16072.15},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23451.23},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20771.09},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8607.26,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17706.56},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8779.41,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20189.62}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":8961.93,"10th_percentile":8766.56,"90th_percentile":10730.31,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"1 through 10","median_amount":23414.89,"10th_percentile":23414.89,"90th_percentile":23414.89,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":8823.03,"10th_percentile":8823.03,"90th_percentile":8823.03,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Degenerative Nervous System Disorders With Mcc","code_information":[{"code":"056","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":12757.68,"maximum":47790.49,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17010.24,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":36233.39},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":41911.05},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":40119.94},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":37866.53},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17010.24,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25361.28},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30402.41},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17010.24,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17010.24,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12757.68,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17010.24,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":47790.49},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31762.84},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":46345.85},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":41049.18},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17010.24,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34992.86},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17350.44,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":39900.06}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":32437.93,"10th_percentile":32437.93,"90th_percentile":36410.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":16462.19,"10th_percentile":2493.82,"90th_percentile":21322.84,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":108927.9,"10th_percentile":108927.9,"90th_percentile":108927.9,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Intracranial Hemorrhage Or Cerebral Infarction With Mcc","code_information":[{"code":"064","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":11043.74,"maximum":41370.01,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14724.98,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":31365.57},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":36280.45},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":34729.97},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":32779.3},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14724.98,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21954.09},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26317.96},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14724.98,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14724.98,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11043.74,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14724.98,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":41370.01},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27495.62},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":40119.45},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35534.37},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14724.98,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30291.69},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15019.48,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34539.63}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"1 through 10","median_amount":20588.18,"10th_percentile":20588.18,"90th_percentile":20588.18,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":15550.84,"10th_percentile":15550.84,"90th_percentile":15550.84,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":15427.44,"10th_percentile":12405.87,"90th_percentile":18320.31,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":15277.23,"10th_percentile":13989.22,"90th_percentile":15445.94,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":17521.92,"10th_percentile":17521.92,"90th_percentile":17521.92,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":14136.26,"10th_percentile":14136.26,"90th_percentile":14136.26,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Cerebrovascular Disorders Without Cc/Mcc","code_information":[{"code":"072","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":4152.8,"maximum":15556.44,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5537.06,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":11794.45},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13642.6},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13059.57},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12326.06},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5537.06,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8255.44},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9896.39},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5537.06,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5537.06,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4152.8,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5537.06,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15556.44},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10339.23},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15086.19},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13362.05},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5537.06,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11390.64},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5647.8,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12988.0}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":877.93,"10th_percentile":877.93,"90th_percentile":877.93,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Traumatic Stupor And Coma >1 Hour With Cc","code_information":[{"code":"083","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":7665.26,"maximum":28714.2,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10220.35,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":21770.29},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25181.63},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24105.47},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22751.54},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10220.35,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15237.95},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18266.83},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10220.35,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10220.35,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7665.26,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10220.35,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":28714.2},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19084.23},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27846.21},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24663.79},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10220.35,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21024.94},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10424.76,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23973.35}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":9125.88,"10th_percentile":9125.88,"90th_percentile":9125.88,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":635.31,"10th_percentile":635.31,"90th_percentile":635.31,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Disorders Of Nervous System With Mcc","code_information":[{"code":"091","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":9644.46,"maximum":36128.3,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12859.28,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":27391.45},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":31683.6},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":30329.57},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28626.06},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12859.28,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19172.44},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22983.39},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12859.28,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12859.28,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9644.46,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12859.28,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":36128.3},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24011.84},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35036.19},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31032.05},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12859.28,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26453.64},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13116.47,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30163.35}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"1 through 10","median_amount":28431.77,"10th_percentile":28431.77,"90th_percentile":28431.77,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":7129.59,"10th_percentile":7129.59,"90th_percentile":7129.59,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"1 through 10","median_amount":28896.73,"10th_percentile":28896.73,"90th_percentile":28896.73},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":13004.09,"10th_percentile":13004.09,"90th_percentile":13004.09,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":14000.03,"10th_percentile":14000.03,"90th_percentile":14000.03,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":15385.6,"10th_percentile":15385.6,"90th_percentile":15385.6,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":14378.6,"10th_percentile":14378.6,"90th_percentile":14378.6,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":167.06,"10th_percentile":167.06,"90th_percentile":167.06,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Non-Bacterial Infection Of Nervous System Except Viral Meningitis Without Cc/Mcc","code_information":[{"code":"099","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":7481.84,"maximum":28027.1,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9975.79,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":21249.35},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24579.06},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23528.65},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22207.12},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9975.79,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14873.32},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17829.73},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9975.79,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9975.79,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7481.84,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9975.79,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":28027.1},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18627.56},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27179.88},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24073.61},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9975.79,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20521.83},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10175.31,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23399.7}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Intraocular Procedures With Cc/Mcc","code_information":[{"code":"116","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":9929.48,"maximum":37195.98,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13239.3,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":28200.94},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":32619.93},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":31225.89},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":29472.03},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13239.3,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19739.03},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23662.6},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13239.3,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13239.3,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9929.48,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13239.3,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":37195.98},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24721.45},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36071.6},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31949.13},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13239.3,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27235.41},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13504.09,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31054.75}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Sinus And Mastoid Procedures Without Cc/Mcc","code_information":[{"code":"136","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":5575.69,"maximum":20886.61,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7434.25,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":15835.63},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18317.03},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17534.23},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16549.39},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7434.25,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11084.03},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13287.23},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7434.25,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7434.25,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5575.69,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7434.25,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":20886.61},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13881.8},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20255.24},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17940.35},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7434.25,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15293.46},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7582.94,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17438.13}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Ear, Nose, Mouth And Throat O.R. Procedures With Cc","code_information":[{"code":"144","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":9516.5,"maximum":35648.98,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12688.67,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":27028.04},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":31263.25},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":29927.18},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28246.27},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12688.67,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18918.07},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22678.46},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12688.67,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12688.67,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9516.5,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12688.67,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":35648.98},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23693.27},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34571.36},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30620.34},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12688.67,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26102.67},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12942.44,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29763.16}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":12638.7,"10th_percentile":12638.7,"90th_percentile":12638.7,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Otitis Media And Uri With Mcc","code_information":[{"code":"152","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":6492.24,"maximum":24320.05,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8656.32,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":18438.77},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21328.07},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20416.59},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19269.86},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8656.32,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12906.08},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15471.45},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8656.32,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8656.32,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6492.24,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8656.32,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":24320.05},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16163.76},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23584.89},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20889.47},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8656.32,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17807.48},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8829.45,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20304.7}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":719.96,"10th_percentile":719.96,"90th_percentile":719.96,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Major Chest Procedures With Mcc","code_information":[{"code":"163","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":24612.53,"maximum":92198.96,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":32816.71,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":69902.63},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":80856.15},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":77400.69},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":73053.34},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":32816.71,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":48927.81},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":58653.32},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":32816.71,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":32816.71,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":24612.53,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":32816.71,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":92198.96},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":61277.9},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":89411.91},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":79193.41},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":32816.71,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":67509.35},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":33473.04,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":76976.48}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"1 through 10","median_amount":71889.69,"10th_percentile":71889.69,"90th_percentile":71889.69,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"1 through 10","median_amount":69374.06,"10th_percentile":69374.06,"90th_percentile":69374.06},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":35713.79,"10th_percentile":35713.79,"90th_percentile":35713.79,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"1 through 10","median_amount":59508.05,"10th_percentile":59508.05,"90th_percentile":59508.05,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":43558.54,"10th_percentile":43558.54,"90th_percentile":43558.54,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":68741.61,"10th_percentile":68741.61,"90th_percentile":68741.61,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"1 through 10","median_amount":79159.47,"10th_percentile":79159.47,"90th_percentile":79159.47,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."}]}]},{"description":"Pulmonary Embolism Without Mcc","code_information":[{"code":"176","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":4420.78,"maximum":16560.35,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5894.38,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":12555.59},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14523.01},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13902.35},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13121.5},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5894.38,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8788.19},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10535.04},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5894.38,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5894.38,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4420.78,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5894.38,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":16560.35},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11006.45},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16059.75},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14224.35},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5894.38,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12125.72},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6012.27,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13826.16}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":8891.9,"10th_percentile":8891.9,"90th_percentile":8891.9,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":6324.64,"10th_percentile":6324.64,"90th_percentile":6325.34,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":6363.22,"10th_percentile":6363.22,"90th_percentile":6363.22,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":6357.73,"10th_percentile":6357.73,"90th_percentile":6357.73,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":12268.81,"10th_percentile":12268.81,"90th_percentile":12268.81,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Major Chest Trauma With Cc","code_information":[{"code":"184","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":5843.68,"maximum":21890.52,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7791.57,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":16596.77},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19197.43},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18377.01},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17344.83},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7791.57,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11616.78},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13925.88},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7791.57,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7791.57,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5843.68,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7791.57,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":21890.52},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14549.02},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21228.8},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18802.65},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7791.57,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16028.54},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7947.4,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18276.29}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"1 through 10","median_amount":10000.0,"10th_percentile":10000.0,"90th_percentile":10000.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":400.18,"10th_percentile":400.18,"90th_percentile":400.18,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":8285.02,"10th_percentile":8278.51,"90th_percentile":8288.71,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":282.88,"10th_percentile":282.88,"90th_percentile":282.88,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":8469.85,"10th_percentile":8469.85,"90th_percentile":8469.85,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"1 through 10","median_amount":24485.78,"10th_percentile":24485.78,"90th_percentile":24485.78,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Chronic Obstructive Pulmonary Disease Without Cc/Mcc","code_information":[{"code":"192","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":3525.64,"maximum":13207.13,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4700.86,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":10013.27},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11582.32},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11087.34},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10464.6},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4700.86,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7008.71},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8401.85},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4700.86,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4700.86,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3525.64,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4700.86,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":13207.13},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8777.82},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12807.9},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11344.14},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4700.86,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9670.45},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4794.88,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11026.57}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Pneumothorax With Cc","code_information":[{"code":"200","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":6036.98,"maximum":22614.65,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8049.31,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":17145.78},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19832.47},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18984.91},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17918.59},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8049.31,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12001.06},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14386.54},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8049.31,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8049.31,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6036.98,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8049.31,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":22614.65},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15030.3},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21931.04},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19424.63},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8049.31,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16558.76},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8210.3,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18880.86}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":554.0,"10th_percentile":554.0,"90th_percentile":554.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":8597.75,"10th_percentile":8597.75,"90th_percentile":8597.75,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"1 through 10","median_amount":19866.11,"10th_percentile":19866.11,"90th_percentile":19866.11,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"1 through 10","median_amount":30200.41,"10th_percentile":30200.41,"90th_percentile":30200.41,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Respiratory System Diagnosis With Ventilator Support <=96 Hours","code_information":[{"code":"208","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":15094.93,"maximum":56545.87,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20126.57,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":42871.47},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":49589.3},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":47470.05},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":44803.81},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20126.57,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30007.56},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35972.24},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20126.57,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20126.57,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15094.93,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20126.57,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":56545.87},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37581.9},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":54836.57},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":48569.53},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20126.57,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":41403.67},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20529.1,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":47209.88}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":20822.48,"10th_percentile":20822.48,"90th_percentile":20822.48,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"1 through 10","median_amount":39186.44,"10th_percentile":39186.44,"90th_percentile":39186.44,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":20801.98,"10th_percentile":20794.08,"90th_percentile":22468.48,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":19013.71,"10th_percentile":18825.48,"90th_percentile":20785.48,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":8279.7,"10th_percentile":8279.7,"90th_percentile":8279.7,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":14361.9,"10th_percentile":14361.9,"90th_percentile":14361.9,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Mcc","code_information":[{"code":"219","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":42166.63,"maximum":157956.91,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":56222.17,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":119758.45},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":138524.21},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":132604.24},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":125156.29},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":56222.17,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":83824.0},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":100485.91},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":56222.17,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":56222.17,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":42166.63,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":56222.17,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":157956.91},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":104982.4},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":153182.09},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":135675.56},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":56222.17,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":115658.23},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":57346.61,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":131877.49}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":59925.32,"10th_percentile":59925.32,"90th_percentile":59925.32,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"1 through 10","median_amount":120681.79,"10th_percentile":120681.79,"90th_percentile":120681.79,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":59967.32,"10th_percentile":59967.32,"90th_percentile":59967.32,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":59958.32,"10th_percentile":59958.32,"90th_percentile":59958.32,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"1 through 10","median_amount":159164.48,"10th_percentile":159164.48,"90th_percentile":159164.48,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":59925.32,"10th_percentile":59925.32,"90th_percentile":59925.32,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":116549.96,"10th_percentile":116549.96,"90th_percentile":116549.96,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Coronary Bypass With Cardiac Catheterization Or Open Ablation Without Mcc","code_information":[{"code":"234","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":29999.3,"maximum":112377.9,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":39999.07,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":85201.73},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":98552.57},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":94340.83},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":89042.01},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":39999.07,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":59636.3},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":71490.35},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":39999.07,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":39999.07,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":29999.3,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":39999.07,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":112377.9},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":74689.37},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":108980.87},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":96525.91},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":39999.07,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":82284.65},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":40799.05,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":93823.78}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":34232.08,"10th_percentile":34232.08,"90th_percentile":34232.08,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":41231.34,"10th_percentile":41231.34,"90th_percentile":41231.34,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"1 through 10","median_amount":112377.9,"10th_percentile":112377.9,"90th_percentile":112377.9,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":41248.84,"10th_percentile":41248.84,"90th_percentile":49398.11,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":79045.46,"10th_percentile":79045.46,"90th_percentile":79045.46,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Permanent Cardiac Pacemaker Implant Without Cc/Mcc","code_information":[{"code":"244","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":9926.18,"maximum":37183.64,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13234.91,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":28191.58},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":32609.11},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":31215.53},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":29462.25},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13234.91,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19732.48},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23654.75},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13234.91,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13234.91,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9926.18,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13234.91,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":37183.64},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24713.24},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36059.63},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31938.53},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13234.91,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27226.37},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13499.61,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31044.45}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":13977.02,"10th_percentile":13977.02,"90th_percentile":13977.02,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":13984.52,"10th_percentile":13984.52,"90th_percentile":13984.52,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":13984.93,"10th_percentile":13984.93,"90th_percentile":13984.93,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Upper Limb And Toe Amputation For Circulatory System Disorders With Cc","code_information":[{"code":"256","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":9324.29,"maximum":34928.96,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12432.39,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":26482.15},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":30631.81},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":29322.73},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27675.77},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12432.39,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18535.97},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22220.42},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12432.39,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12432.39,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9324.29,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12432.39,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":34928.96},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23214.72},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33873.11},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30001.89},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12432.39,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25575.47},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12681.04,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29162.03}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":13117.36,"10th_percentile":13117.36,"90th_percentile":13117.36,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Circulatory System O.R. Procedures","code_information":[{"code":"264","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":18345.44,"maximum":68722.36,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":24460.59,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":52103.34},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":60267.76},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":57692.16},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":54451.78},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":24460.59,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36469.33},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":43718.43},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":24460.59,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":24460.59,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18345.44,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":24460.59,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":68722.36},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":45674.72},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":66644.97},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":59028.4},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":24460.59,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":50319.46},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":24949.8,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":57375.97}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":27082.42,"10th_percentile":27082.42,"90th_percentile":27082.42,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":31078.89,"10th_percentile":31078.89,"90th_percentile":103369.61,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Major Cardiovascular Procedures Without Cc/Mcc","code_information":[{"code":"272","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":14020.22,"maximum":52519.96,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18693.62,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":39819.14},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":46058.67},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":44090.31},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":41613.9},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18693.62,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27871.1},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33411.11},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18693.62,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18693.62,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14020.22,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18693.62,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":52519.96},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34906.17},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":50932.35},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":45111.51},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18693.62,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38455.84},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19067.49,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":43848.67}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Acute Myocardial Infarction, Discharged Alive With Mcc","code_information":[{"code":"280","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":8809.18,"maximum":32999.32,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11745.57,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":25019.15},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28939.57},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27702.81},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26146.83},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11745.57,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17511.96},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20992.86},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11745.57,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11745.57,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8809.18,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11745.57,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":32999.32},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21932.23},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32001.8},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28344.45},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11745.57,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24162.56},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11980.48,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27550.98}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":12712.3,"10th_percentile":12712.3,"90th_percentile":12712.3,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":12712.3,"10th_percentile":6763.27,"90th_percentile":12755.29,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":12616.3,"10th_percentile":11795.3,"90th_percentile":14429.85,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":12229.68,"10th_percentile":12229.68,"90th_percentile":12229.68,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":24479.84,"10th_percentile":24479.84,"90th_percentile":24479.84,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":8450.52,"10th_percentile":8450.52,"90th_percentile":8450.52,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":12966.54,"10th_percentile":12966.54,"90th_percentile":12966.54,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Acute And Subacute Endocarditis With Mcc","code_information":[{"code":"288","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":14861.54,"maximum":55671.57,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19815.38,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":42208.6},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":48822.55},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":46736.07},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":44111.06},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19815.38,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29543.59},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35416.04},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19815.38,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19815.38,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14861.54,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19815.38,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":55671.57},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37000.82},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":53988.69},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":47818.55},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19815.38,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":40763.49},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20211.69,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":46479.93}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cardiac Arrest, Unexplained Without Cc/Mcc","code_information":[{"code":"298","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":2499.26,"maximum":9362.25,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3332.34,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7098.19},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8210.46},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7859.58},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7418.13},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3332.34,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":4968.33},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5955.89},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3332.34,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3332.34,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2499.26,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3332.34,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":9362.25},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6222.4},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9079.25},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8041.62},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3332.34,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6855.17},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3398.99,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7816.5}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cardiac Congenital And Valvular Disorders With Mcc","code_information":[{"code":"306","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":8653.76,"maximum":32417.14,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11538.35,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":24577.75},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28429.01},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27214.07},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25685.54},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11538.35,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17203.01},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20622.49},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11538.35,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11538.35,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8653.76,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11538.35,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":32417.14},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21545.3},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31437.21},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27844.39},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11538.35,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23736.28},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11769.12,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27064.92}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":10342.53,"10th_percentile":10342.53,"90th_percentile":10342.53,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Circulatory System Diagnoses With Mcc","code_information":[{"code":"314","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":11451.21,"maximum":42896.44,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15268.28,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":32522.86},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":37619.09},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":36011.4},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":33988.76},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15268.28,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22764.13},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27289.01},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15268.28,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15268.28,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11451.21,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15268.28,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":42896.44},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28510.13},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":41599.74},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36845.48},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15268.28,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31409.37},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15573.65,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35814.04}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":14949.92,"10th_percentile":14949.92,"90th_percentile":14949.92,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":17519.91,"10th_percentile":17519.91,"90th_percentile":19432.42,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":16187.34,"10th_percentile":16187.34,"90th_percentile":16187.34,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":17067.95,"10th_percentile":17067.95,"90th_percentile":17067.95,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Percutaneous Cardiovascular Procedures With Intraluminal Device Without Mcc","code_information":[{"code":"322","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":9681.8,"maximum":36268.19,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12909.07,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":27497.51},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":31806.28},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":30447.01},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28736.9},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12909.07,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19246.67},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23072.38},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12909.07,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12909.07,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9681.8,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12909.07,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":36268.19},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24104.81},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35171.85},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31152.21},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12909.07,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26556.07},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13167.25,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30280.14}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":14045.4,"10th_percentile":14045.4,"90th_percentile":14045.4,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"1 through 10","median_amount":33546.47,"10th_percentile":33546.47,"90th_percentile":33546.47,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"1 through 10","median_amount":28218.09,"10th_percentile":27290.15,"90th_percentile":28218.09,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"1 through 10","median_amount":43025.75,"10th_percentile":43025.75,"90th_percentile":43025.75},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":17451.78,"10th_percentile":17451.78,"90th_percentile":17451.78,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"1 through 10","median_amount":20878.16,"10th_percentile":20878.16,"90th_percentile":20878.72,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":13931.46,"10th_percentile":13742.38,"90th_percentile":16410.47,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"1 through 10","median_amount":38878.86,"10th_percentile":38878.86,"90th_percentile":38878.86},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"13","median_amount":14013.85,"10th_percentile":13931.46,"90th_percentile":14029.58,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"1 through 10","median_amount":36132.58,"10th_percentile":36132.58,"90th_percentile":36132.58,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":24736.49,"10th_percentile":24736.49,"90th_percentile":24736.49,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"1 through 10","median_amount":50214.18,"10th_percentile":50214.18,"90th_percentile":50214.18,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"19","median_amount":14018.89,"10th_percentile":13263.37,"90th_percentile":16401.88,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"15","median_amount":26982.0,"10th_percentile":26556.07,"90th_percentile":27251.98,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":12714.32,"10th_percentile":12714.32,"90th_percentile":12714.32,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Major Small And Large Bowel Procedures With Cc","code_information":[{"code":"330","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":13164.62,"maximum":49314.86,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17552.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":37389.13},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43247.89},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":41399.64},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":39074.36},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17552.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26170.23},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31372.16},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17552.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17552.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13164.62,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17552.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":49314.86},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32775.98},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":47824.14},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":42358.52},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17552.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36109.02},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17903.88,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":41172.75}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":17149.97,"10th_percentile":17149.97,"90th_percentile":17149.97,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"1 through 10","median_amount":24955.95,"10th_percentile":24955.95,"90th_percentile":24955.95,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":17889.37,"10th_percentile":17889.37,"90th_percentile":17889.37,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":18339.37,"10th_percentile":17336.61,"90th_percentile":18339.37,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":18306.38,"10th_percentile":18306.38,"90th_percentile":18306.38,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":35604.41,"10th_percentile":35604.41,"90th_percentile":35604.41,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Minor Small And Large Bowel Procedures With Mcc","code_information":[{"code":"344","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":14183.86,"maximum":53133.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18911.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":40283.93},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":46596.29},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":44604.96},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":42099.64},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18911.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28196.43},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33801.1},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18911.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18911.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14183.86,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18911.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":53133.0},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35313.62},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":51526.86},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":45638.08},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18911.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38904.72},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19290.06,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":44360.49}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Inguinal And Femoral Hernia Procedures Without Cc/Mcc","code_information":[{"code":"352","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":6413.16,"maximum":24023.82,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8550.88,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":18214.18},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21068.28},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20167.91},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19035.14},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8550.88,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12748.87},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15283.0},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8550.88,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8550.88,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6413.16,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8550.88,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":24023.82},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15966.87},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23297.61},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20635.03},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8550.88,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17590.57},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8721.9,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20057.37}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Percutaneous Coronary Atherectomy With Intraluminal Device Without Mcc","code_information":[{"code":"360","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":13258.52,"maximum":49666.64,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17678.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":37655.84},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43556.39},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":41694.96},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":39353.09},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17678.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26356.91},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31595.94},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17678.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17678.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13258.52,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17678.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":49666.64},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33009.78},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":48165.29},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":42660.68},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17678.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36366.6},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18031.59,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":41466.45}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":21089.16,"10th_percentile":21089.16,"90th_percentile":21089.16,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":37375.24,"10th_percentile":37375.24,"90th_percentile":37375.24,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Digestive Malignancy With Cc","code_information":[{"code":"375","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":6642.71,"maximum":24883.72,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8856.95,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":18866.13},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21822.39},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20889.79},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19716.48},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8856.95,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13205.2},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15830.04},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8856.95,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8856.95,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6642.71,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8856.95,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":24883.72},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16538.39},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24131.52},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21373.63},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8856.95,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18220.2},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9034.09,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20775.3}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":9516.25,"10th_percentile":9516.25,"90th_percentile":9516.25,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":8128.55,"10th_percentile":8128.55,"90th_percentile":8128.55,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Uncomplicated Peptic Ulcer With Mcc","code_information":[{"code":"383","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":7582.34,"maximum":28403.57,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10109.78,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":21534.78},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24909.21},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23844.69},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22505.41},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10109.78,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15073.1},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18069.22},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10109.78,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10109.78,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7582.34,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10109.78,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":28403.57},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18877.77},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27544.97},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24396.97},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10109.78,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20797.48},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10311.98,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23714.01}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":9369.57,"10th_percentile":9369.57,"90th_percentile":9369.57,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With Mcc","code_information":[{"code":"391","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":6965.08,"maximum":26091.29,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9286.77,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":19781.68},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22881.4},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21903.54},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20673.29},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9286.77,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13846.03},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16598.24},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9286.77,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9286.77,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6965.08,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9286.77,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":26091.29},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17340.97},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25302.59},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22410.86},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9286.77,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19104.4},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9472.51,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21783.5}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":7741.49,"10th_percentile":7741.49,"90th_percentile":7741.49,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":9992.29,"10th_percentile":8995.19,"90th_percentile":11799.48,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":17567.94,"10th_percentile":17567.94,"90th_percentile":17567.94,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":9948.19,"10th_percentile":9948.19,"90th_percentile":9948.19,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Single Level Combined Anterior And Posterior Spinal Fusion Except Cervical","code_information":[{"code":"402","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":22079.23,"maximum":82709.16,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":29438.97,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":62707.74},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":72533.84},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":69434.04},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":65534.15},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":29438.97,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":43891.8},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":52616.28},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":29438.97,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":29438.97,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22079.23,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":29438.97,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":82709.16},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":54970.73},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":80208.98},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":71042.24},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":29438.97,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":60560.79},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":30027.75,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":69053.49}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"1 through 10","median_amount":65742.22,"10th_percentile":65742.22,"90th_percentile":65742.22,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":30029.67,"10th_percentile":30029.67,"90th_percentile":30029.67,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":28656.69,"10th_percentile":28656.69,"90th_percentile":28656.69,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":58929.47,"10th_percentile":58929.47,"90th_percentile":58929.47,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cholecystectomy With C.D.E. With Cc","code_information":[{"code":"412","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":11546.22,"maximum":43252.34,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15394.96,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":32792.69},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":37931.2},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":36310.18},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":34270.75},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15394.96,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22952.99},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27515.42},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15394.96,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15394.96,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11546.22,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15394.96,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":43252.34},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28746.66},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":41944.88},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37151.18},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15394.96,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31669.96},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15702.86,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36111.17}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Hepatobiliary Diagnostic Procedures With Mcc","code_information":[{"code":"420","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":18710.64,"maximum":70090.38,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":24947.52,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":53140.54},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":61467.49},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":58840.62},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":55535.73},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":24947.52,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37195.31},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":44588.72},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":24947.52,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":24947.52,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18710.64,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":24947.52,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":70090.38},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":46583.95},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":67971.65},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":60203.46},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":24947.52,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":51321.15},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25446.47,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":58518.13}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical Without Cc/Mcc","code_information":[{"code":"428","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":30874.12,"maximum":115655.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":41165.5,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":87686.33},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":101426.5},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":97091.94},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":91638.6},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":41165.5,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":61375.37},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":73575.11},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":41165.5,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":41165.5,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":30874.12,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":41165.5,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":115655.0},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":76867.41},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":112158.9},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":99340.74},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":41165.5,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":84684.19},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":41988.81,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":96559.82}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":52315.43,"10th_percentile":52315.43,"90th_percentile":52315.43,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":42276.1,"10th_percentile":42276.1,"90th_percentile":42514.58,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Malignancy Of Hepatobiliary System Or Pancreas Without Cc/Mcc","code_information":[{"code":"437","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":4686.04,"maximum":17553.97,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6248.05,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":13308.92},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15394.39},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14736.49},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13908.79},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6248.05,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9315.48},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11167.14},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6248.05,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6248.05,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4686.04,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6248.05,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17553.97},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11666.84},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17023.34},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15077.81},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6248.05,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12853.26},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6373.01,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14655.73}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Disorders Of The Biliary Tract With Cc","code_information":[{"code":"445","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":6010.07,"maximum":22513.84,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8013.43,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":17069.36},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19744.07},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18900.29},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17838.72},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8013.43,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11947.56},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14322.41},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8013.43,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8013.43,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6010.07,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8013.43,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":22513.84},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14963.3},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21833.28},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19338.05},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8013.43,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16484.95},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8173.7,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18796.7}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":8436.85,"10th_percentile":8436.85,"90th_percentile":8436.85,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":8422.44,"10th_percentile":8422.44,"90th_percentile":8422.44,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":8428.92,"10th_percentile":8428.92,"90th_percentile":8428.92,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":25238.5,"10th_percentile":25238.5,"90th_percentile":25238.5,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":9325.58,"10th_percentile":9325.58,"90th_percentile":9325.58,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":16113.65,"10th_percentile":16113.65,"90th_percentile":16113.65,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Or Infection Without Cc/Mcc","code_information":[{"code":"458","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":22914.51,"maximum":85838.14,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":30552.68,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":65080.04},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":75277.88},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":72060.8},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":68013.38},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":30552.68,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":45552.27},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":54606.82},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":30552.68,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":30552.68,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22914.51,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":30552.68,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":85838.14},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":57050.33},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":83243.37},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":73729.84},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":30552.68,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":62851.87},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":31163.73,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":71665.87}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"1 through 10","median_amount":69035.67,"10th_percentile":69035.67,"90th_percentile":69035.67,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Revision Of Hip Or Knee Replacement Without Cc/Mcc","code_information":[{"code":"468","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":15091.09,"maximum":56531.47,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20121.45,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":42860.56},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":49576.67},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":47457.96},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":44792.4},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20121.45,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29999.92},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35963.08},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20121.45,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20121.45,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15091.09,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20121.45,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":56531.47},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37572.33},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":54822.6},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":48557.16},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20121.45,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":41393.12},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20523.88,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":47197.86}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Amputation For Musculoskeletal System And Connective Tissue Disorders Without Cc/Mcc","code_information":[{"code":"476","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":6481.26,"maximum":24278.91,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8641.68,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":18407.58},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21291.99},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20382.05},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19237.26},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8641.68,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12884.24},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15445.28},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8641.68,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8641.68,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6481.26,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8641.68,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":24278.91},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16136.41},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23544.99},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20854.13},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8641.68,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17777.35},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8814.51,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20270.35}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Knee Procedures With Principal Diagnosis Of Infection With Mcc","code_information":[{"code":"485","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":17722.14,"maximum":66387.45,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23629.52,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":50333.08},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":58220.11},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":55732.02},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":52601.73},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23629.52,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35230.25},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":42233.06},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23629.52,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23629.52,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17722.14,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23629.52,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":66387.45},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":44122.88},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":64380.65},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":57022.86},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23629.52,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":48609.81},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":24102.11,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":55426.57}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Mcc","code_information":[{"code":"495","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":19911.12,"maximum":74587.39,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26548.16,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":56550.04},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":65411.25},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":62615.84},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":59098.91},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26548.16,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":39581.77},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":47449.54},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26548.16,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26548.16,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19911.12,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26548.16,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":74587.39},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":49572.78},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":72332.72},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":64066.12},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26548.16,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":54613.92},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27079.12,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":62272.67}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":26233.85,"10th_percentile":26233.85,"90th_percentile":26233.85,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Foot Procedures With Mcc","code_information":[{"code":"503","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":15327.78,"maximum":57418.12,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20437.04,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":43532.79},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":50354.24},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":48202.3},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":45494.93},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20437.04,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30470.44},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36527.13},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20437.04,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20437.04,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15327.78,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20437.04,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":57418.12},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38161.62},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":55682.45},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":49318.74},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20437.04,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":42042.34},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20845.78,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":47938.12}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":12654.85,"10th_percentile":12654.85,"90th_percentile":12654.85,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures Without Cc/Mcc","code_information":[{"code":"512","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":9090.9,"maximum":34054.66,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12121.2,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":25819.27},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":29865.07},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28588.76},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26983.02},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12121.2,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18072.0},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21664.22},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12121.2,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12121.2,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9090.9,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12121.2,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":34054.66},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22633.64},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33025.23},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29250.92},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12121.2,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24935.29},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12363.62,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28432.07}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Back And Neck Procedures Except Spinal Fusion Without Cc/Mcc","code_information":[{"code":"520","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":8204.0,"maximum":30732.3,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10938.66,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":23300.36},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26951.45},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25799.65},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24350.57},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10938.66,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16308.91},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19550.67},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10938.66,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10938.66,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8204.0,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10938.66,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":30732.3},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20425.51},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29803.31},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26397.21},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10938.66,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22502.62},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11157.43,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25658.26}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"1 through 10","median_amount":49693.98,"10th_percentile":49693.98,"90th_percentile":49693.98},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"1 through 10","median_amount":15250.74,"10th_percentile":15250.74,"90th_percentile":15250.74,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh Without Cc/Mcc","code_information":[{"code":"538","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":3955.64,"maximum":14817.91,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5274.19,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":11234.52},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12994.93},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12439.58},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11740.89},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5274.19,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7863.52},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9426.57},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5274.19,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5274.19,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3955.64,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5274.19,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":14817.91},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9848.38},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14369.99},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12727.7},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5274.19,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10849.88},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5379.67,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12371.4}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Connective Tissue Disorders With Cc","code_information":[{"code":"546","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":6334.08,"maximum":23727.58,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8445.44,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":17989.58},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20808.49},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19919.22},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18800.42},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8445.44,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12591.67},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15094.55},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8445.44,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8445.44,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6334.08,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8445.44,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":23727.58},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15769.99},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23010.33},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20380.58},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8445.44,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17373.66},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8614.35,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19810.05}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":8966.15,"10th_percentile":8966.15,"90th_percentile":8966.15,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":7323.68,"10th_percentile":7323.68,"90th_percentile":7323.68,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":7284.47,"10th_percentile":7284.47,"90th_percentile":7284.47,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Bone Diseases And Arthropathies Without Mcc","code_information":[{"code":"554","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":4558.63,"maximum":17076.7,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6078.17,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":12947.07},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14975.83},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14335.83},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13530.63},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6078.17,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9062.2},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10863.52},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6078.17,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6078.17,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4558.63,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6078.17,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17076.7},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11349.63},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16560.5},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14667.87},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6078.17,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12503.8},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6199.73,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14257.26}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":4919.39,"10th_percentile":4919.39,"90th_percentile":4919.39,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":5285.91,"10th_percentile":5285.91,"90th_percentile":5285.91,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":6474.79,"10th_percentile":6474.79,"90th_percentile":6474.79,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":4852.69,"10th_percentile":4852.69,"90th_percentile":4852.69,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":6498.67,"10th_percentile":6498.67,"90th_percentile":6498.67,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":157.58,"10th_percentile":157.58,"90th_percentile":6576.75,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh With Mcc","code_information":[{"code":"562","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":7824.52,"maximum":29310.79,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10432.69,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":22222.61},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25704.82},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24606.3},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23224.24},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10432.69,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15554.54},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18646.36},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10432.69,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10432.69,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7824.52,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10432.69,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":29310.79},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19480.73},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28424.76},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25176.22},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10432.69,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21461.76},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10641.34,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24471.44}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":10959.61,"10th_percentile":10959.61,"90th_percentile":10959.61,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"1 through 10","median_amount":29613.69,"10th_percentile":29613.69,"90th_percentile":29613.69,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Skin Graft For Skin Ulcer Or Cellulitis With Mcc","code_information":[{"code":"573","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":35978.07,"maximum":134774.48,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":47970.76,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":102182.19},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":118193.81},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":113142.68},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":106787.82},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":47970.76,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":71521.63},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":85738.17},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":47970.76,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":47970.76,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":35978.07,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":47970.76,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":134774.48},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":89574.74},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":130700.43},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":115763.24},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":47970.76,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":98683.74},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":48930.18,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":112522.59}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Skin, Subcutaneous Tissue And Breast Procedures Without Cc/Mcc","code_information":[{"code":"581","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":7925.02,"maximum":29687.25,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10566.69,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":22508.03},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26034.97},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24922.34},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23522.53},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10566.69,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15754.32},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18885.85},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10566.69,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10566.69,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7925.02,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10566.69,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":29687.25},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19730.94},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28789.85},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25499.58},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10566.69,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21737.42},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10778.02,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24785.75}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":350.0,"10th_percentile":350.0,"90th_percentile":350.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Major Skin Disorders With Mcc","code_information":[{"code":"595","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":11646.16,"maximum":43626.74,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15528.22,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":33076.56},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":38259.55},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":36624.49},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":34567.41},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15528.22,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23151.68},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27753.6},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15528.22,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15528.22,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11646.16,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15528.22,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":43626.74},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28995.5},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":42307.97},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37472.77},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15528.22,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31944.1},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15838.78,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36423.76}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cellulitis Without Mcc","code_information":[{"code":"603","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":4782.69,"maximum":17916.03,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6376.92,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":13583.43},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15711.91},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15040.44},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14195.67},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6376.92,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9507.62},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11397.47},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6376.92,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6376.92,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4782.69,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6376.92,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17916.03},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11907.48},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17374.46},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15388.8},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6376.92,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13118.37},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6504.46,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14958.01}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":6821.61,"10th_percentile":6821.61,"90th_percentile":6821.61,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"1 through 10","median_amount":13737.83,"10th_percentile":13737.83,"90th_percentile":13737.83,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":6831.8,"10th_percentile":6831.8,"90th_percentile":6831.8,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":4544.09,"10th_percentile":4544.09,"90th_percentile":4544.09,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":6821.61,"10th_percentile":6821.61,"90th_percentile":6821.61,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":6832.61,"10th_percentile":6779.79,"90th_percentile":6894.52,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"1 through 10","median_amount":17607.55,"10th_percentile":17607.55,"90th_percentile":17607.55,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"12","median_amount":4771.57,"10th_percentile":157.58,"90th_percentile":6821.62,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":11971.5,"10th_percentile":11971.5,"90th_percentile":11971.5,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":3363.56,"10th_percentile":3363.56,"90th_percentile":3363.56,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":5614.02,"10th_percentile":5614.02,"90th_percentile":5614.02,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc","code_information":[{"code":"617","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":10271.06,"maximum":38475.55,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13694.74,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":29171.07},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":33742.08},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":32300.08},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":30485.89},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13694.74,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20418.07},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24476.62},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13694.74,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13694.74,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10271.06,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13694.74,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":38475.55},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25571.88},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37312.49},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33048.2},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13694.74,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28172.33},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13968.63,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32123.06}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":14983.45,"10th_percentile":14983.45,"90th_percentile":14983.45,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"1 through 10","median_amount":30944.11,"10th_percentile":30944.11,"90th_percentile":30944.11,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":14890.14,"10th_percentile":14890.14,"90th_percentile":14890.14,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":15052.52,"10th_percentile":15052.52,"90th_percentile":15052.52,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":14861.7,"10th_percentile":14861.7,"90th_percentile":14959.85,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":29095.69,"10th_percentile":29095.69,"90th_percentile":29095.69,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Thyroid, Parathyroid And Thyroglossal Procedures With Mcc","code_information":[{"code":"625","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":16585.36,"maximum":62129.07,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22113.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":47104.5},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":54485.62},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":52157.13},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":49227.63},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22113.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32970.43},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":39524.05},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22113.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22113.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16585.36,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22113.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":62129.07},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":41292.65},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":60251.0},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":53365.17},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22113.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":45491.77},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22556.1,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":51871.27}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Diabetes Without Cc/Mcc","code_information":[{"code":"639","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":3411.42,"maximum":12779.24,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4548.56,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":9688.86},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11207.07},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10728.12},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10125.56},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4548.56,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6781.64},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8129.64},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4548.56,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4548.56,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3411.42,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4548.56,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":12779.24},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8493.43},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12392.94},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10976.6},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4548.56,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9357.14},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4639.53,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10669.33}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":5039.73,"10th_percentile":5039.73,"90th_percentile":5039.73,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"1 through 10","median_amount":6615.65,"10th_percentile":6615.65,"90th_percentile":6615.65,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":9345.11,"10th_percentile":9345.11,"90th_percentile":9345.11,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Kidney Transplant With Hemodialysis Without Mcc","code_information":[{"code":"651","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":20351.0,"maximum":76235.2,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27134.67,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":57799.36},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":66856.34},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":63999.17},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":60404.54},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27134.67,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":40456.22},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":48497.8},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27134.67,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27134.67,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20351.0,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27134.67,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":76235.2},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":50667.96},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":73930.71},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":65481.49},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27134.67,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":55820.47},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27677.36,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":63648.41}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Kidney And Ureter Procedures For Non-Neoplasm With Mcc","code_information":[{"code":"659","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":13953.76,"maximum":52271.04,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18605.02,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":39630.42},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":45840.38},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43881.34},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":41416.67},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18605.02,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27739.01},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33252.76},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18605.02,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18605.02,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13953.76,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18605.02,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":52271.04},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34740.73},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":50690.96},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":44897.7},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18605.02,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38273.58},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18977.12,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":43640.85}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":19114.49,"10th_percentile":19114.49,"90th_percentile":19114.49,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":31951.86,"10th_percentile":31951.86,"90th_percentile":31951.86,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":10400.02,"10th_percentile":10400.02,"90th_percentile":10400.02,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":18415.5,"10th_percentile":18415.5,"90th_percentile":18415.5,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":19951.33,"10th_percentile":18738.36,"90th_percentile":21678.97,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Prostatectomy Without Cc/Mcc","code_information":[{"code":"667","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":6074.88,"maximum":22756.59,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8099.84,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":17253.4},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19956.95},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19104.07},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18031.06},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8099.84,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12076.39},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14476.84},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8099.84,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8099.84,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6074.88,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8099.84,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":22756.59},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15124.64},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22068.69},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19546.55},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8099.84,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16662.69},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8261.84,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18999.37}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Kidney And Urinary Tract Procedures Without Cc/Mcc","code_information":[{"code":"675","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":9014.02,"maximum":33766.65,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12018.69,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":25600.92},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":29612.5},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28346.98},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26754.82},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12018.69,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17919.16},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21481.0},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12018.69,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12018.69,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9014.02,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12018.69,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":33766.65},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22442.22},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32745.93},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29003.54},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12018.69,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24724.41},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12259.06,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28191.62}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Kidney And Urinary Tract Infections Without Mcc","code_information":[{"code":"690","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":4445.5,"maximum":16652.92,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5927.33,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":12625.77},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14604.19},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13980.07},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13194.85},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5927.33,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8837.31},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10593.93},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5927.33,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5927.33,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4445.5,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5927.33,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":16652.92},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11067.98},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16149.53},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14303.87},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5927.33,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12193.5},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6045.88,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13903.45}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":6271.26,"10th_percentile":6034.24,"90th_percentile":6289.19,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":4739.41,"10th_percentile":4739.41,"90th_percentile":4739.41,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"1 through 10","median_amount":11253.78,"10th_percentile":11253.78,"90th_percentile":11253.78},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":6242.99,"10th_percentile":6183.34,"90th_percentile":6243.97,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"14","median_amount":6276.76,"10th_percentile":6034.46,"90th_percentile":6913.68,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"18","median_amount":5093.43,"10th_percentile":280.07,"90th_percentile":6658.89,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":11969.0,"10th_percentile":11969.0,"90th_percentile":12089.56,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":4818.9,"10th_percentile":4818.9,"90th_percentile":4818.9,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Kidney And Urinary Tract Diagnoses Without Cc/Mcc","code_information":[{"code":"700","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":3788.7,"maximum":14192.53,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5051.6,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":10760.37},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12446.49},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11914.57},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11245.37},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5051.6,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7531.64},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9028.72},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5051.6,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5051.6,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3788.7,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5051.6,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":14192.53},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9432.73},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13763.51},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12190.53},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5051.6,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10391.96},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5152.63,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11849.27}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":10456.73,"10th_percentile":10456.73,"90th_percentile":10456.73,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Transurethral Prostatectomy Without Cc/Mcc","code_information":[{"code":"714","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":5806.88,"maximum":21752.68,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7742.51,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":16492.27},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19076.55},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18261.3},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17235.62},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7742.51,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11543.64},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13838.19},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7742.51,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7742.51,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5806.88,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7742.51,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":21752.68},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14457.42},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21095.13},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18684.26},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7742.51,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15927.62},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7897.36,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18161.22}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Benign Prostatic Hypertrophy With Mcc","code_information":[{"code":"725","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":6426.34,"maximum":24073.19,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8568.46,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":18251.61},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21111.58},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20209.35},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19074.26},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8568.46,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12775.07},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15314.41},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8568.46,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8568.46,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6426.34,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8568.46,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":24073.19},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15999.69},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23345.49},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20677.43},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8568.46,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17626.72},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8739.83,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20098.59}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Mcc","code_information":[{"code":"736","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":19629.94,"maximum":73534.11,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26173.26,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":55751.48},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":64487.55},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":61731.62},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":58264.35},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26173.26,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":39022.82},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":46779.48},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26173.26,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26173.26,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19629.94,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26173.26,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":73534.11},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":48872.74},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":71311.28},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":63161.42},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26173.26,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":53842.69},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26696.73,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":61393.29}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"D&C, Conization, Laparoscopy And Tubal Interruption With Cc/Mcc","code_information":[{"code":"744","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":11252.96,"maximum":42153.8,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15003.95,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":31959.81},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":36967.81},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":35387.96},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":33400.33},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15003.95,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22370.02},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26816.57},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15003.95,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15003.95,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11252.96,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15003.95,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":42153.8},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28016.55},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":40879.55},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36207.6},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15003.95,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30865.59},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15304.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35194.01}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Malignancy, Female Reproductive System With Cc","code_information":[{"code":"755","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":5973.83,"maximum":22378.07,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7965.11,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":16966.42},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19625.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18786.31},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17731.14},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7965.11,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11875.51},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14236.04},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7965.11,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7965.11,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5973.83,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7965.11,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":22378.07},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14873.07},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21701.61},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19221.43},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7965.11,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16385.53},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8124.41,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18683.35}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Postpartum And Post Abortion Diagnoses With O.R. Procedures","code_information":[{"code":"769","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":9279.81,"maximum":34762.33,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12373.08,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":26355.81},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":30485.68},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":29182.85},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27543.74},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12373.08,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18447.55},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22114.41},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12373.08,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12373.08,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9279.81,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12373.08,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":34762.33},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23103.98},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33711.51},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29858.77},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12373.08,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25453.46},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12620.54,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29022.91}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"1 through 10","median_amount":4921.77,"10th_percentile":4921.77,"90th_percentile":4921.77,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":10221.26,"10th_percentile":10221.26,"90th_percentile":10221.26,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cesarean Section Without Sterilization With Cc","code_information":[{"code":"787","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":6133.09,"maximum":22974.65,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8177.45,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":17418.73},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20148.19},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19287.14},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18203.84},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8177.45,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12192.11},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14615.56},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8177.45,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8177.45,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6133.09,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8177.45,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":22974.65},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15269.57},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22280.16},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19733.86},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8177.45,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16822.36},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8341.0,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19181.43}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":4212.9,"10th_percentile":4212.9,"90th_percentile":4212.9,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"1 through 10","median_amount":11563.07,"10th_percentile":11250.59,"90th_percentile":12545.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":4423.55,"10th_percentile":4423.55,"90th_percentile":4423.55,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":4171.33,"10th_percentile":4171.33,"90th_percentile":4171.33,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"1 through 10","median_amount":8219.0,"10th_percentile":8219.0,"90th_percentile":8219.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":5251.3,"10th_percentile":5251.3,"90th_percentile":5251.3,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":13152.77,"10th_percentile":12259.98,"90th_percentile":13198.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":5251.3,"10th_percentile":5251.3,"90th_percentile":5251.3,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Normal Newborn","code_information":[{"code":"795","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":1097.24,"maximum":4110.26,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1462.98,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3116.28},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3604.59},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3450.55},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3256.74},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1462.98,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2181.22},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2614.78},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1462.98,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1462.98,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1097.24,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1462.98,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4110.26},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2731.79},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3986.01},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3530.47},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1462.98,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3009.59},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1492.24,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3431.63}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"15","median_amount":1453.91,"10th_percentile":1448.78,"90th_percentile":2082.59,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"12","median_amount":2481.66,"10th_percentile":2018.89,"90th_percentile":4074.27,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"45","median_amount":1966.4,"10th_percentile":1229.0,"90th_percentile":3687.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1526.61,"10th_percentile":1521.22,"90th_percentile":3244.54,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"1 through 10","median_amount":1154.0,"10th_percentile":1154.0,"90th_percentile":1154.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1526.61,"10th_percentile":1448.78,"90th_percentile":3244.54,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"1 through 10","median_amount":2793.38,"10th_percentile":2498.86,"90th_percentile":3814.53},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1453.91,"10th_percentile":1448.78,"90th_percentile":2132.79,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"1 through 10","median_amount":2109.49,"10th_percentile":2109.49,"90th_percentile":2181.24,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":2003.51,"10th_percentile":2003.51,"90th_percentile":2003.51,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":2082.59,"10th_percentile":1453.91,"90th_percentile":3090.04,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"1 through 10","median_amount":511.22,"10th_percentile":511.22,"90th_percentile":511.22},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"12","median_amount":1526.61,"10th_percentile":1521.22,"90th_percentile":2239.43,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"1 through 10","median_amount":3085.66,"10th_percentile":1668.53,"90th_percentile":3085.66,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":2669.67,"10th_percentile":2402.7,"90th_percentile":2731.79,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1453.91,"10th_percentile":1448.78,"90th_percentile":1453.91,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"1 through 10","median_amount":3351.02,"10th_percentile":3351.02,"90th_percentile":3351.02,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"83","median_amount":2266.0,"10th_percentile":1133.0,"90th_percentile":2928.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"27","median_amount":1453.91,"10th_percentile":1448.78,"90th_percentile":2082.59,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other O.R. Procedures Of The Blood And Blood Forming Organs With Cc","code_information":[{"code":"803","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":10208.45,"maximum":38241.03,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13611.27,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":28993.26},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":33536.41},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":32103.2},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":30300.07},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13611.27,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20293.61},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24327.42},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13611.27,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13611.27,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10208.45,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13611.27,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":38241.03},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25416.01},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37085.06},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32846.76},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13611.27,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28000.61},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13883.5,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31927.26}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Red Blood Cell Disorders With Mcc","code_information":[{"code":"811","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":7711.94,"maximum":28889.06,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10282.59,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":21902.87},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25334.98},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24252.26},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22890.09},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10282.59,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15330.74},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18378.07},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10282.59,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10282.59,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7711.94,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10282.59,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":28889.06},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19200.45},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28015.79},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24813.98},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10282.59,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21152.97},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10488.24,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24119.34}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":13128.43,"10th_percentile":13128.43,"90th_percentile":13128.43,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":8936.15,"10th_percentile":8936.15,"90th_percentile":8936.15,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Antepartum Diagnoses With O.R. Procedures Without Cc/Mcc","code_information":[{"code":"819","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":4722.28,"maximum":17689.74,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6296.37,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":13411.86},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15513.46},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14850.47},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14016.37},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6296.37,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9387.53},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11253.51},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6296.37,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6296.37,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4722.28,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6296.37,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17689.74},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11757.08},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17155.01},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15194.43},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6296.37,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12952.67},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6422.3,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14769.08}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Cc","code_information":[{"code":"827","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":12692.33,"maximum":47545.68,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16923.11,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":36047.79},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":41696.36},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":39914.42},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":37672.56},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16923.11,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25231.37},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30246.67},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16923.11,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16923.11,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12692.33,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16923.11,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":47545.68},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31600.14},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":46108.44},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":40838.9},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16923.11,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34813.61},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17261.57,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":39695.67}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Acute Leukemia With Cc","code_information":[{"code":"835","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":11454.51,"maximum":42908.79,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15272.68,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":32532.22},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":37629.92},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":36021.77},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":33998.54},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15272.68,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22770.68},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27296.86},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15272.68,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15272.68,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11454.51,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15272.68,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":42908.79},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28518.33},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":41611.71},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36856.09},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15272.68,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31418.41},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15578.13,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35824.35}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Mcc","code_information":[{"code":"843","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":10954.77,"maximum":41036.75,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14606.36,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":31112.9},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":35988.19},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":34450.2},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":32515.24},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14606.36,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21777.23},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26105.95},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14606.36,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14606.36,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10954.77,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14606.36,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":41036.75},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27274.12},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":39796.26},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35248.12},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14606.36,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30047.67},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14898.49,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34261.39}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":13451.2,"10th_percentile":13451.2,"90th_percentile":13451.2,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Infectious And Parasitic Diseases With O.R. Procedures With Mcc","code_information":[{"code":"853","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":27121.12,"maximum":101596.19,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":36161.5,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":77027.34},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":89097.28},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":85289.62},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":80499.18},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":36161.5,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":53914.7},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":64631.46},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":36161.5,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":36161.5,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27121.12,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":36161.5,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":101596.19},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":67523.55},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":98525.07},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":87265.06},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":36161.5,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":74390.13},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":36884.73,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":84822.18}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":19067.23,"10th_percentile":19067.23,"90th_percentile":19067.23,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":38771.03,"10th_percentile":38771.03,"90th_percentile":38771.03,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"1 through 10","median_amount":41826.88,"10th_percentile":41826.88,"90th_percentile":53341.9,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":38776.03,"10th_percentile":38776.03,"90th_percentile":38776.03,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"1 through 10","median_amount":56626.22,"10th_percentile":56626.22,"90th_percentile":56626.22,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":109667.68,"10th_percentile":109667.68,"90th_percentile":109667.68,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":17873.56,"10th_percentile":17873.56,"90th_percentile":17873.56,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"12","median_amount":38759.23,"10th_percentile":35257.15,"90th_percentile":44211.1,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"1 through 10","median_amount":42097.33,"10th_percentile":42097.33,"90th_percentile":42097.33,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":66169.88,"10th_percentile":66169.88,"90th_percentile":66169.88,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"11","median_amount":36308.53,"10th_percentile":14121.6,"90th_percentile":37945.26,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":75334.58,"10th_percentile":75334.58,"90th_percentile":108434.13,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Fever And Inflammatory Conditions","code_information":[{"code":"864","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":4874.95,"maximum":18261.64,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6499.93,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":13845.46},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16015.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15330.58},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14469.51},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6499.93,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9691.02},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11617.33},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6499.93,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6499.93,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4874.95,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6499.93,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":18261.64},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12137.18},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17709.62},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15685.66},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6499.93,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13371.43},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6629.93,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15246.56}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"1 through 10","median_amount":15056.77,"10th_percentile":15056.77,"90th_percentile":15056.77,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":6976.82,"10th_percentile":6976.82,"90th_percentile":6976.82,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":8074.49,"10th_percentile":8074.49,"90th_percentile":8074.49,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":10414.0,"10th_percentile":10414.0,"90th_percentile":10414.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc","code_information":[{"code":"872","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":5619.62,"maximum":21051.18,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7492.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":15960.41},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18461.36},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17672.39},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16679.79},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7492.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11171.37},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13391.93},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7492.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7492.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5619.62,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7492.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":21051.18},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13991.18},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20414.84},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18081.71},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7492.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15413.97},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7642.68,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17575.54}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":9543.75,"10th_percentile":9543.75,"90th_percentile":9543.75,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"1 through 10","median_amount":13179.67,"10th_percentile":13179.67,"90th_percentile":13179.67,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"1 through 10","median_amount":16080.51,"10th_percentile":15276.48,"90th_percentile":16083.98,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":9363.4,"10th_percentile":9363.4,"90th_percentile":9363.4,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"1 through 10","median_amount":15536.78,"10th_percentile":15536.78,"90th_percentile":15536.78,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"1 through 10","median_amount":11768.69,"10th_percentile":11768.69,"90th_percentile":11768.69},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"1 through 10","median_amount":10885.3,"10th_percentile":10885.3,"90th_percentile":10885.3,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":6215.97,"10th_percentile":6215.97,"90th_percentile":7922.83,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"19","median_amount":8006.87,"10th_percentile":7989.37,"90th_percentile":9531.15,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"19","median_amount":7413.92,"10th_percentile":5376.1,"90th_percentile":9055.04,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"12","median_amount":13267.49,"10th_percentile":10671.43,"90th_percentile":15529.95,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1663.0,"10th_percentile":1663.0,"90th_percentile":1663.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Behavioral And Developmental Disorders","code_information":[{"code":"886","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":11396.84,"maximum":42692.78,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15195.79,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":32368.45},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":37440.49},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":35840.43},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":33827.39},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15195.79,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22656.05},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27159.45},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15195.79,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15195.79,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11396.84,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15195.79,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":42692.78},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28374.77},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":41402.24},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36670.55},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15195.79,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31260.24},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15499.71,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35644.0}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Wound Debridements For Injuries Without Cc/Mcc","code_information":[{"code":"903","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":6423.04,"maximum":24060.85,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8564.06,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":18242.25},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21100.75},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20198.99},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19064.48},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8564.06,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12768.52},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15306.56},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8564.06,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8564.06,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6423.04,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8564.06,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":24060.85},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15991.48},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23333.52},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20666.83},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8564.06,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17617.68},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8735.34,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20088.29}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Traumatic Injury Without Mcc","code_information":[{"code":"914","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":4862.86,"maximum":18216.38,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6483.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":13811.14},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15975.31},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15292.59},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14433.65},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6483.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9667.0},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11588.54},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6483.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6483.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4862.86,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6483.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":18216.38},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12107.1},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17665.73},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15646.79},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6483.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13338.29},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6613.5,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15208.77}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":7121.71,"10th_percentile":7121.71,"90th_percentile":7121.71,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":5661.46,"10th_percentile":5661.46,"90th_percentile":5661.46,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Injury, Poisoning And Toxic Effect Diagnoses With Mcc","code_information":[{"code":"922","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":9607.11,"maximum":35988.41,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12809.48,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":27285.39},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":31560.93},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":30212.14},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28515.22},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12809.48,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19098.2},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22894.4},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12809.48,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12809.48,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9607.11,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12809.48,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":35988.41},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23918.86},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34900.53},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30911.9},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12809.48,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26351.21},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13065.67,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30046.56}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":13126.06,"10th_percentile":13126.06,"90th_percentile":13126.06,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"O.R. Procedures With Diagnoses Of Other Contact With Health Services With Mcc","code_information":[{"code":"939","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":19926.5,"maximum":74644.99,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26568.66,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":56593.71},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":65461.77},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":62664.2},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":59144.55},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26568.66,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":39612.33},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":47486.18},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26568.66,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26568.66,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19926.5,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26568.66,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":74644.99},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":49611.07},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":72388.58},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":64115.6},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26568.66,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":54656.1},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27100.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":62320.76}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Aftercare Without Cc/Mcc","code_information":[{"code":"950","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":3447.11,"maximum":12912.96,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4596.15,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":9790.24},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11324.34},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10840.38},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10231.51},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4596.15,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6852.6},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8214.71},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4596.15,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4596.15,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3447.11,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4596.15,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":12912.96},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8582.3},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12522.62},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11091.46},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4596.15,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9455.05},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4688.07,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10780.97}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Multiple Significant Trauma With Cc","code_information":[{"code":"964","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":8416.52,"maximum":31528.43,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11222.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":23903.96},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27649.64},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26468.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24981.38},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11222.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16731.39},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20057.14},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11222.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11222.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8416.52,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11222.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":31528.43},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20954.64},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30575.37},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27081.04},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11222.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23085.55},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11446.47,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26322.94}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":11416.32,"10th_percentile":11416.32,"90th_percentile":11416.32,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc","code_information":[{"code":"981","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":25765.78,"maximum":96519.05,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":34354.37,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":73178.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":84644.76},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":81027.39},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":76476.34},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":34354.37,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":51220.38},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":61401.59},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":34354.37,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":34354.37,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25765.78,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":34354.37,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":96519.05},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":64149.15},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":93601.41},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":82904.11},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":34354.37,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":70672.58},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":35041.46,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":80583.31}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":36853.36,"10th_percentile":36853.36,"90th_percentile":36853.36,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"1 through 10","median_amount":43059.3,"10th_percentile":43059.3,"90th_percentile":43059.3},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":36861.66,"10th_percentile":36861.66,"90th_percentile":36861.66,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":35322.34,"10th_percentile":35322.34,"90th_percentile":36820.25,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":27560.59,"10th_percentile":27560.59,"90th_percentile":27560.59,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Kidney And Urinary Tract Neoplasms Without Cc/Mcc","code_information":[{"code":"688","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":4340.06,"maximum":16257.94,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5786.75,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":12326.31},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14257.8},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13648.48},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12881.89},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5786.75,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8627.71},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10342.66},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5786.75,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5786.75,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4340.06,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5786.75,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":16257.94},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10805.46},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15766.49},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13964.6},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5786.75,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11904.29},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5902.48,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13573.68}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Kidney And Urinary Tract Diagnoses With Mcc","code_information":[{"code":"698","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":9085.4,"maximum":34034.09,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12113.87,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":25803.68},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":29847.03},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28571.49},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26966.72},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12113.87,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18061.08},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21651.13},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12113.87,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12113.87,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9085.4,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12113.87,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":34034.09},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22619.97},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33005.28},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29233.25},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12113.87,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24920.23},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12356.15,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28414.9}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":12935.4,"10th_percentile":12935.4,"90th_percentile":12935.4,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"1 through 10","median_amount":26217.0,"10th_percentile":26217.0,"90th_percentile":26217.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":10171.55,"10th_percentile":10171.55,"90th_percentile":12960.39,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"19","median_amount":13018.22,"10th_percentile":11375.74,"90th_percentile":15391.51,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"12","median_amount":13018.23,"10th_percentile":11058.22,"90th_percentile":13054.73,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":15362.75,"10th_percentile":15362.75,"90th_percentile":24959.37,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Testes Procedures Without Cc/Mcc","code_information":[{"code":"712","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":6039.18,"maximum":22622.87,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8052.24,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":17152.02},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19839.69},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18991.82},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17925.11},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8052.24,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12005.42},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14391.77},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8052.24,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8052.24,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6039.18,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8052.24,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":22622.87},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15035.77},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21939.02},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19431.7},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8052.24,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16564.78},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8213.28,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18887.73}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Malignancy, Male Reproductive System With Cc","code_information":[{"code":"723","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":6275.32,"maximum":23507.46,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8367.1,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":17822.69},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20615.45},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19734.43},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18626.01},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8367.1,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12474.86},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14954.51},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8367.1,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8367.1,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6275.32,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8367.1,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":23507.46},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15623.69},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22796.87},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20191.51},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8367.1,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17212.49},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8534.44,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19626.27}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy With Cc/Mcc","code_information":[{"code":"734","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":11697.24,"maximum":43818.06,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15596.32,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":33221.61},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":38427.33},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":36785.1},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":34719.0},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15596.32,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23253.21},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27875.31},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15596.32,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15596.32,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11697.24,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15596.32,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":43818.06},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29122.66},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":42493.5},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37637.1},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15596.32,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32084.19},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15908.25,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36583.5}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Uterine And Adnexa Procedures For Non-Malignancy With Cc/Mcc","code_information":[{"code":"742","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":10076.1,"maximum":37745.25,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13434.8,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":28617.38},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":33101.63},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":31687.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":29907.24},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13434.8,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20030.51},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24012.03},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13434.8,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13434.8,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10076.1,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13434.8,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":37745.25},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25086.5},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36604.26},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32420.92},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13434.8,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27637.59},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13703.5,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31513.33}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Female Reproductive System O.R. Procedures Without Cc/Mcc","code_information":[{"code":"750","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":8104.6,"maximum":30359.95,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10806.13,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":23018.05},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26624.91},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25487.07},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24055.54},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10806.13,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16111.31},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19313.79},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10806.13,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10806.13,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8104.6,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10806.13,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":30359.95},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20178.04},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29442.21},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26077.39},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10806.13,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22229.98},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11022.25,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25347.38}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Menstrual And Other Female Reproductive System Disorders Without Cc/Mcc","code_information":[{"code":"761","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":3132.99,"maximum":11736.25,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4177.32,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":8898.09},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10292.39},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":9852.54},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":9299.15},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4177.32,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6228.15},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7466.13},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4177.32,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4177.32,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3132.99,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4177.32,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":11736.25},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7800.22},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11381.48},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10080.74},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4177.32,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8593.44},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4260.87,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9798.54}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cesarean Section With Sterilization Without Cc/Mcc","code_information":[{"code":"785","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":5259.92,"maximum":19703.73,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7013.22,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":14938.81},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17279.67},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16541.21},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15612.14},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7013.22,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10456.3},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12534.73},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7013.22,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7013.22,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5259.92,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7013.22,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":19703.73},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13095.63},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19108.11},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16924.33},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7013.22,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14427.34},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7153.48,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16450.55}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"1 through 10","median_amount":23126.43,"10th_percentile":23126.43,"90th_percentile":23126.43,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"1 through 10","median_amount":13308.0,"10th_percentile":13308.0,"90th_percentile":13308.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"1 through 10","median_amount":20594.37,"10th_percentile":20594.37,"90th_percentile":20594.37},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":11466.2,"10th_percentile":11466.2,"90th_percentile":11466.2,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":12585.34,"10th_percentile":10558.4,"90th_percentile":13198.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":4267.85,"10th_percentile":4267.85,"90th_percentile":4267.85,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Full Term Neonate With Major Problems","code_information":[{"code":"793","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":22898.03,"maximum":85776.43,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":30530.71,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":65033.25},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":75223.75},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":72008.99},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":67964.48},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":30530.71,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":45519.52},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":54567.56},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":30530.71,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":30530.71,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22898.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":30530.71,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":85776.43},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":57009.31},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":83183.52},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":73676.83},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":30530.71,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":62806.68},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":31141.32,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":71614.34}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"1 through 10","median_amount":12235.7,"10th_percentile":12235.7,"90th_percentile":12235.7,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"1 through 10","median_amount":7431.0,"10th_percentile":7431.0,"90th_percentile":7431.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"1 through 10","median_amount":3846.11,"10th_percentile":3846.11,"90th_percentile":3846.11,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":4035.8,"10th_percentile":4035.8,"90th_percentile":4035.8,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":5002.11,"10th_percentile":5002.11,"90th_percentile":5002.11,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"1 through 10","median_amount":10609.0,"10th_percentile":10609.0,"90th_percentile":10609.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":4114.72,"10th_percentile":3367.97,"90th_percentile":6729.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":8014.26,"10th_percentile":8014.26,"90th_percentile":8014.26,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Splenic Procedures Without Cc/Mcc","code_information":[{"code":"801","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":10483.04,"maximum":39269.62,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13977.38,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":29773.11},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":34438.46},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":32966.7},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":31115.07},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13977.38,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20839.46},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24981.77},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13977.38,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13977.38,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10483.04,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13977.38,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":39269.62},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26099.65},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38082.56},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33730.26},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13977.38,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28753.76},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14256.93,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32786.03}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"1 through 10","median_amount":73101.34,"10th_percentile":73101.34,"90th_percentile":73101.34,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","code_information":[{"code":"809","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":6951.89,"maximum":26041.92,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9269.19,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":19744.24},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22838.1},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21862.09},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20634.17},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9269.19,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13819.83},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16566.83},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9269.19,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9269.19,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6951.89,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9269.19,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":26041.92},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17308.16},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25254.71},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22368.45},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9269.19,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19068.25},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9454.57,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21742.28}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":9591.93,"10th_percentile":9591.93,"90th_percentile":9591.93,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":9601.13,"10th_percentile":9601.13,"90th_percentile":9601.13,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":9596.39,"10th_percentile":9596.39,"90th_percentile":9596.39,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":9631.93,"10th_percentile":9631.93,"90th_percentile":9631.93,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Antepartum Diagnoses With O.R. Procedures With Mcc","code_information":[{"code":"817","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":12529.78,"maximum":46936.76,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16706.37,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":35586.12},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":41162.35},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":39403.23},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":37190.08},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16706.37,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24908.23},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29859.3},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16706.37,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16706.37,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12529.78,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16706.37,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":46936.76},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31195.43},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":45517.92},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":40315.87},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16706.37,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34367.74},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17040.5,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":39187.28}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Lymphoma And Non-Acute Leukemia With Other Procedures Without Cc/Mcc","code_information":[{"code":"825","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":7410.45,"maximum":27759.67,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9880.6,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":21046.59},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24344.53},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23304.14},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21995.22},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9880.6,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14731.4},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17659.6},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9880.6,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9880.6,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7410.45,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9880.6,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":27759.67},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18449.82},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26920.53},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23843.9},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9880.6,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20326.01},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10078.21,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23176.42}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":8395.84,"10th_percentile":8395.84,"90th_percentile":8395.84,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":8015.79,"10th_percentile":8015.79,"90th_percentile":8015.79,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Antepartum Diagnoses Without O.R. Procedures Without Cc/Mcc","code_information":[{"code":"833","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":2871.59,"maximum":10757.03,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3828.79,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":8155.67},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":9433.64},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":9030.48},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8523.27},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3828.79,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5708.5},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6843.19},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3828.79,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3828.79,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2871.59,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3828.79,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":10757.03},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7149.41},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10431.86},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9239.64},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3828.79,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7876.44},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3905.37,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8980.99}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":2122.36,"10th_percentile":2122.36,"90th_percentile":2122.36,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"1 through 10","median_amount":7930.5,"10th_percentile":7930.5,"90th_percentile":7930.5,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":2228.48,"10th_percentile":2228.48,"90th_percentile":2228.48,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":2975.42,"10th_percentile":2975.42,"90th_percentile":2975.42,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":2990.03,"10th_percentile":2990.03,"90th_percentile":2990.03,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Lymphoma And Non-Acute Leukemia With Cc","code_information":[{"code":"841","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":8959.1,"maximum":33560.93,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11945.46,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":25444.95},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":29432.09},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28174.28},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26591.82},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11945.46,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17809.99},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21350.13},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11945.46,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11945.46,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8959.1,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11945.46,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":33560.93},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22305.5},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32546.43},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28826.84},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11945.46,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24573.78},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12184.37,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28019.87}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":12074.85,"10th_percentile":12074.85,"90th_percentile":12074.85,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":282.58,"10th_percentile":282.58,"90th_percentile":282.58,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Radiotherapy","code_information":[{"code":"849","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":14879.66,"maximum":55739.45,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19839.54,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":42260.07},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":48882.09},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":46793.07},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":44164.85},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19839.54,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29579.61},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35459.23},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19839.54,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19839.54,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14879.66,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19839.54,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":55739.45},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37045.94},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":54054.53},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":47876.87},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19839.54,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":40813.2},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20236.33,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":46536.61}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Postoperative And Post-Traumatic Infections With Mcc","code_information":[{"code":"862","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":10015.15,"maximum":37516.9,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13353.53,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":28444.25},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":32901.37},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":31495.3},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":29726.31},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13353.53,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19909.33},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23866.76},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13353.53,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13353.53,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10015.15,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13353.53,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":37516.9},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24934.74},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36382.82},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32224.78},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13353.53,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27470.39},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13620.6,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31322.69}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":14252.95,"10th_percentile":14252.95,"90th_percentile":14252.95,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":17091.58,"10th_percentile":17091.58,"90th_percentile":17091.58,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":16695.25,"10th_percentile":16695.25,"90th_percentile":16695.25,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":8328.17,"10th_percentile":8328.17,"90th_percentile":8328.17,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Septicemia Or Severe Sepsis With Mv >96 Hours","code_information":[{"code":"870","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":37957.27,"maximum":142188.58,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":50609.69,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":107803.34},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":124695.78},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":119366.79},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":112662.34},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":50609.69,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":75456.12},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":90454.73},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":50609.69,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":50609.69,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":37957.27,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":50609.69,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":142188.58},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":94502.35},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":137890.41},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":122131.51},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":50609.69,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":104112.44},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":51621.88,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":118712.58}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"1 through 10","median_amount":164923.34,"10th_percentile":164923.34,"90th_percentile":164923.34,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":54566.72,"10th_percentile":54566.72,"90th_percentile":54566.72,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":95113.51,"10th_percentile":95113.51,"90th_percentile":95113.51,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":64303.13,"10th_percentile":64303.13,"90th_percentile":64303.13,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Organic Disturbances And Intellectual Disability","code_information":[{"code":"884","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":8835.53,"maximum":33098.07,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11780.71,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":25094.01},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":29026.16},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27785.7},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26225.07},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11780.71,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17564.36},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21055.67},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11780.71,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11780.71,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8835.53,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11780.71,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":33098.07},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21997.86},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32097.56},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28429.26},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11780.71,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24234.86},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12016.32,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27633.42}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"1 through 10","median_amount":13135.36,"10th_percentile":13135.36,"90th_percentile":13135.36,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":27793.4,"10th_percentile":27793.4,"90th_percentile":27793.4,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":6334.05,"10th_percentile":6334.05,"90th_percentile":6334.05,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":11191.16,"10th_percentile":11191.16,"90th_percentile":11191.16,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":12583.51,"10th_percentile":11343.23,"90th_percentile":13351.22,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":11199.35,"10th_percentile":11199.35,"90th_percentile":11199.35,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":13199.35,"10th_percentile":13199.35,"90th_percentile":13199.35,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Wound Debridements For Injuries With Mcc","code_information":[{"code":"901","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":23046.31,"maximum":86331.87,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":30728.41,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":65454.37},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":75710.86},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":72475.28},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":68404.58},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":30728.41,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":45814.28},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":54920.9},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":30728.41,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":30728.41,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23046.31,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":30728.41,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":86331.87},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":57378.48},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":83722.17},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":74153.92},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":30728.41,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":63213.39},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":31342.98,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":72078.07}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other O.R. Procedures For Injuries Without Cc/Mcc","code_information":[{"code":"909","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":7208.9,"maximum":27004.68,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9611.87,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":20474.18},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23682.42},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22670.33},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21397.01},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9611.87,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14330.75},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17179.3},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9611.87,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9611.87,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7208.9,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9611.87,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":27004.68},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17948.04},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26188.37},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23195.41},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9611.87,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19773.2},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9804.11,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22546.08}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":11901.46,"10th_percentile":11901.46,"90th_percentile":11901.46,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Complications Of Treatment With Cc","code_information":[{"code":"920","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":5504.3,"maximum":20619.18,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7339.06,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":15632.87},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18082.49},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17309.72},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16337.49},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7339.06,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10942.11},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13117.1},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7339.06,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7339.06,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5504.3,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7339.06,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":20619.18},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13704.06},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19995.89},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17710.64},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7339.06,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15097.64},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7485.84,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17214.85}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":6043.08,"10th_percentile":6043.08,"90th_percentile":6043.08,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":7709.23,"10th_percentile":7709.23,"90th_percentile":7709.23,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"1 through 10","median_amount":10572.2,"10th_percentile":10572.2,"90th_percentile":10572.2,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":215.11,"10th_percentile":215.11,"90th_percentile":215.11,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":15302.5,"10th_percentile":15302.5,"90th_percentile":15302.5,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Full Thickness Burn Without Skin Graft Or Inhalation Injury","code_information":[{"code":"934","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":12139.87,"maximum":45476.15,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16186.49,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":34478.73},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":39881.43},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":38177.06},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":36032.78},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16186.49,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24133.12},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28930.12},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16186.49,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16186.49,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12139.87,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16186.49,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":45476.15},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30224.67},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":44101.47},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":39061.3},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16186.49,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33298.27},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16510.22,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37967.83}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Signs And Symptoms Without Mcc","code_information":[{"code":"948","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":4396.07,"maximum":16467.77,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5861.43,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":12485.4},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14441.82},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13824.64},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13048.15},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5861.43,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8739.06},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10476.14},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5861.43,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5861.43,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4396.07,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5861.43,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":16467.77},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10944.92},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15969.98},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14144.84},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5861.43,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12057.93},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5978.66,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13748.87}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":4955.22,"10th_percentile":4577.49,"90th_percentile":7335.11,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"1 through 10","median_amount":12391.82,"10th_percentile":12391.82,"90th_percentile":12391.82,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":6051.94,"10th_percentile":6051.94,"90th_percentile":6105.63,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"1 through 10","median_amount":6821.66,"10th_percentile":6821.66,"90th_percentile":6821.66,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":410.07,"10th_percentile":407.87,"90th_percentile":4283.98,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":11849.17,"10th_percentile":11849.17,"90th_percentile":11849.17,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":4790.48,"10th_percentile":4790.48,"90th_percentile":4790.48,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other O.R. Procedures For Multiple Significant Trauma Without Cc/Mcc","code_information":[{"code":"959","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":16168.0,"maximum":60565.61,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21557.34,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":45919.13},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":53114.51},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":50844.61},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":47988.83},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21557.34,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32140.74},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38529.44},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21557.34,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21557.34,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16168.0,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21557.34,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":60565.61},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":40253.53},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":58734.8},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":52022.25},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21557.34,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":44346.98},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21988.49,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":50565.95}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Hiv With Major Related Condition Without Cc/Mcc","code_information":[{"code":"976","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":4957.32,"maximum":18570.22,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6609.76,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":14079.41},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16285.61},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15589.63},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14714.01},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6609.76,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9854.78},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11813.63},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6609.76,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6609.76,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4957.32,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6609.76,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":18570.22},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12342.27},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18008.87},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15950.71},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6609.76,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13597.37},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6741.96,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15504.19}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Liver Transplant Without Mcc","code_information":[{"code":"006","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":25464.83,"maximum":95391.71,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":33953.11,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":72323.29},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":83656.12},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":80080.99},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":75583.1},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":33953.11,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":50622.13},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":60684.42},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":33953.11,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":33953.11,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25464.83,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":33953.11,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":95391.71},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":63399.89},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":92508.15},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":81935.79},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":33953.11,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":69847.13},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":34632.17,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":79642.1}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Autologous Bone Marrow Transplant With Cc/Mcc","code_information":[{"code":"016","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":32563.9,"maximum":121984.96,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":43418.54,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":92485.53},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":106977.72},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":102405.92},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":96654.11},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":43418.54,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":64734.53},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":77601.98},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":43418.54,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":43418.54,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":32563.9,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":43418.54,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":121984.96},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":81074.48},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":118297.52},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":104777.8},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":43418.54,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":89319.07},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":44286.91,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":101844.67}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis Without Mcc","code_information":[{"code":"024","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":21482.84,"maximum":80475.06,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":28643.78,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":61013.9},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":70574.59},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":67558.51},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":63763.97},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":28643.78,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":42706.21},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":51195.04},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":28643.78,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":28643.78,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21482.84,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":28643.78,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":80475.06},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":53485.88},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":78042.41},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":69123.27},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":28643.78,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":58924.95},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":29216.66,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":67188.25}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Ventricular Shunt Procedures With Cc","code_information":[{"code":"032","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":11702.73,"maximum":43838.63,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15603.64,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":33237.21},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":38445.37},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":36802.37},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":34735.3},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15603.64,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23264.13},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27888.4},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15603.64,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15603.64,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11702.73,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15603.64,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":43838.63},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29136.33},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":42513.45},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37654.77},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15603.64,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32099.25},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15915.71,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36600.67}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":16551.57,"10th_percentile":16551.57,"90th_percentile":16551.57,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Peripheral, Cranial Nerve And Other Nervous System Procedures With Mcc","code_information":[{"code":"040","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":21204.4,"maximum":79432.07,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":28272.54,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":60223.14},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":69659.91},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":66682.92},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":62937.56},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":28272.54,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":42152.72},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":50531.52},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":28272.54,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":28272.54,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21204.4,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":28272.54,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":79432.07},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":52792.68},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":77030.94},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":68227.4},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":28272.54,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":58161.26},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":28837.99,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":66317.46}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Degenerative Nervous System Disorders Without Mcc","code_information":[{"code":"057","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":7115.0,"maximum":26652.9,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9486.66,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":20207.47},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23373.92},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22375.01},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21118.28},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9486.66,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14144.07},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16955.52},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9486.66,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9486.66,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7115.0,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9486.66,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":26652.9},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17714.23},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25847.22},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22893.25},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9486.66,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19515.62},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9676.39,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22252.38}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":6685.24,"10th_percentile":6685.24,"90th_percentile":6685.24,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":20883.67,"10th_percentile":20883.67,"90th_percentile":36098.46,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":10369.04,"10th_percentile":10205.52,"90th_percentile":19896.62,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":6685.24,"10th_percentile":6685.24,"90th_percentile":6685.24,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"16","median_amount":16349.87,"10th_percentile":10356.65,"90th_percentile":35744.67,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"14","median_amount":9455.66,"10th_percentile":343.76,"90th_percentile":36098.06,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":81090.0,"10th_percentile":81090.0,"90th_percentile":81090.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":8963.55,"10th_percentile":8963.55,"90th_percentile":8963.55,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours","code_information":[{"code":"065","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":5548.22,"maximum":20783.75,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7397.63,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":15757.65},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18226.82},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17447.88},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16467.89},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7397.63,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11029.45},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13221.8},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7397.63,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7397.63,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5548.22,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7397.63,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":20783.75},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13813.44},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20155.49},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17852.0},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7397.63,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15218.15},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7545.58,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17352.26}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":7408.36,"10th_percentile":7408.36,"90th_percentile":7408.36,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":7881.57,"10th_percentile":7799.81,"90th_percentile":7899.27,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":7892.16,"10th_percentile":7892.16,"90th_percentile":7892.16,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":7408.36,"10th_percentile":7408.36,"90th_percentile":7408.36,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"17","median_amount":7882.67,"10th_percentile":7408.36,"90th_percentile":8860.21,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":7753.18,"10th_percentile":5477.38,"90th_percentile":8046.01,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":15166.05,"10th_percentile":15166.05,"90th_percentile":15166.05,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":952.97,"10th_percentile":952.97,"90th_percentile":6455.39,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cranial And Peripheral Nerve Disorders With Mcc","code_information":[{"code":"073","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":8810.27,"maximum":33003.43,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11747.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":25022.27},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28943.18},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27706.26},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26150.09},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11747.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17514.14},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20995.47},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11747.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11747.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8810.27,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11747.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":33003.43},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21934.97},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32005.79},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28347.98},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11747.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24165.57},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11981.97,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27554.41}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Traumatic Stupor And Coma >1 Hour Without Cc/Mcc","code_information":[{"code":"084","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":5248.93,"maximum":19662.58,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6998.57,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":14907.61},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17243.59},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16506.67},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15579.54},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6998.57,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10434.47},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12508.55},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6998.57,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6998.57,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5248.93,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6998.57,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":19662.58},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13068.28},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19068.21},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16888.99},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6998.57,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14397.22},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7138.54,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16416.2}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Disorders Of Nervous System With Cc","code_information":[{"code":"092","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":5617.97,"maximum":21045.01,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7490.63,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":15955.73},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18455.94},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17667.21},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16674.9},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7490.63,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11168.09},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13388.0},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7490.63,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7490.63,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5617.97,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7490.63,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":21045.01},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13987.08},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20408.85},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18076.41},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7490.63,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15409.45},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7640.44,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17570.38}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":8149.13,"10th_percentile":8149.13,"90th_percentile":8149.13,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":1093.12,"10th_percentile":1093.12,"90th_percentile":1093.12,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":7635.27,"10th_percentile":7635.27,"90th_percentile":7635.27,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":63.69,"10th_percentile":63.69,"90th_percentile":63.69,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":6239.41,"10th_percentile":157.58,"90th_percentile":8213.42,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Seizures With Mcc","code_information":[{"code":"100","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":10636.25,"maximum":39843.58,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14181.67,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":30208.27},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":34941.81},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":33448.54},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":31569.84},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14181.67,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21144.05},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25346.9},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14181.67,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14181.67,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10636.25,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14181.67,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":39843.58},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26481.11},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38639.16},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34223.26},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14181.67,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29174.02},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14465.3,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33265.22}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":13677.78,"10th_percentile":13677.78,"90th_percentile":13677.78,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":15408.75,"10th_percentile":14462.13,"90th_percentile":15413.55,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":13601.11,"10th_percentile":13601.11,"90th_percentile":15408.25,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Intraocular Procedures Without Cc/Mcc","code_information":[{"code":"117","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":5957.9,"maximum":22318.41,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7943.87,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":16921.19},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19572.68},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18736.22},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17683.87},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7943.87,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11843.85},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14198.09},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7943.87,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7943.87,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5957.9,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7943.87,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":22318.41},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14833.41},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21643.76},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19170.18},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7943.87,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16341.85},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8102.75,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18633.54}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Mouth Procedures With Cc/Mcc","code_information":[{"code":"137","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":8200.15,"maximum":30717.9,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10933.53,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":23289.44},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26938.82},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25787.56},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24339.16},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10933.53,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16301.26},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19541.51},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10933.53,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10933.53,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8200.15,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10933.53,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":30717.9},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20415.94},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29789.34},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26384.84},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10933.53,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22492.07},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11152.2,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25646.23}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Ear, Nose, Mouth And Throat O.R. Procedures Without Cc/Mcc","code_information":[{"code":"145","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":6602.62,"maximum":24733.55,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8803.5,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":18752.27},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21690.69},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20763.72},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19597.49},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8803.5,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13125.51},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15734.5},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8803.5,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8803.5,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6602.62,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8803.5,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":24733.55},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16438.58},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23985.89},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21244.64},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8803.5,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18110.24},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8979.57,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20649.92}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Otitis Media And Uri Without Mcc","code_information":[{"code":"153","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":4053.94,"maximum":15186.15,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5405.26,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":11513.71},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13317.87},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12748.71},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12032.66},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5405.26,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8058.93},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9660.82},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5405.26,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5405.26,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4053.94,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5405.26,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15186.15},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10093.12},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14727.09},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13043.99},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5405.26,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11119.51},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5513.37,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12678.84}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"1 through 10","median_amount":17851.29,"10th_percentile":17851.29,"90th_percentile":17851.29,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":5622.01,"10th_percentile":5622.01,"90th_percentile":5622.01,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":5641.11,"10th_percentile":5641.11,"90th_percentile":5648.41,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Major Chest Procedures With Cc","code_information":[{"code":"164","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":13860.95,"maximum":51923.37,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18481.27,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":39366.83},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":45535.48},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43589.48},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":41141.2},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18481.27,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27554.51},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33031.59},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18481.27,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18481.27,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13860.95,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18481.27,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":51923.37},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34509.67},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":50353.8},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":44599.08},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18481.27,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38019.01},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18850.9,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":43350.58}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":18915.45,"10th_percentile":18915.45,"90th_percentile":18915.45,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"1 through 10","median_amount":39257.65,"10th_percentile":39257.65,"90th_percentile":39257.65,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":20053.19,"10th_percentile":20053.19,"90th_percentile":20053.19,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":19520.85,"10th_percentile":19515.65,"90th_percentile":23481.74,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"1 through 10","median_amount":50210.16,"10th_percentile":50210.16,"90th_percentile":50210.16,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":19530.16,"10th_percentile":19530.16,"90th_percentile":19530.16,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Respiratory Infections And Inflammations With Mcc","code_information":[{"code":"177","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":8581.82,"maximum":32147.65,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11442.43,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":24373.43},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28192.67},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26987.83},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25472.01},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11442.43,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17060.0},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20451.05},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11442.43,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11442.43,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8581.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11442.43,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":32147.65},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21366.19},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31175.87},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27612.91},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11442.43,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23538.95},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11671.28,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26839.92}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":10839.37,"10th_percentile":10839.37,"90th_percentile":10843.33,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"1 through 10","median_amount":20776.0,"10th_percentile":20776.0,"90th_percentile":20776.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":8058.96,"10th_percentile":8058.96,"90th_percentile":8058.96,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":8147.24,"10th_percentile":8147.24,"90th_percentile":8147.24,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":12535.96,"10th_percentile":12535.96,"90th_percentile":12535.96,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":10876.98,"10th_percentile":10876.98,"90th_percentile":10876.98,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"22","median_amount":12529.96,"10th_percentile":11233.93,"90th_percentile":14202.46,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":21490.58,"10th_percentile":21490.58,"90th_percentile":21490.58,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"13","median_amount":11966.38,"10th_percentile":10559.46,"90th_percentile":12559.46,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":24349.34,"10th_percentile":24349.34,"90th_percentile":24349.34,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Major Chest Trauma Without Cc/Mcc","code_information":[{"code":"185","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":4319.19,"maximum":16179.77,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5758.92,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":12267.04},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14189.25},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13582.86},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12819.95},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5758.92,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8586.22},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10292.93},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5758.92,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5758.92,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4319.19,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5758.92,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":16179.77},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10753.51},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15690.68},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13897.46},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5758.92,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11847.05},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5874.1,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13508.41}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Simple Pneumonia And Pleurisy With Mcc","code_information":[{"code":"193","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":7218.24,"maximum":27039.65,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9624.32,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":20500.7},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23713.09},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22699.69},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21424.72},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9624.32,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14349.3},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17201.55},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9624.32,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9624.32,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7218.24,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9624.32,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":27039.65},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17971.28},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26222.28},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23225.45},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9624.32,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19798.81},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9816.81,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22575.28}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":6766.96,"10th_percentile":6766.96,"90th_percentile":6766.96,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":10227.51,"10th_percentile":8616.31,"90th_percentile":12228.37,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"1 through 10","median_amount":18552.17,"10th_percentile":18552.17,"90th_percentile":18552.17,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"1 through 10","median_amount":11735.1,"10th_percentile":11735.1,"90th_percentile":11735.1},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":8490.31,"10th_percentile":8490.31,"90th_percentile":8490.31,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":9063.73,"10th_percentile":4251.72,"90th_percentile":10224.6,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"26","median_amount":10210.81,"10th_percentile":8588.31,"90th_percentile":11713.87,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"24","median_amount":9887.38,"10th_percentile":6421.02,"90th_percentile":10268.37,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":11543.56,"10th_percentile":11069.05,"90th_percentile":30888.18,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":6766.96,"10th_percentile":6364.49,"90th_percentile":6766.96,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":10409.41,"10th_percentile":8896.58,"90th_percentile":10895.14,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Pneumothorax Without Cc/Mcc","code_information":[{"code":"201","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":3927.09,"maximum":14710.94,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5236.12,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":11153.41},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12901.12},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12349.78},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11656.13},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5236.12,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7806.75},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9358.51},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5236.12,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5236.12,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3927.09,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5236.12,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":14710.94},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9777.28},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14266.25},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12635.82},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5236.12,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10771.55},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5340.84,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12282.09}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"1 through 10","median_amount":10902.26,"10th_percentile":10902.26,"90th_percentile":10902.26,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":10098.27,"10th_percentile":10098.27,"90th_percentile":10098.27,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Complex Aortic Arch Procedures","code_information":[{"code":"209","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":62159.02,"maximum":232848.77,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":82878.7,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":176539.32},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":204202.47},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":195475.68},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":184496.44},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":82878.7,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":123567.34},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":148129.14},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":82878.7,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":82878.7,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":62159.02,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":82878.7,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":232848.77},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":154757.54},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":225810.06},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":200003.2},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":82878.7,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":170495.08},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":84536.27,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":194404.35}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Cc","code_information":[{"code":"220","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":29285.93,"maximum":109705.62,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":39047.91,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":83175.68},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":96209.04},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":92097.46},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":86924.64},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":39047.91,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":58218.18},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":69790.35},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":39047.91,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":39047.91,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":29285.93,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":39047.91,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":109705.62},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":72913.29},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":106389.36},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":94230.58},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":39047.91,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":80327.97},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":39828.87,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":91592.71}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":50625.6,"10th_percentile":50625.6,"90th_percentile":50625.6,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"1 through 10","median_amount":73402.67,"10th_percentile":73402.67,"90th_percentile":73402.67,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"1 through 10","median_amount":82612.63,"10th_percentile":82612.63,"90th_percentile":82612.63,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"1 through 10","median_amount":115363.96,"10th_percentile":115363.96,"90th_percentile":115363.96,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":40801.61,"10th_percentile":40801.61,"90th_percentile":41057.24,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":41054.85,"10th_percentile":41043.85,"90th_percentile":50481.4,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":41058.35,"10th_percentile":41058.35,"90th_percentile":41058.35,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":79784.19,"10th_percentile":79784.19,"90th_percentile":79784.19,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Coronary Bypass Without Cardiac Catheterization With Mcc","code_information":[{"code":"235","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":32228.37,"maximum":120728.02,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":42971.16,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":91532.55},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":105875.41},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":101350.72},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":95658.18},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":42971.16,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":64067.51},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":76802.37},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":42971.16,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":42971.16,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":32228.37,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":42971.16,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":120728.02},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":80239.08},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":117078.57},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":103698.16},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":42971.16,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":88398.72},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":43830.58,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":100795.26}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"1 through 10","median_amount":128109.29,"10th_percentile":128109.29,"90th_percentile":128109.29,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":53111.68,"10th_percentile":53111.68,"90th_percentile":53111.68,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Aicd Generator Procedures","code_information":[{"code":"245","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":25055.16,"maximum":93857.05,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":33406.88,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":71159.75},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":82310.26},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":78792.65},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":74367.12},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":33406.88,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":49807.72},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":59708.13},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":33406.88,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":33406.88,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25055.16,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":33406.88,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":93857.05},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":62379.92},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":91019.88},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":80617.61},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":33406.88,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":68723.43},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":34075.02,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":78360.82}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Upper Limb And Toe Amputation For Circulatory System Disorders Without Cc/Mcc","code_information":[{"code":"257","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":5997.99,"maximum":22468.59,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7997.32,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":17035.04},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19704.38},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18862.29},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17802.86},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7997.32,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11923.55},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14293.62},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7997.32,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7997.32,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5997.99,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7997.32,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":22468.59},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14933.22},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21789.39},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19299.17},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7997.32,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16451.81},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8157.27,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18758.92}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Aicd Lead Procedures","code_information":[{"code":"265","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":19869.93,"maximum":74433.1,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26493.24,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":56433.07},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":65275.95},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":62486.31},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":58976.66},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26493.24,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":39499.89},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":47351.38},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26493.24,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26493.24,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19869.93,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26493.24,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":74433.1},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":49470.24},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":72183.09},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":63933.59},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26493.24,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":54500.95},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27023.1,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":62143.85}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Percutaneous And Other Intracardiac Procedures With Mcc","code_information":[{"code":"273","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":22655.85,"maximum":84869.21,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":30207.8,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":64345.42},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":74428.15},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":71247.39},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":67245.65},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":30207.8,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":45038.08},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":53990.42},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":30207.8,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":30207.8,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22655.85,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":30207.8,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":84869.21},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":56406.35},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":82303.73},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":72897.59},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":30207.8,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":62142.41},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":30811.96,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":70856.91}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":34920.68,"10th_percentile":34920.68,"90th_percentile":34920.68,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":30098.74,"10th_percentile":30098.74,"90th_percentile":30098.74,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":37523.62,"10th_percentile":30291.26,"90th_percentile":41205.07,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":30300.26,"10th_percentile":30300.26,"90th_percentile":30300.26,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Acute Myocardial Infarction, Discharged Alive With Cc","code_information":[{"code":"281","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":5047.39,"maximum":18907.6,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6729.85,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":14335.2},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16581.48},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15872.86},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14981.33},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6729.85,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10033.81},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12028.26},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6729.85,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6729.85,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5047.39,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6729.85,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":18907.6},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12566.5},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18336.05},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16240.5},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6729.85,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13844.4},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6864.45,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15785.86}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":7402.35,"10th_percentile":7402.35,"90th_percentile":7402.35,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"1 through 10","median_amount":14377.31,"10th_percentile":14377.31,"90th_percentile":14377.31,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":7155.64,"10th_percentile":7155.64,"90th_percentile":7155.64,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":7139.14,"10th_percentile":6850.04,"90th_percentile":8550.74,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":7141.65,"10th_percentile":6789.75,"90th_percentile":7174.15,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":13747.73,"10th_percentile":13747.73,"90th_percentile":13747.73,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Acute And Subacute Endocarditis With Cc","code_information":[{"code":"289","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":9373.72,"maximum":35114.11,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12498.29,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":26622.52},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":30794.18},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":29478.16},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27822.47},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12498.29,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18634.23},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22338.2},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12498.29,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12498.29,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9373.72,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12498.29,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":35114.11},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23337.78},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34052.66},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30160.92},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12498.29,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25711.03},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12748.26,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29316.6}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Peripheral Vascular Disorders With Mcc","code_information":[{"code":"299","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":8966.24,"maximum":33587.68,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11954.98,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":25465.22},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":29455.54},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28196.73},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26613.01},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11954.98,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17824.19},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21367.14},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11954.98,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11954.98,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8966.24,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11954.98,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":33587.68},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22323.27},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32572.37},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28849.81},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11954.98,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24593.36},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12194.08,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28042.19}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":12527.98,"10th_percentile":12527.98,"90th_percentile":12527.98,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":14547.58,"10th_percentile":14547.58,"90th_percentile":14547.58,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":13296.22,"10th_percentile":13296.22,"90th_percentile":13296.22,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cardiac Congenital And Valvular Disorders Without Mcc","code_information":[{"code":"307","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":5014.99,"maximum":18786.22,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6686.65,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":14243.18},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16475.04},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15770.96},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14885.16},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6686.65,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9969.4},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11951.05},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6686.65,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6686.65,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5014.99,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6686.65,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":18786.22},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12485.83},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18218.34},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16136.24},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6686.65,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13755.53},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6820.38,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15684.53}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Circulatory System Diagnoses With Cc","code_information":[{"code":"315","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":5290.12,"maximum":19816.87,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7053.49,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":15024.59},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17378.9},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16636.19},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15701.79},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7053.49,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10516.35},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12606.71},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7053.49,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7053.49,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5290.12,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7053.49,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":19816.87},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13170.83},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19217.84},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17021.51},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7053.49,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14510.19},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7194.56,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16545.01}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"1 through 10","median_amount":15008.99,"10th_percentile":15008.99,"90th_percentile":15008.99,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":7407.11,"10th_percentile":7407.11,"90th_percentile":7407.11,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":7496.91,"10th_percentile":7496.91,"90th_percentile":16678.41,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":5492.81,"10th_percentile":5492.81,"90th_percentile":5492.81,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":5942.5,"10th_percentile":5942.5,"90th_percentile":5942.5,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Coronary Intravascular Lithotripsy With Intraluminal Device With Mcc","code_information":[{"code":"323","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":23764.62,"maximum":89022.67,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":31686.16,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":67494.46},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":78070.62},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":74734.2},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":70536.62},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":31686.16,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":47242.23},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":56632.68},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":31686.16,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":31686.16,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23764.62,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":31686.16,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":89022.67},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":59166.85},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":86331.63},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":76465.16},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":31686.16,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":65183.63},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":32319.88,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":74324.61}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":32988.18,"10th_percentile":32988.18,"90th_percentile":32988.18,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":33020.63,"10th_percentile":33020.63,"90th_percentile":33020.63,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":33041.59,"10th_percentile":33041.59,"90th_percentile":33041.59,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Major Small And Large Bowel Procedures Without Cc/Mcc","code_information":[{"code":"331","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":9241.92,"maximum":34620.38,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12322.56,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":26248.19},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":30361.2},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":29063.68},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27431.27},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12322.56,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18372.22},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22024.11},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12322.56,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12322.56,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9241.92,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12322.56,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":34620.38},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23009.64},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33573.86},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29736.84},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12322.56,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25349.52},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12569.01,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28904.4}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":14995.31,"10th_percentile":14995.31,"90th_percentile":14995.31,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":12794.56,"10th_percentile":12794.56,"90th_percentile":12794.56,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":11753.66,"10th_percentile":11753.66,"90th_percentile":11753.66,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":9848.89,"10th_percentile":9848.89,"90th_percentile":9848.89,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Minor Small And Large Bowel Procedures With Cc","code_information":[{"code":"345","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":8263.3,"maximum":30954.48,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11017.74,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":23468.81},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27146.29},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25986.17},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24526.61},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11017.74,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16426.81},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19692.01},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11017.74,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11017.74,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8263.3,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11017.74,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":30954.48},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20573.18},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30018.77},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26588.05},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11017.74,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22665.3},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11238.09,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25843.75}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"1 through 10","median_amount":16528.07,"10th_percentile":16528.07,"90th_percentile":16528.07,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":11529.68,"10th_percentile":11529.68,"90th_percentile":11529.68,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Hernia Procedures Except Inguinal And Femoral With Mcc","code_information":[{"code":"353","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":15936.8,"maximum":59699.54,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21249.07,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":45262.49},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":52354.98},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":50117.54},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":47302.6},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21249.07,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31681.13},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37978.47},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21249.07,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21249.07,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15936.8,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21249.07,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":59699.54},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":39677.91},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":57894.9},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":51278.34},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21249.07,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":43712.83},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21674.05,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":49842.87}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Major Esophageal Disorders With Mcc","code_information":[{"code":"368","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":8742.18,"maximum":32748.34,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11656.24,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":24828.86},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28719.47},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27492.11},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25947.97},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11656.24,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17378.77},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20833.2},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11656.24,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11656.24,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8742.18,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11656.24,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":32748.34},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21765.43},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31758.41},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28128.87},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11656.24,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23978.79},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11889.36,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27341.44}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":12956.32,"10th_percentile":12956.32,"90th_percentile":12956.32,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":13192.5,"10th_percentile":13192.5,"90th_percentile":13192.5,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Digestive Malignancy Without Cc/Mcc","code_information":[{"code":"376","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":5075.94,"maximum":19014.57,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6767.92,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":14416.31},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16675.3},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15962.66},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15066.09},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6767.92,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10090.58},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12096.31},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6767.92,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6767.92,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5075.94,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6767.92,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":19014.57},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12637.59},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18439.79},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16332.38},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6767.92,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13922.73},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6903.28,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15875.18}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Uncomplicated Peptic Ulcer Without Mcc","code_information":[{"code":"384","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":4694.27,"maximum":17584.83,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6259.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":13332.32},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15421.45},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14762.4},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13933.24},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6259.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9331.85},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11186.77},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6259.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6259.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4694.27,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6259.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17584.83},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11687.35},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17053.26},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15104.32},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6259.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12875.85},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6384.21,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14681.49}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without Mcc","code_information":[{"code":"392","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":4281.3,"maximum":16037.82,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5708.4,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":12159.42},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14064.76},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13463.69},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12707.48},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5708.4,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8510.89},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10202.63},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5708.4,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5708.4,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4281.3,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5708.4,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":16037.82},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10659.17},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15553.02},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13775.53},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5708.4,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11743.11},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5822.57,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13389.9}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"1 through 10","median_amount":12170.34,"10th_percentile":12170.34,"90th_percentile":12170.34,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":5978.54,"10th_percentile":5978.54,"90th_percentile":5978.54,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":6043.26,"10th_percentile":6043.26,"90th_percentile":6050.25,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":6698.26,"10th_percentile":6698.26,"90th_percentile":6698.26,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":6115.23,"10th_percentile":6115.23,"90th_percentile":6115.23,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":8696.72,"10th_percentile":8696.72,"90th_percentile":8696.72,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"11","median_amount":6124.58,"10th_percentile":6084.47,"90th_percentile":7258.42,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":10668.74,"10th_percentile":10668.74,"90th_percentile":10668.74,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":5370.45,"10th_percentile":280.07,"90th_percentile":6085.85,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":11637.39,"10th_percentile":9351.61,"90th_percentile":13456.13,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":8127.87,"10th_percentile":8127.87,"90th_percentile":8127.87,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":4662.84,"10th_percentile":4662.84,"90th_percentile":4662.84,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Pancreas, Liver And Shunt Procedures With Mcc","code_information":[{"code":"405","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":30042.14,"maximum":112538.36,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":40056.18,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":85323.39},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":98693.29},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":94475.54},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":89169.15},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":40056.18,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":59721.45},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":71592.43},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":40056.18,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":40056.18,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":30042.14,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":40056.18,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":112538.36},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":74796.01},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":109136.48},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":96663.74},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":40056.18,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":82402.14},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":40857.3,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":93957.75}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cholecystectomy With C.D.E. Without Cc/Mcc","code_information":[{"code":"413","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":9118.9,"maximum":34159.57,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12158.54,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":25898.82},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":29957.08},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28676.84},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27066.15},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12158.54,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18127.68},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21730.96},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12158.54,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12158.54,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9118.9,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12158.54,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":34159.57},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22703.37},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33126.98},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29341.04},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12158.54,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25012.11},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12401.71,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28519.67}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Hepatobiliary Diagnostic Procedures With Cc","code_information":[{"code":"421","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":9541.76,"maximum":35743.61,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12722.35,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":27099.79},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":31346.24},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":30006.63},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28321.25},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12722.35,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18968.29},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22738.66},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12722.35,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12722.35,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9541.76,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12722.35,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":35743.61},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23756.16},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34663.13},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30701.63},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12722.35,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26171.96},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12976.8,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29842.17}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":15008.23,"10th_percentile":15008.23,"90th_percentile":15008.23,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Combined Anterior And Posterior Cervical Spinal Fusion With Mcc","code_information":[{"code":"429","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":49477.68,"maximum":185344.23,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":65970.24,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":140522.73},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":162542.19},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":155595.79},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":146856.48},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":65970.24,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":98357.8},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":117908.64},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":65970.24,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":65970.24,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":49477.68,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":65970.24,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":185344.23},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":123184.75},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":179741.52},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":159199.63},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":65970.24,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":135711.6},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":67289.64,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":154743.03}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Disorders Of Pancreas Except Malignancy With Mcc","code_information":[{"code":"438","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":8952.51,"maximum":33536.25,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11936.68,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":25426.23},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":29410.44},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28153.55},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26572.26},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11936.68,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17796.89},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21334.43},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11936.68,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11936.68,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8952.51,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11936.68,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":33536.25},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22289.09},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32522.49},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28805.63},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11936.68,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24555.7},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12175.41,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27999.26}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":5190.56,"10th_percentile":5190.56,"90th_percentile":5190.56,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":12994.91,"10th_percentile":12994.91,"90th_percentile":12994.91,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":12885.01,"10th_percentile":12885.01,"90th_percentile":12885.01,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":12837.3,"10th_percentile":12837.3,"90th_percentile":12837.3,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Disorders Of The Biliary Tract Without Cc/Mcc","code_information":[{"code":"446","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":4543.25,"maximum":17019.1,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6057.67,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":12903.4},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14925.32},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14287.47},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13484.99},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6057.67,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9031.63},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10826.88},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6057.67,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6057.67,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4543.25,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6057.67,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17019.1},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11311.35},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16504.64},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14618.39},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6057.67,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12461.62},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6178.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14209.17}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":6245.18,"10th_percentile":6245.18,"90th_percentile":6245.18,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"1 through 10","median_amount":14309.09,"10th_percentile":14309.09,"90th_percentile":14309.09,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":8920.25,"10th_percentile":8920.25,"90th_percentile":8920.25,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Bilateral Or Multiple Major Joint Procedures Of Lower Extremity With Mcc","code_information":[{"code":"461","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":30330.45,"maximum":113618.38,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":40440.6,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":86142.23},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":99640.44},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":95382.21},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":90024.9},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":40440.6,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":60294.59},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":72279.5},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":40440.6,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":40440.6,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":30330.45,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":40440.6,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":113618.38},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":75513.83},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":110183.85},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":97591.41},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":40440.6,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":83192.95},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":41249.41,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":94859.46}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With Mcc Or Total Ankle Repl","code_information":[{"code":"469","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":16657.31,"maximum":62398.57,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22209.75,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":47308.82},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":54721.96},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":52383.36},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":49441.16},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22209.75,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33113.44},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":39695.49},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22209.75,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22209.75,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16657.31,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22209.75,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":62398.57},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":41471.76},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":60512.34},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":53596.64},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22209.75,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":45689.09},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22653.94,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":52096.27}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":25315.4,"10th_percentile":25315.4,"90th_percentile":25315.4,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Biopsies Of Musculoskeletal System And Connective Tissue With Mcc Or Insertion Of Antibiotic-Eluting","code_information":[{"code":"477","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":18971.5,"maximum":71067.55,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25295.33,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":53881.4},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":62324.44},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":59660.94},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":56309.98},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25295.33,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37713.87},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":45210.35},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25295.33,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25295.33,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18971.5,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25295.33,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":71067.55},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":47233.4},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":68919.27},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":61042.78},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25295.33,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":52036.64},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25801.24,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":59333.96}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":280.07,"10th_percentile":280.07,"90th_percentile":280.07,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Knee Procedures With Principal Diagnosis Of Infection With Cc","code_information":[{"code":"486","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":11483.62,"maximum":43017.82,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15311.49,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":32614.89},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":37725.54},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":36113.3},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":34084.93},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15311.49,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22828.54},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27366.23},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15311.49,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15311.49,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11483.62,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15311.49,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":43017.82},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28590.79},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":41717.45},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36949.74},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15311.49,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31498.24},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15617.72,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35915.37}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Cc","code_information":[{"code":"496","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":9906.41,"maximum":37109.58,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13208.55,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":28135.43},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":32544.16},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":31153.35},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":29403.57},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13208.55,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19693.18},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23607.64},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13208.55,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13208.55,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9906.41,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13208.55,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":37109.58},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24664.02},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35987.81},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31874.91},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13208.55,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27172.15},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13472.72,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30982.61}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":15285.97,"10th_percentile":15285.97,"90th_percentile":15285.97,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":13320.47,"10th_percentile":13320.47,"90th_percentile":13320.47,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Foot Procedures With Cc","code_information":[{"code":"504","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":10265.02,"maximum":38452.92,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13686.69,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":29153.91},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":33722.24},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":32281.08},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":30467.96},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13686.69,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20406.06},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24462.22},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13686.69,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13686.69,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10265.02,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13686.69,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":38452.92},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25556.84},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37290.54},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33028.76},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13686.69,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28155.76},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13960.42,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32104.16}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures With Cc/Mcc","code_information":[{"code":"513","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":8645.52,"maximum":32386.28,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11527.36,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":24554.36},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28401.95},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27188.16},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25661.09},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11527.36,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17186.63},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20602.86},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11527.36,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11527.36,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8645.52,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11527.36,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":32386.28},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21524.79},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31407.29},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27817.88},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11527.36,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23713.68},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11757.91,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27039.15}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Hip Replacement With Principal Diagnosis Of Hip Fracture With Mcc","code_information":[{"code":"521","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":15762.16,"maximum":59045.35,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21016.22,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":44766.51},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":51781.28},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":49568.35},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":46784.26},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21016.22,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31333.97},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37562.31},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21016.22,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21016.22,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15762.16,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21016.22,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":59045.35},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":39243.13},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":57260.49},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":50716.43},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21016.22,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":43233.82},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21436.54,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":49296.69}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":20853.95,"10th_percentile":20853.95,"90th_percentile":20853.95,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":22606.74,"10th_percentile":22563.91,"90th_percentile":25159.08,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":22546.41,"10th_percentile":22546.41,"90th_percentile":22546.41,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"1 through 10","median_amount":62447.3,"10th_percentile":62447.3,"90th_percentile":62447.3,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Osteomyelitis With Mcc","code_information":[{"code":"539","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":10816.93,"maximum":40520.39,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14422.57,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":30721.41},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":35535.36},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":34016.72},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":32106.11},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14422.57,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21503.21},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25777.46},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14422.57,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14422.57,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10816.93,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14422.57,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":40520.39},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26930.94},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":39295.52},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34804.6},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14422.57,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29669.59},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14711.02,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33830.29}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":14860.69,"10th_percentile":14860.69,"90th_percentile":14860.69,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Connective Tissue Disorders Without Cc/Mcc","code_information":[{"code":"547","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":4592.13,"maximum":17202.19,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6122.84,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":13042.21},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15085.88},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14441.17},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13630.06},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6122.84,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9128.8},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10943.35},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6122.84,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6122.84,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4592.13,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6122.84,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17202.19},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11433.04},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16682.19},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14775.65},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6122.84,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12595.68},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6245.3,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14362.03}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Signs And Symptoms Of Musculoskeletal System And Connective Tissue With Mcc","code_information":[{"code":"555","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":7258.88,"maximum":27191.88,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9678.5,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":20616.11},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23846.59},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22827.49},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21545.34},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9678.5,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14430.09},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17298.4},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9678.5,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9678.5,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7258.88,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9678.5,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":27191.88},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18072.46},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26369.91},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23356.21},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9678.5,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19910.27},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9872.07,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22702.38}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":8786.66,"10th_percentile":8786.66,"90th_percentile":8786.66,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh Without Mcc","code_information":[{"code":"563","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":4917.78,"maximum":18422.1,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6557.04,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":13967.11},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16155.72},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15465.29},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14596.65},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6557.04,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9776.17},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11719.41},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6557.04,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6557.04,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4917.78,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6557.04,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":18422.1},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12243.82},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17865.23},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15823.49},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6557.04,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13488.92},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6688.18,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15380.53}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":6922.29,"10th_percentile":6922.29,"90th_percentile":6922.29,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":255.94,"10th_percentile":255.94,"90th_percentile":6938.79,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":6779.88,"10th_percentile":6170.36,"90th_percentile":6944.29,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":6780.59,"10th_percentile":5760.99,"90th_percentile":8331.19,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":4465.27,"10th_percentile":4465.27,"90th_percentile":4465.27,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"1 through 10","median_amount":18107.09,"10th_percentile":18107.09,"90th_percentile":18107.09,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Skin Graft For Skin Ulcer Or Cellulitis With Cc","code_information":[{"code":"574","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":19063.76,"maximum":71413.15,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25418.34,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":54143.43},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":62627.53},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":59951.08},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":56583.82},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25418.34,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37897.27},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":45430.21},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25418.34,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25418.34,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19063.76,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25418.34,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":71413.15},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":47463.1},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":69254.43},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":61339.64},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25418.34,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":52289.7},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25926.71,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":59622.51}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Mastectomy For Malignancy With Cc/Mcc","code_information":[{"code":"582","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":10580.24,"maximum":39633.75,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14106.98,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":30049.18},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":34757.79},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":33272.38},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":31403.58},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14106.98,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21032.69},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25213.41},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14106.98,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14106.98,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10580.24,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14106.98,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":39633.75},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26341.65},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38435.67},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34043.02},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14106.98,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29020.38},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14389.12,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33090.03}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":13562.69,"10th_percentile":13562.69,"90th_percentile":13562.69,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Major Skin Disorders Without Mcc","code_information":[{"code":"596","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":5944.72,"maximum":22269.04,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7926.3,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":16883.75},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19529.38},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18694.78},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17644.75},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7926.3,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11817.65},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14166.68},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7926.3,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7926.3,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5944.72,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7926.3,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":22269.04},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14800.6},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21595.88},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19127.78},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7926.3,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16305.7},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8084.83,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18592.32}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":8406.11,"10th_percentile":8406.11,"90th_percentile":8406.11,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Trauma To The Skin, Subcutaneous Tissue And Breast With Mcc","code_information":[{"code":"604","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":8084.27,"maximum":30283.84,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10779.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":22960.34},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26558.16},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25423.17},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23995.23},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10779.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16070.92},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19265.37},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10779.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10779.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8084.27,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10779.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":30283.84},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20127.45},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29368.4},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26012.01},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10779.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22174.24},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10994.61,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25283.83}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":13012.02,"10th_percentile":13012.02,"90th_percentile":13012.02,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc","code_information":[{"code":"618","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":7788.82,"maximum":29177.07,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10385.1,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":22121.23},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25587.55},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24494.04},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23118.29},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10385.1,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15483.58},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18561.29},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10385.1,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10385.1,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7788.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10385.1,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":29177.07},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19391.86},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28295.09},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25061.36},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10385.1,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21363.85},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10592.8,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24359.8}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Thyroid, Parathyroid And Thyroglossal Procedures With Cc","code_information":[{"code":"626","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":8234.2,"maximum":30845.45,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10978.93,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":23386.14},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27050.68},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25894.64},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24440.22},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10978.93,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16368.95},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19622.65},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10978.93,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10978.93,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8234.2,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10978.93,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":30845.45},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20500.71},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29913.03},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26494.4},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10978.93,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22585.46},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11198.51,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25752.72}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With Mcc","code_information":[{"code":"640","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":7334.66,"maximum":27475.78,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9779.55,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":20831.35},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24095.56},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23065.81},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21770.28},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9779.55,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14580.75},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17479.0},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9779.55,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9779.55,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7334.66,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9779.55,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":27475.78},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18261.14},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26645.22},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23600.05},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9779.55,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20118.14},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9975.14,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22939.4}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":7330.99,"10th_percentile":7330.99,"90th_percentile":7330.99,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":10691.01,"10th_percentile":10691.01,"90th_percentile":10691.01,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":6652.78,"10th_percentile":6652.78,"90th_percentile":6652.78,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":10243.01,"10th_percentile":10243.01,"90th_percentile":10243.01,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":6652.78,"10th_percentile":6652.78,"90th_percentile":6652.78,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":10233.02,"10th_percentile":8668.09,"90th_percentile":12151.2,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":10163.16,"10th_percentile":302.51,"90th_percentile":10877.21,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":18179.49,"10th_percentile":18179.49,"90th_percentile":18179.49,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":8957.08,"10th_percentile":8957.08,"90th_percentile":8957.08,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Kidney Transplant","code_information":[{"code":"652","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":17735.32,"maximum":66436.82,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23647.1,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":50370.51},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":58263.41},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":55773.47},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":52640.85},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23647.1,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35256.45},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":42264.47},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23647.1,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23647.1,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17735.32,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23647.1,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":66436.82},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":44155.69},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":64428.53},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":57065.27},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23647.1,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":48645.96},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":24120.04,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":55467.79}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Kidney And Ureter Procedures For Non-Neoplasm With Cc","code_information":[{"code":"660","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":7258.33,"maximum":27189.83,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9677.77,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":20614.55},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23844.79},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22825.76},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21543.71},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9677.77,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14429.0},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17297.09},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9677.77,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9677.77,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7258.33,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9677.77,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":27189.83},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18071.09},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26367.92},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23354.44},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9677.77,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19908.77},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9871.33,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22700.66}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":10361.81,"10th_percentile":10361.81,"90th_percentile":10361.81,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"1 through 10","median_amount":20899.98,"10th_percentile":20899.98,"90th_percentile":20899.98,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":9912.52,"10th_percentile":9912.52,"90th_percentile":9912.52,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":5241.29,"10th_percentile":5241.29,"90th_percentile":5241.29,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":10389.02,"10th_percentile":10378.02,"90th_percentile":12315.18,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"1 through 10","median_amount":27564.24,"10th_percentile":27564.24,"90th_percentile":27564.24,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":46706.42,"10th_percentile":46706.42,"90th_percentile":46706.42,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"1 through 10","median_amount":18100.81,"10th_percentile":18100.81,"90th_percentile":18100.81,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":9892.93,"10th_percentile":7761.43,"90th_percentile":10414.53,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":19908.77,"10th_percentile":19908.77,"90th_percentile":19908.77,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":3819.52,"10th_percentile":3819.52,"90th_percentile":4388.48,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":9007.79,"10th_percentile":9007.79,"90th_percentile":9007.79,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Transurethral Procedures With Mcc","code_information":[{"code":"668","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":16035.65,"maximum":60069.83,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21380.87,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":45543.24},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":52679.72},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":50428.4},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":47596.0},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21380.87,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31877.64},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38214.04},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21380.87,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21380.87,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16035.65,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21380.87,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":60069.83},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":39924.02},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":58254.0},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":51596.4},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21380.87,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":43983.96},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21808.49,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":50152.02}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":11989.84,"10th_percentile":11989.84,"90th_percentile":11989.84,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":22586.15,"10th_percentile":22586.15,"90th_percentile":22586.15,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Renal Failure With Mcc","code_information":[{"code":"682","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":8133.15,"maximum":30466.92,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10844.2,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":23099.16},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26718.72},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25576.87},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24140.3},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10844.2,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16168.08},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19381.85},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10844.2,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10844.2,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8133.15,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10844.2,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":30466.92},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20249.14},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29545.95},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26169.27},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10844.2,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22308.3},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11061.08,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25436.69}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":11304.95,"10th_percentile":11304.95,"90th_percentile":11304.95,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"1 through 10","median_amount":11356.47,"10th_percentile":11356.47,"90th_percentile":11356.47},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":9490.61,"10th_percentile":9490.61,"90th_percentile":11560.57,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":11637.41,"10th_percentile":11193.78,"90th_percentile":11659.41,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"12","median_amount":9671.91,"10th_percentile":6285.87,"90th_percentile":11657.16,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":20003.66,"10th_percentile":20003.66,"90th_percentile":20003.66,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":7929.01,"10th_percentile":7929.01,"90th_percentile":7929.01,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Urinary Stones With Mcc","code_information":[{"code":"693","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":7383.54,"maximum":27658.87,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9844.72,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":20970.17},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24256.12},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23219.52},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21915.35},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9844.72,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14677.91},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17595.47},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9844.72,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9844.72,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7383.54,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9844.72,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":27658.87},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18382.82},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26822.78},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23757.32},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9844.72,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20252.2},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10041.61,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23092.26}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":6266.18,"10th_percentile":6266.18,"90th_percentile":6266.18,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Major Male Pelvic Procedures With Cc/Mcc","code_information":[{"code":"707","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":10984.97,"maximum":41149.89,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14646.63,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":31198.68},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":36087.41},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":34545.18},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":32604.89},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14646.63,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21837.28},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26177.93},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14646.63,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14646.63,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10984.97,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14646.63,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":41149.89},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27349.32},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":39905.99},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35345.3},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14646.63,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30130.52},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14939.56,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34355.85}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":15040.53,"10th_percentile":15040.53,"90th_percentile":15040.53,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Male Reproductive System And Other O.R. Procedures For Malignancy With Cc/Mcc","code_information":[{"code":"715","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":12286.49,"maximum":46025.42,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16381.99,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":34895.17},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":40363.13},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":38638.17},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":36467.99},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16381.99,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24424.6},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29279.55},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16381.99,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16381.99,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12286.49,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16381.99,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":46025.42},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30589.73},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":44634.14},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":39533.09},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16381.99,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33700.45},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16709.63,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38426.41}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Benign Prostatic Hypertrophy Without Mcc","code_information":[{"code":"726","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":3964.98,"maximum":14852.88,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5286.64,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":11261.03},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13025.6},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12468.94},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11768.6},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5286.64,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7882.07},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9448.81},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5286.64,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5286.64,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3964.98,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5286.64,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":14852.88},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9871.62},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14403.9},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12757.74},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5286.64,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10875.49},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5392.37,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12400.6}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":5017.73,"10th_percentile":5017.73,"90th_percentile":5017.73,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Cc","code_information":[{"code":"737","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":11316.12,"maximum":42390.37,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15088.16,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":32139.18},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":37175.28},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":35586.56},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":33587.78},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15088.16,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22495.57},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26967.07},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15088.16,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15088.16,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11316.12,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15088.16,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":42390.37},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28173.78},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":41108.97},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36410.8},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15088.16,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31038.82},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15389.92,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35391.53}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"D&C, Conization, Laparoscopy And Tubal Interruption Without Cc/Mcc","code_information":[{"code":"745","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":6246.76,"maximum":23400.49,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8329.02,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":17741.59},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20521.64},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19644.63},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18541.25},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8329.02,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12418.09},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14886.46},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8329.02,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8329.02,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6246.76,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8329.02,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":23400.49},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15552.59},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22693.13},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20099.63},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8329.02,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17134.16},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8495.6,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19536.96}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Malignancy, Female Reproductive System Without Cc/Mcc","code_information":[{"code":"756","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":5274.74,"maximum":19759.27,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7032.99,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":14980.92},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17328.38},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16587.84},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15656.15},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7032.99,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10485.78},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12570.06},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7032.99,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7032.99,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5274.74,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7032.99,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":19759.27},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13132.54},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19161.98},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16972.04},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7032.99,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14468.01},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7173.65,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16496.92}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Abortion With D&C, Aspiration Curettage Or Hysterotomy","code_information":[{"code":"770","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":5506.49,"maximum":20627.4,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7341.99,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":15639.11},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18089.71},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17316.63},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16344.01},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7341.99,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10946.48},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13122.33},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7341.99,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7341.99,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5506.49,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7341.99,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":20627.4},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13709.53},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20003.87},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17717.71},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7341.99,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15103.67},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7488.83,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17221.72}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":11710.36,"10th_percentile":11710.36,"90th_percentile":11710.36,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":5030.02,"10th_percentile":5030.02,"90th_percentile":5030.02,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cesarean Section Without Sterilization Without Cc/Mcc","code_information":[{"code":"788","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":5265.4,"maximum":19724.3,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7020.54,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":14954.4},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17297.71},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16558.48},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15628.44},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7020.54,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10467.22},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12547.82},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7020.54,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7020.54,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5265.4,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7020.54,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":19724.3},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13109.3},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19128.06},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16942.0},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7020.54,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14442.4},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7160.95,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16467.73}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":4212.9,"10th_percentile":4212.9,"90th_percentile":5251.3,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"1 through 10","median_amount":19083.01,"10th_percentile":15823.32,"90th_percentile":25194.42,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"15","median_amount":12545.0,"10th_percentile":10561.82,"90th_percentile":13308.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":4423.55,"10th_percentile":4423.55,"90th_percentile":5513.87,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"1 through 10","median_amount":16509.63,"10th_percentile":16509.63,"90th_percentile":16509.63},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":4212.9,"10th_percentile":4212.9,"90th_percentile":4212.9,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"1 through 10","median_amount":8498.0,"10th_percentile":8498.0,"90th_percentile":8498.02,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":5364.24,"10th_percentile":5364.24,"90th_percentile":5364.24,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":5513.87,"10th_percentile":4423.55,"90th_percentile":7329.47,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"1 through 10","median_amount":13261.25,"10th_percentile":13261.25,"90th_percentile":15833.04,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":11316.63,"10th_percentile":11316.63,"90th_percentile":11316.63,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":5251.3,"10th_percentile":5251.3,"90th_percentile":5251.3,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":5046.72,"10th_percentile":5046.72,"90th_percentile":5046.72,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"32","median_amount":13067.0,"10th_percentile":11618.18,"90th_percentile":13198.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"11","median_amount":4212.9,"10th_percentile":4212.9,"90th_percentile":4212.9,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Vaginal Delivery With Sterilization And/Or D&C With Mcc","code_information":[{"code":"796","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":6408.77,"maximum":24007.36,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8545.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":18201.7},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21053.85},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20154.09},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19022.1},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8545.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12740.14},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15272.53},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8545.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8545.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6408.77,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8545.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":24007.36},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15955.94},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23281.65},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20620.89},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8545.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17578.52},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8715.93,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20043.63}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other O.R. Procedures Of The Blood And Blood Forming Organs Without Cc/Mcc","code_information":[{"code":"804","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":7446.69,"maximum":27895.44,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9928.92,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":21149.53},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24463.6},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23418.12},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22102.8},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9928.92,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14803.45},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17745.97},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9928.92,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9928.92,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7446.69,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9928.92,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":27895.44},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18540.06},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27052.2},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23960.52},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9928.92,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20425.43},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10127.5,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23289.77}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Red Blood Cell Disorders Without Mcc","code_information":[{"code":"812","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":5042.44,"maximum":18889.08,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6723.26,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":14321.17},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16565.25},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15857.31},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14966.66},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6723.26,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10023.99},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12016.48},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6723.26,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6723.26,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5042.44,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6723.26,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":18889.08},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12554.19},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18318.09},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16224.59},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6723.26,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13830.85},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6857.73,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15770.41}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":7728.14,"10th_percentile":7728.14,"90th_percentile":7728.14,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":4171.46,"10th_percentile":4171.46,"90th_percentile":4171.46,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"1 through 10","median_amount":10075.32,"10th_percentile":10075.32,"90th_percentile":10075.32,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":6069.67,"10th_percentile":6069.67,"90th_percentile":6069.67,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":8248.78,"10th_percentile":8248.78,"90th_percentile":8248.78,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":7153.17,"10th_percentile":5729.17,"90th_percentile":8547.88,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"1 through 10","median_amount":18985.77,"10th_percentile":18985.77,"90th_percentile":18985.77,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":7162.27,"10th_percentile":5659.17,"90th_percentile":8542.38,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":13901.64,"10th_percentile":13901.64,"90th_percentile":13901.64,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Lymphoma And Leukemia With Major O.R. Procedures With Mcc","code_information":[{"code":"820","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":32207.5,"maximum":120649.84,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":42943.33,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":91473.29},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":105806.86},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":101285.1},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":95596.24},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":42943.33,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":64026.02},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":76752.64},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":42943.33,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":42943.33,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":32207.5,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":42943.33,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":120649.84},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":80187.12},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":117002.76},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":103631.02},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":42943.33,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":88341.48},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":43802.2,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":100729.99}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures Without C","code_information":[{"code":"828","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":9356.69,"maximum":35050.34,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12475.59,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":26574.17},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":30738.26},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":29424.63},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27771.94},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12475.59,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18600.38},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22297.63},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12475.59,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12475.59,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9356.69,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12475.59,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":35050.34},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23295.39},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33990.81},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30106.15},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12475.59,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25664.34},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12725.1,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29263.36}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Acute Leukemia Without Cc/Mcc","code_information":[{"code":"836","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":6697.08,"maximum":25087.38,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8929.44,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":19020.54},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22001.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21060.77},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19877.85},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8929.44,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13313.28},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15959.6},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8929.44,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8929.44,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6697.08,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8929.44,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":25087.38},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16673.75},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24329.03},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21548.57},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8929.44,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18369.33},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9108.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20945.34}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Cc","code_information":[{"code":"844","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":6685.55,"maximum":25044.18,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8914.07,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":18987.79},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21963.11},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21024.5},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19843.62},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8914.07,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13290.36},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15932.11},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8914.07,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8914.07,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6685.55,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8914.07,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":25044.18},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16645.04},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24287.13},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21511.46},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8914.07,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18337.7},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9092.35,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20909.27}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":9315.79,"10th_percentile":9315.79,"90th_percentile":9315.79,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":18003.3,"10th_percentile":18003.3,"90th_percentile":18003.3,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Infectious And Parasitic Diseases With O.R. Procedures With Cc","code_information":[{"code":"854","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":10972.89,"maximum":41104.63,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14630.52,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":31164.37},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":36047.72},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":34507.19},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":32569.03},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14630.52,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21813.26},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26149.13},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14630.52,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14630.52,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10972.89,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14630.52,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":41104.63},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27319.24},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":39862.1},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35306.43},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14630.52,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30097.38},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14923.13,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34318.07}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":15543.99,"10th_percentile":15543.99,"90th_percentile":16946.6,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"1 through 10","median_amount":28770.19,"10th_percentile":28770.19,"90th_percentile":30736.65,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":15509.11,"10th_percentile":15509.11,"90th_percentile":15509.11,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":5714.09,"10th_percentile":5714.09,"90th_percentile":5714.09,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":15185.47,"10th_percentile":8285.35,"90th_percentile":15891.4,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":14339.94,"10th_percentile":14339.94,"90th_percentile":14339.94,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":21046.02,"10th_percentile":21046.02,"90th_percentile":30097.38,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":19067.23,"10th_percentile":19067.23,"90th_percentile":19067.23,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Viral Illness With Mcc","code_information":[{"code":"865","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":8228.16,"maximum":30822.82,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10970.88,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":23368.99},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27030.83},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25875.64},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24422.29},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10970.88,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16356.94},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19608.25},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10970.88,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10970.88,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8228.16,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10970.88,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":30822.82},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20485.67},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29891.09},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26474.96},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10970.88,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22568.89},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11190.3,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25733.83}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":10852.33,"10th_percentile":10852.33,"90th_percentile":10852.33,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":9999.74,"10th_percentile":9999.74,"90th_percentile":9999.74,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":10036.56,"10th_percentile":10036.56,"90th_percentile":10036.56,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"O.R. Procedures With Principal Diagnosis Of Mental Illness","code_information":[{"code":"876","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":21224.72,"maximum":79508.18,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":28299.63,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":60280.85},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":69726.66},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":66746.82},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":62997.87},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":28299.63,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":42193.11},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":50579.95},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":28299.63,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":28299.63,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21224.72,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":28299.63,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":79508.18},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":52843.27},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":77104.76},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":68292.78},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":28299.63,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":58216.99},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":28865.62,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":66381.01}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":4968.27,"10th_percentile":4968.27,"90th_percentile":4968.27,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":28791.45,"10th_percentile":28791.45,"90th_percentile":28791.45,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":9101.19,"10th_percentile":9101.19,"90th_percentile":9101.19,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Mental Disorder Diagnoses","code_information":[{"code":"887","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":5881.02,"maximum":22030.4,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7841.36,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":16702.83},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19320.11},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18494.44},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17455.67},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7841.36,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11691.02},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14014.87},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7841.36,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7841.36,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5881.02,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7841.36,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":22030.4},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14642.0},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21364.46},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18922.8},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7841.36,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16130.97},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7998.19,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18393.08}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":125.0,"10th_percentile":125.0,"90th_percentile":125.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Skin Grafts For Injuries With Cc/Mcc","code_information":[{"code":"904","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":20171.42,"maximum":75562.5,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26895.23,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":57289.34},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":66266.4},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":63434.44},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":59871.53},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26895.23,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":40099.23},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":48069.86},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26895.23,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26895.23,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20171.42,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26895.23,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":75562.5},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":50220.86},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":73278.35},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":64903.68},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26895.23,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":55327.91},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27433.13,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":63086.78}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Allergic Reactions With Mcc","code_information":[{"code":"915","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":9234.78,"maximum":34593.64,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12313.04,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":26227.92},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":30337.75},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":29041.23},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27410.08},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12313.04,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18358.03},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22007.1},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12313.04,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12313.04,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9234.78,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12313.04,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":34593.64},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22991.86},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33547.92},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29713.87},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12313.04,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25329.94},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12559.3,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28882.07}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Injury, Poisoning And Toxic Effect Diagnoses Without Mcc","code_information":[{"code":"923","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":5588.86,"maximum":20935.98,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7451.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":15873.07},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18360.33},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17575.68},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16588.51},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7451.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11110.23},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13318.64},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7451.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7451.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5588.86,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7451.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":20935.98},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13914.62},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20303.12},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17982.76},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7451.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15329.62},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7600.86,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17479.35}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":7912.93,"10th_percentile":7912.93,"90th_percentile":7912.93,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"O.R. Procedures With Diagnoses Of Other Contact With Health Services With Cc","code_information":[{"code":"940","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":12833.47,"maximum":48074.38,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17111.29,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":36448.63},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":42160.01},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":40358.26},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":38091.47},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17111.29,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25511.94},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30583.01},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17111.29,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17111.29,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12833.47,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17111.29,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":48074.38},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31951.52},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":46621.16},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":41293.02},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17111.29,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35200.72},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17453.52,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":40137.08}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":6052.34,"10th_percentile":6052.34,"90th_percentile":6052.34,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":16379.86,"10th_percentile":16379.86,"90th_percentile":16379.86,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Factors Influencing Health Status","code_information":[{"code":"951","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":3053.36,"maximum":11437.95,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4071.15,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":8671.93},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10030.8},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":9602.12},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":9062.8},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4071.15,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6069.85},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7276.37},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4071.15,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4071.15,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3053.36,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4071.15,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":11437.95},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7601.97},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11092.2},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9824.52},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4071.15,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8375.03},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4152.57,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9549.49}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":9903.83,"10th_percentile":9903.83,"90th_percentile":9903.83,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"1 through 10","median_amount":6189.94,"10th_percentile":6189.94,"90th_percentile":6189.94,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":4364.37,"10th_percentile":4364.37,"90th_percentile":4369.87,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":4606.85,"10th_percentile":4136.25,"90th_percentile":4629.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":3936.7,"10th_percentile":3430.25,"90th_percentile":4630.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":8540.72,"10th_percentile":8540.72,"90th_percentile":8540.72,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Multiple Significant Trauma Without Cc/Mcc","code_information":[{"code":"965","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":5164.9,"maximum":19347.83,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6886.54,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":14668.98},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16967.56},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16242.44},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15330.15},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6886.54,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10267.44},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12308.32},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6886.54,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6886.54,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5164.9,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6886.54,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":19347.83},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12859.09},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18762.98},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16618.64},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6886.54,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14166.75},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7024.27,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16153.42}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc","code_information":[{"code":"982","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":13501.25,"maximum":50575.92,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18001.67,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":38345.22},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":44353.8},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":42458.3},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":40073.55},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18001.67,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26839.44},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32174.39},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18001.67,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18001.67,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13501.25,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18001.67,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":50575.92},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33614.11},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":49047.08},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":43441.7},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18001.67,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37032.39},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18361.7,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":42225.6}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":18008.26,"10th_percentile":18008.26,"90th_percentile":18008.26,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":21255.37,"10th_percentile":21255.37,"90th_percentile":21255.37,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":18595.23,"10th_percentile":18595.23,"90th_percentile":18595.23,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Simultaneous Pancreas, Islet Cell And Kidney Transplant","code_information":[{"code":"008","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":30778.57,"maximum":115297.05,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":41038.09,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":87414.95},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":101112.59},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":96791.44},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":91354.98},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":41038.09,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":61185.42},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":73347.4},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":41038.09,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":41038.09,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":30778.57,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":41038.09,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":115297.05},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":76629.51},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":111811.77},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":99033.28},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":41038.09,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":84422.09},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":41858.85,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":96260.97}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies","code_information":[{"code":"018","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":237145.34,"maximum":888350.52,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":316193.78,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":673522.13},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":779060.89},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":745766.96},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":703879.64},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":316193.78,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":471426.63},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":565133.3},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":316193.78,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":316193.78,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":237145.34,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":316193.78,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":888350.52},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":590421.58},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":861496.86},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":763040.08},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":316193.78,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":650462.52},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":322517.66,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":741679.7}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Craniotomy And Endovascular Intracranial Procedures With Cc","code_information":[{"code":"026","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":17074.67,"maximum":63962.03,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22766.23,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":48494.19},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":56093.08},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":53695.88},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":50679.96},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22766.23,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33943.14},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":40690.1},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22766.23,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22766.23,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17074.67,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22766.23,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":63962.03},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":42510.88},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":62028.54},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":54939.56},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22766.23,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":46833.88},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23221.55,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":53401.6}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"1 through 10","median_amount":47704.98,"10th_percentile":47704.98,"90th_percentile":47704.98,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":23728.23,"10th_percentile":23728.23,"90th_percentile":23728.23,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Carotid Artery Stent Procedures With Mcc","code_information":[{"code":"034","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":21256.58,"maximum":79627.5,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":28342.1,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":60371.31},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":69831.3},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":66846.99},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":63092.41},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":28342.1,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":42256.43},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":50655.85},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":28342.1,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":28342.1,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21256.58,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":28342.1,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":79627.5},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":52922.57},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":77220.47},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":68395.27},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":28342.1,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":58304.35},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":28908.94,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":66480.63}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Peripheral, Cranial Nerve And Other Nervous System Procedures Without Cc/Mcc","code_information":[{"code":"042","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":9487.94,"maximum":35542.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12650.59,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":26946.94},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":31169.44},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":29837.38},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28161.51},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12650.59,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18861.3},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22610.41},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12650.59,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12650.59,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9487.94,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12650.59,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":35542.0},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23622.17},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34467.62},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30528.46},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12650.59,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26024.35},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12903.6,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29673.85}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Multiple Sclerosis And Cerebellar Ataxia With Cc","code_information":[{"code":"059","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":6814.6,"maximum":25527.62,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9086.14,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":19354.32},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22387.08},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21430.34},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20226.67},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9086.14,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13546.91},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16239.66},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9086.14,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9086.14,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6814.6,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9086.14,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":25527.62},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16966.34},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24755.96},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21926.7},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9086.14,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18691.68},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9267.86,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21312.89}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":5268.97,"10th_percentile":5268.97,"90th_percentile":5268.97,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":9119.07,"10th_percentile":9119.07,"90th_percentile":9119.07,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":18691.68,"10th_percentile":18691.68,"90th_percentile":18691.68,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Precerebral Occlusion Without Infarction With Mcc","code_information":[{"code":"067","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":8065.6,"maximum":30213.89,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10754.14,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":22907.31},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26496.82},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25364.45},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23939.81},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10754.14,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16033.8},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19220.88},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10754.14,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10754.14,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8065.6,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10754.14,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":30213.89},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20080.96},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29300.57},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25951.93},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10754.14,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22123.03},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10969.22,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25225.44}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":7007.68,"10th_percentile":7007.68,"90th_percentile":7007.68,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":9733.29,"10th_percentile":9733.29,"90th_percentile":9733.29,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Viral Meningitis With Cc/Mcc","code_information":[{"code":"075","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":10530.26,"maximum":39446.54,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14040.35,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":29907.25},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":34593.62},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":33115.23},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":31255.25},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14040.35,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20933.35},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25094.32},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14040.35,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14040.35,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10530.26,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14040.35,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":39446.54},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26217.23},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38254.13},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33882.23},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14040.35,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28883.3},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14321.16,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32933.73}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":25944.51,"10th_percentile":25944.51,"90th_percentile":25944.51,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Traumatic Stupor And Coma <1 Hour With Cc","code_information":[{"code":"086","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":7153.99,"maximum":26798.96,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9538.65,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":20318.21},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23502.01},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22497.63},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21234.01},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9538.65,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14221.58},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17048.43},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9538.65,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9538.65,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7153.99,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9538.65,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":26798.96},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17811.31},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25988.87},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23018.71},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9538.65,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19622.57},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9729.42,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22374.33}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":9409.77,"10th_percentile":9409.77,"90th_percentile":9409.77,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":8515.59,"10th_percentile":8515.59,"90th_percentile":10180.07,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":10185.38,"10th_percentile":10185.38,"90th_percentile":10185.38,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Bacterial And Tuberculous Infections Of Nervous System With Mcc","code_information":[{"code":"094","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":19327.36,"maximum":72400.6,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25769.81,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":54892.08},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":63493.5},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":60780.04},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":57366.22},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25769.81,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38421.29},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":46058.39},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25769.81,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25769.81,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19327.36,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25769.81,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":72400.6},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":48119.38},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":70212.03},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":62187.8},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25769.81,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":53012.72},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26285.21,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":60446.93}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Headaches With Mcc","code_information":[{"code":"102","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":6155.6,"maximum":23059.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8207.47,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":17482.68},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20222.16},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19357.94},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18270.67},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8207.47,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12236.87},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14669.22},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8207.47,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8207.47,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6155.6,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8207.47,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":23059.0},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15325.63},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22361.96},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19806.3},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8207.47,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16884.12},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8371.62,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19251.85}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"1 through 10","median_amount":18545.29,"10th_percentile":18545.29,"90th_percentile":18545.29,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":9619.66,"10th_percentile":9619.66,"90th_percentile":9619.66,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Acute Major Eye Infections Without Cc/Mcc","code_information":[{"code":"122","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":4315.35,"maximum":16165.37,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5753.8,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":12256.12},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14176.62},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13570.77},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12808.54},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5753.8,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8578.58},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10283.76},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5753.8,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5753.8,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4315.35,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5753.8,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":16165.37},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10743.94},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15676.71},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13885.09},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5753.8,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11836.51},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5868.88,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13496.39}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Salivary Gland Procedures","code_information":[{"code":"139","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":6786.04,"maximum":25420.65,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9048.06,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":19273.21},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22293.26},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21340.54},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20141.91},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9048.06,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13490.14},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16171.61},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9048.06,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9048.06,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6786.04,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9048.06,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":25420.65},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16895.24},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24652.22},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21834.82},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9048.06,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18613.35},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9229.02,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21223.58}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Ear, Nose, Mouth And Throat Malignancy With Cc","code_information":[{"code":"147","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":6982.65,"maximum":26157.12,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9310.2,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":19831.59},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22939.13},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21958.81},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20725.45},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9310.2,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13880.97},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16640.12},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9310.2,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9310.2,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6982.65,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9310.2,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":26157.12},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17384.72},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25366.43},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22467.41},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9310.2,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19152.6},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9496.4,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21838.46}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Ear, Nose, Mouth And Throat Diagnoses With Cc","code_information":[{"code":"155","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":5033.11,"maximum":18854.11,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6710.81,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":14294.65},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16534.58},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15827.96},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14938.95},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6710.81,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10005.43},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11994.24},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6710.81,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6710.81,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5033.11,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6710.81,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":18854.11},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12530.95},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18284.18},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16194.56},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6710.81,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13805.24},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6845.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15741.21}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":8434.14,"10th_percentile":8434.14,"90th_percentile":8434.14,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Respiratory System O.R. Procedures With Mcc","code_information":[{"code":"166","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":20526.19,"maximum":76891.44,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27368.25,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":58296.91},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":67431.85},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":64550.08},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":60924.51},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27368.25,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":40804.47},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":48915.28},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27368.25,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27368.25,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20526.19,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27368.25,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":76891.44},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":51104.11},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":74567.12},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":66045.16},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27368.25,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":56300.98},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27915.62,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":64196.31}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":34800.76,"10th_percentile":34800.76,"90th_percentile":34800.76,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":28031.29,"10th_percentile":28031.29,"90th_percentile":28031.29,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Respiratory Infections And Inflammations Without Cc/Mcc","code_information":[{"code":"179","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":4146.2,"maximum":15531.75,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5528.27,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":11775.74},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13620.96},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13038.85},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12306.5},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5528.27,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8242.34},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9880.69},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5528.27,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5528.27,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4146.2,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5528.27,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15531.75},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10322.82},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15062.25},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13340.85},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5528.27,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11372.57},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5638.84,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12967.39}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":6046.55,"10th_percentile":6046.55,"90th_percentile":6046.55,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":688.4,"10th_percentile":688.4,"90th_percentile":688.4,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":7900.12,"10th_percentile":7900.12,"90th_percentile":7900.12,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Pleural Effusion With Cc","code_information":[{"code":"187","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":5431.8,"maximum":20347.63,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7242.4,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":15426.99},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17844.35},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17081.76},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16122.33},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7242.4,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10798.0},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12944.35},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7242.4,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7242.4,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5431.8,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7242.4,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":20347.63},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13523.58},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19732.55},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17477.4},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7242.4,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14898.81},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7387.25,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16988.14}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":7621.03,"10th_percentile":7621.03,"90th_percentile":7621.03,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":142.88,"10th_percentile":142.88,"90th_percentile":142.88,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Simple Pneumonia And Pleurisy Without Cc/Mcc","code_information":[{"code":"195","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":3451.51,"maximum":12929.41,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4602.01,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":9802.71},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11338.77},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10854.2},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10244.55},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4602.01,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6861.33},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8225.18},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4602.01,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4602.01,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3451.51,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4602.01,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":12929.41},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8593.24},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12538.58},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11105.6},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4602.01,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9467.1},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4694.05,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10794.71}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"1 through 10","median_amount":9712.25,"10th_percentile":9712.25,"90th_percentile":9712.25,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":5023.46,"10th_percentile":5023.46,"90th_percentile":5023.46,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":5030.27,"10th_percentile":5030.27,"90th_percentile":5030.27,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Bronchitis And Asthma Without Cc/Mcc","code_information":[{"code":"203","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":3679.41,"maximum":13783.15,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4905.88,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":10449.99},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12087.47},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11570.9},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10921.0},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4905.88,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7314.39},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8768.29},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4905.88,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4905.88,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3679.41,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4905.88,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":13783.15},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9160.65},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13366.5},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11838.9},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4905.88,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10092.21},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5004.0,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11507.48}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Endovascular Abdominal Aorta With Iliac Branch Procedures","code_information":[{"code":"213","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":31340.36,"maximum":117401.55,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":41787.15,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":89010.52},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":102958.18},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":98558.16},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":93022.47},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":41787.15,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":62302.23},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":74686.2},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":41787.15,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":41787.15,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":31340.36,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":41787.15,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":117401.55},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":78028.22},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":113852.66},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":100840.92},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":41787.15,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":85963.03},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":42622.89,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":98018.0}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Cardiothoracic Procedures With Mcc","code_information":[{"code":"228","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":27169.45,"maximum":101777.22,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":36225.93,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":77164.6},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":89256.04},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":85441.6},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":80642.62},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":36225.93,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":54010.77},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":64746.62},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":36225.93,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":36225.93,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27169.45,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":36225.93,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":101777.22},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":67643.87},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":98700.63},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":87420.56},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":36225.93,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":74522.69},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":36950.45,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":84973.33}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":38600.51,"10th_percentile":38600.51,"90th_percentile":38600.51,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":7249.09,"10th_percentile":7249.09,"90th_percentile":7249.09,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":38594.61,"10th_percentile":38594.61,"90th_percentile":38594.61,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":38511.62,"10th_percentile":38511.62,"90th_percentile":38511.62,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Amputation For Circulatory System Disorders Except Upper Limb And Toe With Mcc","code_information":[{"code":"239","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":27028.31,"maximum":101248.52,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":36037.75,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":76763.75},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":88792.39},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":84997.76},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":80223.71},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":36037.75,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":53730.2},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":64410.29},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":36037.75,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":36037.75,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27028.31,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":36037.75,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":101248.52},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":67292.48},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":98187.92},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":86966.44},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":36037.75,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":74135.57},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":36758.5,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":84531.92}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":45788.47,"10th_percentile":45788.47,"90th_percentile":45788.47,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":39044.76,"10th_percentile":39044.76,"90th_percentile":39044.76,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Percutaneous Cardiovascular Procedures Without Intraluminal Device Without Mcc","code_information":[{"code":"251","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":8207.29,"maximum":30744.64,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10943.05,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":23309.72},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26962.27},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25810.02},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24360.35},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10943.05,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16315.46},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19558.52},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10943.05,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10943.05,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8207.29,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10943.05,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":30744.64},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20433.72},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29815.28},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26407.82},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10943.05,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22511.65},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11161.91,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25668.56}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":12107.51,"10th_percentile":12107.51,"90th_percentile":12107.51,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cardiac Pacemaker Device Replacement Without Mcc","code_information":[{"code":"259","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":11104.69,"maximum":41598.36,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14806.25,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":31538.69},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":36480.71},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":34921.67},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":32960.23},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14806.25,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22075.27},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26463.22},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14806.25,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14806.25,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11104.69,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14806.25,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":41598.36},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27647.38},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":40340.9},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35730.51},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14806.25,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30458.89},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15102.38,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34730.28}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Endovascular Cardiac Valve Replacement And Supplement Procedures Without Mcc","code_information":[{"code":"267","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":26144.71,"maximum":97938.51,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":34859.61,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":74254.2},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":85889.59},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":82219.02},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":77601.04},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":34859.61,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":51973.65},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":62304.59},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":34859.61,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":34859.61,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26144.71,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":34859.61,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":97938.51},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":65092.56},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":94977.96},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":84123.34},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":34859.61,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":71711.93},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":35556.8,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":81768.41}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":36442.82,"10th_percentile":36442.82,"90th_percentile":36442.82,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":36436.92,"10th_percentile":36218.48,"90th_percentile":36442.41,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":36442.42,"10th_percentile":36167.42,"90th_percentile":44297.86,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":37960.44,"10th_percentile":36441.17,"90th_percentile":70913.84,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cardiac Defibrillator Implant With Cardiac Catheterization And Mcc","code_information":[{"code":"275","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":39157.75,"maximum":146685.59,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":52210.33,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":111212.85},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":128639.55},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":123142.01},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":116225.52},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":52210.33,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":77842.58},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":93315.54},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":52210.33,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":52210.33,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":39157.75,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":52210.33,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":146685.59},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":97491.18},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":142251.48},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":125994.17},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":52210.33,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":107405.22},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":53254.54,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":122467.12}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"1 through 10","median_amount":62914.91,"10th_percentile":62914.91,"90th_percentile":62914.91,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":106450.22,"10th_percentile":106450.22,"90th_percentile":106450.22,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Acute Myocardial Infarction, Expired With Mcc","code_information":[{"code":"283","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":10877.89,"maximum":40748.74,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14503.85,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":30894.54},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":35735.61},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":34208.42},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":32287.04},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14503.85,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21624.39},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25922.73},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14503.85,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14503.85,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10877.89,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14503.85,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":40748.74},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27082.71},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":39516.96},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35000.74},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14503.85,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29836.79},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14793.93,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34020.93}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"1 through 10","median_amount":91368.32,"10th_percentile":91368.32,"90th_percentile":91368.32},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":9615.39,"10th_percentile":9615.39,"90th_percentile":9615.39,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":15445.07,"10th_percentile":15445.07,"90th_percentile":15445.07,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Heart Failure And Shock With Mcc","code_information":[{"code":"291","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":7050.2,"maximum":26410.15,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9400.26,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":20023.43},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23161.04},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22171.23},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20925.94},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9400.26,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14015.24},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16801.09},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9400.26,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9400.26,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7050.2,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9400.26,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":26410.15},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17552.9},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25611.81},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22684.75},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9400.26,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19337.88},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9588.27,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22049.71}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":5077.75,"10th_percentile":5077.75,"90th_percentile":5077.75,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":9204.82,"10th_percentile":8918.01,"90th_percentile":10164.59,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"1 through 10","median_amount":17743.44,"10th_percentile":17743.44,"90th_percentile":17743.44,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"1 through 10","median_amount":19893.71,"10th_percentile":19893.71,"90th_percentile":19893.71,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":7907.85,"10th_percentile":7907.85,"90th_percentile":7907.85,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"1 through 10","median_amount":26671.72,"10th_percentile":26671.72,"90th_percentile":26671.72},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":5077.75,"10th_percentile":5077.75,"90th_percentile":5077.75,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":9701.38,"10th_percentile":9701.38,"90th_percentile":9701.38,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"17","median_amount":9800.8,"10th_percentile":9234.94,"90th_percentile":10210.8,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":8462.92,"10th_percentile":8462.92,"90th_percentile":8462.92,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"66","median_amount":10111.7,"10th_percentile":8763.79,"90th_percentile":11257.68,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":28029.84,"10th_percentile":28029.84,"90th_percentile":28029.84,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"1 through 10","median_amount":18111.63,"10th_percentile":18111.63,"90th_percentile":18111.63,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"53","median_amount":9983.69,"10th_percentile":8071.9,"90th_percentile":10145.4,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":19436.53,"10th_percentile":9487.95,"90th_percentile":25011.88,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":7152.72,"10th_percentile":5078.27,"90th_percentile":7531.29,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":10076.94,"10th_percentile":10076.94,"90th_percentile":10076.94,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":8729.7,"10th_percentile":8729.7,"90th_percentile":8729.7,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Peripheral Vascular Disorders Without Cc/Mcc","code_information":[{"code":"301","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":3952.35,"maximum":14805.57,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5269.8,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":11225.16},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12984.11},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12429.22},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11731.11},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5269.8,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7856.96},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9418.71},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5269.8,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5269.8,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3952.35,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5269.8,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":14805.57},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9840.18},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14358.02},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12717.1},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5269.8,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10840.84},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5375.2,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12361.1}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":6832.29,"10th_percentile":6832.29,"90th_percentile":6832.29,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":843.46,"10th_percentile":843.46,"90th_percentile":843.46,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cardiac Arrhythmia And Conduction Disorders With Cc","code_information":[{"code":"309","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":4040.21,"maximum":15134.72,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5386.95,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":11474.71},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13272.76},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12705.54},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11991.91},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5386.95,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8031.64},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9628.11},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5386.95,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5386.95,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4040.21,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5386.95,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15134.72},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10058.94},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14677.22},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12999.82},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5386.95,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11081.85},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5494.69,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12635.9}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":5831.24,"10th_percentile":5653.04,"90th_percentile":5840.14,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"1 through 10","median_amount":17434.35,"10th_percentile":17434.35,"90th_percentile":17434.35},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"1 through 10","median_amount":8070.95,"10th_percentile":8070.95,"90th_percentile":8070.95,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":4592.1,"10th_percentile":4592.1,"90th_percentile":4592.1,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"13","median_amount":5531.01,"10th_percentile":4905.14,"90th_percentile":5843.84,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"1 through 10","median_amount":15208.78,"10th_percentile":15208.78,"90th_percentile":15208.78,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":11260.0,"10th_percentile":11260.0,"90th_percentile":11260.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":5798.18,"10th_percentile":459.52,"90th_percentile":6844.5,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":11136.08,"10th_percentile":7704.54,"90th_percentile":11136.08,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":4367.12,"10th_percentile":4367.12,"90th_percentile":4367.12,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Concomitant Left Atrial Appendage Closure And Cardiac Ablation","code_information":[{"code":"317","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":36720.0,"maximum":137553.74,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":48960.0,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":104289.34},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":120631.15},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":115475.86},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":108989.95},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":48960.0,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":72996.52},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":87506.23},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":48960.0,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":48960.0,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":36720.0,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":48960.0,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":137553.74},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":91421.91},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":133395.68},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":118150.46},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":48960.0,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":100718.75},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":49939.2,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":114842.98}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":54224.01,"10th_percentile":54224.01,"90th_percentile":54224.01,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"1 through 10","median_amount":74425.5,"10th_percentile":74425.5,"90th_percentile":74425.5,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"1 through 10","median_amount":110628.14,"10th_percentile":110628.14,"90th_percentile":110628.14,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":50758.1,"10th_percentile":50758.1,"90th_percentile":50758.1,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":63614.49,"10th_percentile":54229.51,"90th_percentile":68533.58,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":68527.29,"10th_percentile":68527.29,"90th_percentile":68535.19,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Coronary Intravascular Lithotripsy Without Intraluminal Device","code_information":[{"code":"325","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":17630.43,"maximum":66043.9,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23507.24,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":50072.61},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":57918.83},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":55443.61},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":52329.52},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23507.24,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35047.94},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":42014.5},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23507.24,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23507.24,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17630.43,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23507.24,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":66043.9},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":43894.55},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":64047.48},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":56727.77},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23507.24,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":48358.26},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23977.38,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":55139.74}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Rectal Resection With Cc","code_information":[{"code":"333","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":12862.57,"maximum":48183.41,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17150.09,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":36531.29},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":42255.63},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":40449.79},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":38177.86},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17150.09,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25569.8},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30652.37},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17150.09,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17150.09,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12862.57,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17150.09,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":48183.41},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32023.99},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":46726.89},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":41386.67},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17150.09,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35280.56},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17493.09,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":40228.1}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Anal And Stomal Procedures With Mcc","code_information":[{"code":"347","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":12606.66,"maximum":47224.76,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16808.88,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":35804.47},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":41414.92},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":39645.01},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":37418.28},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16808.88,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25061.07},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30042.52},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16808.88,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16808.88,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12606.66,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16808.88,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":47224.76},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31386.84},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":45797.22},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":40563.25},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16808.88,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34578.62},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17145.06,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":39427.73}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Hernia Procedures Except Inguinal And Femoral Without Cc/Mcc","code_information":[{"code":"355","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":7386.28,"maximum":27669.15,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9848.38,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":20977.97},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24265.15},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23228.15},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21923.5},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9848.38,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14683.37},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17602.02},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9848.38,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9848.38,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7386.28,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9848.38,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":27669.15},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18389.66},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26832.75},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23766.15},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9848.38,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20259.74},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10045.35,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23100.85}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Major Esophageal Disorders Without Cc/Mcc","code_information":[{"code":"370","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":3848.56,"maximum":14416.76,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5131.41,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":10930.38},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12643.13},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12102.82},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11423.04},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5131.41,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7650.63},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9171.37},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5131.41,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5131.41,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3848.56,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5131.41,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":14416.76},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9581.77},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13980.96},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12383.14},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5131.41,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10556.15},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5234.04,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12036.49}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Gastrointestinal Hemorrhage With Cc","code_information":[{"code":"378","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":5385.68,"maximum":20174.82,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7180.9,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":15295.98},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17692.81},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16936.69},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15985.41},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7180.9,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10706.3},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12834.42},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7180.9,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7180.9,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5385.68,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7180.9,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":20174.82},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13408.73},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19564.97},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17328.97},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7180.9,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14772.28},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7324.52,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16843.87}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":7635.59,"10th_percentile":7635.59,"90th_percentile":7650.39,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"1 through 10","median_amount":12641.5,"10th_percentile":12641.5,"90th_percentile":12641.5,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"1 through 10","median_amount":16133.11,"10th_percentile":16133.11,"90th_percentile":16133.11,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":5978.54,"10th_percentile":5978.54,"90th_percentile":5978.54,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"1 through 10","median_amount":10763.1,"10th_percentile":10763.1,"90th_percentile":10763.1,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":7669.99,"10th_percentile":6792.79,"90th_percentile":7681.19,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":5419.71,"10th_percentile":5419.71,"90th_percentile":5419.71,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"17","median_amount":7641.09,"10th_percentile":7031.93,"90th_percentile":7914.89,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"19","median_amount":7647.4,"10th_percentile":5991.58,"90th_percentile":8631.07,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":14703.71,"10th_percentile":14703.71,"90th_percentile":14703.71,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":3721.47,"10th_percentile":3721.47,"90th_percentile":3721.47,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Inflammatory Bowel Disease With Cc","code_information":[{"code":"386","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":5361.51,"maximum":20084.31,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7148.68,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":15227.35},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17613.43},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16860.7},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15913.69},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7148.68,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10658.27},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12776.84},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7148.68,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7148.68,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5361.51,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7148.68,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":20084.31},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13348.57},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19477.19},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17251.22},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7148.68,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14706.01},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7291.65,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16768.29}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":1232.33,"10th_percentile":1232.33,"90th_percentile":1232.33,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"1 through 10","median_amount":29784.71,"10th_percentile":29784.71,"90th_percentile":29784.71,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."}]}]},{"description":"Other Digestive System Diagnoses With Cc","code_information":[{"code":"394","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":5138.55,"maximum":19249.09,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6851.4,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":14594.11},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16880.96},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16159.54},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15251.91},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6851.4,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10215.04},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12245.51},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6851.4,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6851.4,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5138.55,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6851.4,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":19249.09},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12793.46},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18667.22},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16533.82},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6851.4,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14094.45},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6988.43,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16070.97}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":7290.17,"10th_percentile":7290.17,"90th_percentile":7290.17,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":7451.34,"10th_percentile":7451.34,"90th_percentile":7451.34,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":7296.59,"10th_percentile":7295.67,"90th_percentile":7297.17,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":7245.47,"10th_percentile":7245.47,"90th_percentile":7245.47,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":10696.7,"10th_percentile":10696.7,"90th_percentile":10696.7,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":8132.21,"10th_percentile":8132.21,"90th_percentile":8132.21,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":5841.98,"10th_percentile":5841.98,"90th_percentile":5841.98,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Pancreas, Liver And Shunt Procedures Without Cc/Mcc","code_information":[{"code":"407","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":12189.29,"maximum":45661.3,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16252.39,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":34619.1},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":40043.8},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":38332.49},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":36179.48},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16252.39,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24231.37},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29047.91},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16252.39,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16252.39,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12189.29,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16252.39,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":45661.3},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30347.73},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":44281.02},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":39220.33},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16252.39,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33433.83},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16577.44,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38122.41}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cholecystectomy Except By Laparoscope Without C.D.E. With Cc","code_information":[{"code":"415","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":11349.62,"maximum":42515.86,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15132.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":32234.32},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":37285.33},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":35691.91},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":33687.21},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15132.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22562.16},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27046.9},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15132.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15132.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11349.62,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15132.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":42515.86},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28257.18},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":41230.67},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36518.59},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15132.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31130.7},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15435.48,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35496.3}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":17610.32,"10th_percentile":17610.32,"90th_percentile":17610.32,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Hepatobiliary Or Pancreas O.R. Procedures With Mcc","code_information":[{"code":"423","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":22806.87,"maximum":85434.93,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":30409.16,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":64774.34},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":74924.27},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":71722.31},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":67693.9},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":30409.16,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":45338.3},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":54350.31},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":30409.16,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":30409.16,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22806.87,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":30409.16,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":85434.93},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":56782.35},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":82852.35},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":73383.51},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":30409.16,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":62556.64},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":31017.34,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":71329.23}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"1 through 10","median_amount":56547.54,"10th_percentile":56547.54,"90th_percentile":56547.54,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cirrhosis And Alcoholic Hepatitis With Mcc","code_information":[{"code":"432","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":10808.69,"maximum":40489.53,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14411.59,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":30698.02},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":35508.3},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":33990.81},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":32081.66},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14411.59,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21486.84},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25757.83},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14411.59,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14411.59,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10808.69,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14411.59,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":40489.53},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26910.43},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":39265.59},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34778.09},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14411.59,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29647.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14699.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33804.52}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":7837.9,"10th_percentile":7837.9,"90th_percentile":18765.58,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":8085.72,"10th_percentile":8085.72,"90th_percentile":8085.72,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":17902.66,"10th_percentile":17902.66,"90th_percentile":17902.66,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":14633.82,"10th_percentile":14633.82,"90th_percentile":14633.82,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":8357.1,"10th_percentile":8357.1,"90th_percentile":8357.1,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":8774.96,"10th_percentile":8774.96,"90th_percentile":8774.96,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":14094.82,"10th_percentile":14094.82,"90th_percentile":15656.25,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":26786.01,"10th_percentile":26786.01,"90th_percentile":26786.01,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":14178.0,"10th_percentile":14178.0,"90th_percentile":14178.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":23235.34,"10th_percentile":23235.34,"90th_percentile":23235.34,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":18412.08,"10th_percentile":18412.08,"90th_percentile":18412.08,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Disorders Of Pancreas Except Malignancy Without Cc/Mcc","code_information":[{"code":"440","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":3412.52,"maximum":12783.35,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4550.02,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":9691.98},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11210.68},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10731.58},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10128.82},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4550.02,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6783.82},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8132.26},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4550.02,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4550.02,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3412.52,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4550.02,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":12783.35},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8496.16},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12396.93},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10980.14},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4550.02,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9360.15},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4641.02,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10672.76}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":3330.71,"10th_percentile":3330.71,"90th_percentile":3330.71,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"1 through 10","median_amount":12653.75,"10th_percentile":12653.75,"90th_percentile":12653.75,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":8895.24,"10th_percentile":8895.24,"90th_percentile":8895.24,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":3928.71,"10th_percentile":3928.71,"90th_percentile":3928.71,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Multiple Level Spinal Fusion Except Cervical Without Mcc","code_information":[{"code":"448","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":23289.04,"maximum":87241.14,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":31052.05,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":66143.76},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":76508.27},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":73238.62},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":69125.04},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":31052.05,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":46296.81},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":55499.35},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":31052.05,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":31052.05,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23289.04,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":31052.05,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":87241.14},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":57982.8},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":84603.96},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":74934.94},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":31052.05,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":63879.17},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":31673.09,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":72837.22}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":31431.92,"10th_percentile":31431.92,"90th_percentile":31431.92,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":36825.58,"10th_percentile":31646.26,"90th_percentile":39530.12,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":31625.87,"10th_percentile":31625.87,"90th_percentile":31625.87,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":50490.31,"10th_percentile":50490.31,"90th_percentile":50490.31,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Wound Debridement Or Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders With","code_information":[{"code":"463","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":31299.73,"maximum":117249.32,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":41732.97,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":88895.1},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":102824.68},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":98430.37},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":92901.85},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":41732.97,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":62221.44},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":74589.36},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":41732.97,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":41732.97,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":31299.73,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":41732.97,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":117249.32},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":77927.04},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":113705.03},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":100710.17},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":41732.97,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":85851.57},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":42567.63,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":97890.91}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cervical Spinal Fusion With Mcc","code_information":[{"code":"471","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":26517.58,"maximum":99335.34,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":35356.78,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":75313.23},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":87114.58},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":83391.65},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":78707.81},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":35356.78,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":52714.92},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":63193.2},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":35356.78,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":35356.78,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26517.58,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":35356.78,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":99335.34},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":66020.93},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":96332.57},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":85323.13},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":35356.78,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":72734.71},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":36063.92,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":82934.61}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Biopsies Of Musculoskeletal System And Connective Tissue Without Cc/Mcc","code_information":[{"code":"479","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":10208.45,"maximum":38241.03,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13611.27,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":28993.26},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":33536.41},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":32103.2},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":30300.07},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13611.27,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20293.61},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24327.42},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13611.27,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13611.27,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10208.45,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13611.27,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":38241.03},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25416.01},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37085.06},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32846.76},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13611.27,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28000.61},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13883.5,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31927.26}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Knee Procedures Without Principal Diagnosis Of Infection With Cc/Mcc","code_information":[{"code":"488","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":9714.2,"maximum":36389.56,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12952.27,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":27589.53},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":31912.72},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":30548.9},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28833.07},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12952.27,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19311.08},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23149.59},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12952.27,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12952.27,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9714.2,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12952.27,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":36389.56},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24185.48},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35289.56},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31256.46},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12952.27,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26644.94},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13211.32,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30381.48}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur With Cc/Mcc","code_information":[{"code":"498","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":16567.24,"maximum":62061.19,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22089.66,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":47053.03},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":54426.09},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":52100.14},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":49173.84},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22089.66,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32934.41},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":39480.86},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22089.66,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22089.66,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16567.24,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22089.66,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":62061.19},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":41247.53},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":60185.16},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":53306.86},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22089.66,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":45442.06},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22531.45,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":51814.6}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Major Thumb Or Joint Procedures","code_information":[{"code":"506","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":7409.35,"maximum":27755.55,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9879.13,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":21043.47},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24340.92},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23300.68},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21991.96},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9879.13,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14729.22},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17656.98},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9879.13,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9879.13,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7409.35,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9879.13,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":27755.55},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18447.09},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26916.54},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23840.36},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9879.13,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20323.0},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10076.71,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23172.98}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":11632.22,"10th_percentile":11632.22,"90th_percentile":11632.22,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Musculoskeletal System And Connective Tissue O.R. Procedures With Mcc","code_information":[{"code":"515","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":17501.38,"maximum":65560.46,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23335.17,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":49706.08},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":57494.86},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":55037.76},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":51946.47},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23335.17,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34791.39},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":41706.96},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23335.17,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23335.17,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17501.38,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23335.17,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":65560.46},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":43573.24},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":63578.66},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":56312.52},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23335.17,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":48004.27},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23801.87,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":54736.12}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":24950.17,"10th_percentile":24950.17,"90th_percentile":24950.17,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Fractures Of Femur With Mcc","code_information":[{"code":"533","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":8609.28,"maximum":32250.5,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11479.04,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":24451.42},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28282.88},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27074.18},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25553.51},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11479.04,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17114.58},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20516.49},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11479.04,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11479.04,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8609.28,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11479.04,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":32250.5},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21434.55},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31275.62},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27701.26},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11479.04,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23614.27},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11708.62,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26925.8}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Osteomyelitis Without Cc/Mcc","code_information":[{"code":"541","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":4324.13,"maximum":16198.28,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5765.51,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":12281.08},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14205.48},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13598.4},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12834.62},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5765.51,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8596.05},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10304.7},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5765.51,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5765.51,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4324.13,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5765.51,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":16198.28},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10765.81},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15708.63},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13913.36},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5765.51,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11860.61},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5880.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13523.87}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Septic Arthritis With Cc","code_information":[{"code":"549","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":6629.54,"maximum":24834.35,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8839.38,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":18828.7},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21779.1},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20848.34},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19677.36},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8839.38,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13179.0},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15798.63},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8839.38,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8839.38,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6629.54,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8839.38,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":24834.35},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16505.57},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24083.64},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21331.22},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8839.38,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18184.05},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9016.17,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20734.08}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Tendonitis, Myositis And Bursitis With Mcc","code_information":[{"code":"557","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":8165.55,"maximum":30588.3,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10887.4,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":23191.18},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26825.16},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25678.76},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24236.47},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10887.4,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16232.49},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19459.06},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10887.4,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10887.4,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8165.55,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10887.4,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":30588.3},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20329.8},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29663.66},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26273.52},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10887.4,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22397.17},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11105.15,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25538.03}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":12190.72,"10th_percentile":12190.72,"90th_percentile":12190.72,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":12002.11,"10th_percentile":12002.11,"90th_percentile":12002.11,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Musculoskeletal System And Connective Tissue Diagnoses With Cc","code_information":[{"code":"565","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":5351.08,"maximum":20045.22,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7134.77,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":15197.72},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17579.15},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16827.89},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15882.72},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7134.77,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10637.52},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12751.97},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7134.77,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7134.77,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5351.08,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7134.77,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":20045.22},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13322.59},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19439.28},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17217.65},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7134.77,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14677.39},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7277.47,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16735.66}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":6254.89,"10th_percentile":6254.89,"90th_percentile":6254.89,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":1060.26,"10th_percentile":1060.26,"90th_percentile":1060.26,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Skin Graft Except For Skin Ulcer Or Cellulitis With Mcc","code_information":[{"code":"576","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":26915.73,"maximum":100826.8,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":35887.64,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":76444.02},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":88422.55},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":84643.72},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":79889.56},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":35887.64,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":53506.4},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":64142.0},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":35887.64,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":35887.64,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26915.73,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":35887.64,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":100826.8},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":67012.2},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":97778.94},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":86604.2},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":35887.64,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":73826.78},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":36605.39,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":84179.83}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Breast Biopsy, Local Excision And Other Breast Procedures With Cc/Mcc","code_information":[{"code":"584","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":11756.0,"maximum":44038.18,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15674.67,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":33388.5},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":38620.37},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":36969.89},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":34893.41},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15674.67,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23370.02},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28015.34},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15674.67,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15674.67,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11756.0,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15674.67,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":44038.18},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29268.96},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":42706.97},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37826.17},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15674.67,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32245.36},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15988.16,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36767.27}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Malignant Breast Disorders With Cc","code_information":[{"code":"598","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":6212.72,"maximum":23272.95,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8283.62,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":17644.89},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20409.78},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19537.55},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18440.19},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8283.62,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12350.4},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14805.32},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8283.62,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8283.62,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6212.72,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8283.62,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":23272.95},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15467.82},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22569.44},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19990.07},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8283.62,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17040.77},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8449.29,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19430.47}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":8636.35,"10th_percentile":8636.35,"90th_percentile":8636.35,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Minor Skin Disorders With Mcc","code_information":[{"code":"606","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":8309.98,"maximum":31129.34,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11079.98,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":23601.38},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27299.64},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26132.96},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24665.16},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11079.98,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16519.6},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19803.25},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11079.98,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11079.98,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8309.98,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11079.98,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":31129.34},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20689.39},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30188.34},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26738.24},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11079.98,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22793.33},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11301.58,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25989.74}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":4733.05,"10th_percentile":4733.05,"90th_percentile":4733.05,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"O.R. Procedures For Obesity With Cc","code_information":[{"code":"620","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":8788.3,"maximum":32921.15,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11717.74,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":24959.88},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28871.01},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27637.18},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26084.89},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11717.74,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17470.48},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20943.13},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11717.74,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11717.74,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8788.3,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11717.74,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":32921.15},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21880.28},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31925.99},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28277.3},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11717.74,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24105.32},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11952.09,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27485.71}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Mcc Or Insertion Of Antibiotic-Eluti","code_information":[{"code":"628","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":20466.32,"maximum":76667.21,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27288.43,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":58126.9},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":67235.2},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":64361.84},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":60746.84},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27288.43,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":40685.48},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":48772.63},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27288.43,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27288.43,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20466.32,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27288.43,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":76667.21},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":50955.08},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":74349.66},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":65852.56},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27288.43,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":56136.79},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27834.2,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":64009.09}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":28941.62,"10th_percentile":28941.62,"90th_percentile":28941.62,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":30558.62,"10th_percentile":30558.62,"90th_percentile":30558.62,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Inborn And Other Disorders Of Metabolism","code_information":[{"code":"642","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":7809.69,"maximum":29255.24,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10412.92,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":22180.49},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25656.11},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24559.67},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23180.23},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10412.92,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15525.07},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18611.02},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10412.92,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10412.92,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7809.69,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10412.92,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":29255.24},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19443.82},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28370.9},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25128.51},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10412.92,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21421.09},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10621.18,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24425.07}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":9623.87,"10th_percentile":9623.87,"90th_percentile":9623.87,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":18694.69,"10th_percentile":18694.69,"90th_percentile":18694.69,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Major Bladder Procedures With Cc","code_information":[{"code":"654","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":15372.81,"maximum":57586.81,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20497.08,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":43660.68},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":50502.17},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":48343.91},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":45628.59},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20497.08,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30559.96},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36634.44},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20497.08,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20497.08,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15372.81,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20497.08,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":57586.81},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38273.74},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":55846.04},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":49463.63},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20497.08,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":42165.86},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20907.02,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":48078.96}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":21885.81,"10th_percentile":21885.81,"90th_percentile":21885.81,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":21889.59,"10th_percentile":21889.59,"90th_percentile":21889.59,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":51609.66,"10th_percentile":51609.66,"90th_percentile":51609.66,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Minor Bladder Procedures With Mcc","code_information":[{"code":"662","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":16812.72,"maximum":62980.75,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22416.96,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":47750.22},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":55232.52},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":52872.11},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":49902.45},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22416.96,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33422.4},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":40065.85},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22416.96,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22416.96,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16812.72,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22416.96,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":62980.75},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":41858.7},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":61076.93},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":54096.71},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22416.96,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":46115.37},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22865.3,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":52582.33}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":24204.76,"10th_percentile":24204.76,"90th_percentile":24204.76,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Transurethral Procedures Without Cc/Mcc","code_information":[{"code":"670","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":5367.0,"maximum":20104.88,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7156.0,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":15242.95},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17631.47},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16877.97},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15929.99},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7156.0,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10669.18},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12789.93},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7156.0,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7156.0,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5367.0,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7156.0,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":20104.88},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13362.24},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19497.14},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17268.89},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7156.0,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14721.07},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7299.12,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16785.47}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Renal Failure Without Cc/Mcc","code_information":[{"code":"684","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":3296.65,"maximum":12349.29,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4395.53,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":9362.88},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10830.01},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10367.18},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":9784.89},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4395.53,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6553.48},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7856.13},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4395.53,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4395.53,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3296.65,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4395.53,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":12349.29},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8207.67},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11975.99},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10607.3},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4395.53,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9042.32},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4483.44,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10310.36}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":4919.39,"10th_percentile":4919.39,"90th_percentile":4919.39,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Kidney And Urinary Tract Signs And Symptoms With Mcc","code_information":[{"code":"695","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":6281.36,"maximum":23530.09,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8375.15,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":17839.85},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20635.3},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19753.43},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18643.94},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8375.15,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12486.86},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14968.91},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8375.15,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8375.15,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6281.36,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8375.15,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":23530.09},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15638.73},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22818.81},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20210.95},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8375.15,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17229.06},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8542.65,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19645.17}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Penis Procedures With Cc/Mcc","code_information":[{"code":"709","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":12779.65,"maximum":47872.78,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17039.53,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":36295.78},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":41983.21},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":40189.02},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":37931.73},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17039.53,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25404.95},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30454.76},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17039.53,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17039.53,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12779.65,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17039.53,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":47872.78},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31817.53},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":46425.65},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":41119.86},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17039.53,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35053.11},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17380.32,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":39968.76}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Male Reproductive System O.R. Procedures With Cc/Mcc","code_information":[{"code":"717","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":10381.99,"maximum":38891.1,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13842.65,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":29486.13},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":34106.51},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":32648.94},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":30815.15},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13842.65,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20638.59},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24740.97},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13842.65,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13842.65,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10381.99,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13842.65,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":38891.1},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25848.07},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37715.48},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33405.14},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13842.65,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28476.6},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14119.5,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32470.0}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":14375.96,"10th_percentile":14375.96,"90th_percentile":14375.96,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Inflammation Of The Male Reproductive System Without Mcc","code_information":[{"code":"728","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":4454.84,"maximum":16687.89,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5939.78,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":12652.29},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14634.86},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14009.42},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13222.56},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5939.78,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8855.87},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10616.17},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5939.78,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5939.78,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4454.84,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5939.78,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":16687.89},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11091.22},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16183.44},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14333.9},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5939.78,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12219.11},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6058.58,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13932.64}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"1 through 10","median_amount":6620.72,"10th_percentile":6620.72,"90th_percentile":6620.72,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":6397.93,"10th_percentile":6397.93,"90th_percentile":6397.93,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Mcc","code_information":[{"code":"739","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":19675.52,"maximum":73704.86,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26234.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":55880.93},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":64637.29},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":61874.96},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":58399.64},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26234.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":39113.43},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":46888.1},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26234.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26234.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19675.52,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26234.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":73704.86},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":48986.23},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":71476.86},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":63308.08},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26234.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":53967.72},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26758.71,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":61535.84}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Vagina, Cervix And Vulva Procedures Without Cc/Mcc","code_information":[{"code":"747","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":4721.18,"maximum":17685.63,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6294.91,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":13408.74},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15509.85},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14847.02},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14013.11},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6294.91,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9385.34},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11250.89},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6294.91,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6294.91,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4721.18,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6294.91,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17685.63},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11754.34},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17151.02},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15190.9},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6294.91,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12949.66},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6420.81,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14765.65}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Infections, Female Reproductive System With Cc","code_information":[{"code":"758","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":5376.34,"maximum":20139.85,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7168.45,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":15269.46},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17662.14},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16907.33},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15957.7},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7168.45,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10687.74},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12812.17},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7168.45,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7168.45,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5376.34,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7168.45,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":20139.85},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13385.49},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19531.05},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17298.93},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7168.45,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14746.68},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7311.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16814.67}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":9108.01,"10th_percentile":9108.01,"90th_percentile":9108.01,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Abortion Without D&C","code_information":[{"code":"779","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":4620.14,"maximum":17307.11,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6160.18,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":13121.76},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15177.89},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14529.25},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13713.19},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6160.18,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9184.47},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11010.09},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6160.18,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6160.18,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4620.14,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6160.18,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17307.11},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11502.77},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16783.94},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14865.77},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6160.18,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12672.5},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6283.38,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14449.62}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":6957.75,"10th_percentile":6957.75,"90th_percentile":6957.75,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Extreme Immaturity Or Respiratory Distress Syndrome, Neonate","code_information":[{"code":"790","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":32639.69,"maximum":122268.85,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":43519.59,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":92700.77},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":107226.68},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":102644.25},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":96879.05},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":43519.59,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":64885.19},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":77782.58},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":43519.59,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":43519.59,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":32639.69,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":43519.59,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":122268.85},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":81263.16},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":118572.83},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":105021.65},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":43519.59,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":89526.94},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":44389.98,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":102081.69}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"1 through 10","median_amount":39771.0,"10th_percentile":39771.0,"90th_percentile":39771.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":5147.55,"10th_percentile":5147.55,"90th_percentile":5147.55,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"1 through 10","median_amount":12428.9,"10th_percentile":12428.9,"90th_percentile":12428.9,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":8529.0,"10th_percentile":8529.0,"90th_percentile":8529.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":11658.45,"10th_percentile":11658.45,"90th_percentile":16278.95,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Vaginal Delivery With Sterilization And/Or D&C Without Cc/Mcc","code_information":[{"code":"798","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":5256.07,"maximum":19689.33,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7008.09,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":14927.89},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17267.04},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16529.12},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15600.73},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7008.09,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10448.66},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12525.57},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7008.09,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7008.09,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5256.07,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7008.09,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":19689.33},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13086.06},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19094.15},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16911.96},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7008.09,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14416.8},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7148.25,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16438.53}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":7201.0,"10th_percentile":7201.0,"90th_percentile":7201.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Vaginal Delivery Without Sterilization Or D&C With Cc","code_information":[{"code":"806","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":4140.71,"maximum":15511.18,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5520.95,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":11760.14},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13602.91},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13021.58},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12290.2},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5520.95,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8231.42},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9867.6},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5520.95,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5520.95,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4140.71,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5520.95,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15511.18},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10309.15},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15042.3},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13323.18},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5520.95,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11357.5},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5631.37,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12950.21}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":2838.97,"10th_percentile":2838.97,"90th_percentile":2838.97,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"1 through 10","median_amount":10229.94,"10th_percentile":10229.94,"90th_percentile":10229.94,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"1 through 10","median_amount":7561.0,"10th_percentile":7561.0,"90th_percentile":9073.2,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":3507.57,"10th_percentile":2980.92,"90th_percentile":3577.1,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"1 through 10","median_amount":11132.6,"10th_percentile":11132.6,"90th_percentile":11132.6,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"1 through 10","median_amount":8118.36,"10th_percentile":8118.36,"90th_percentile":8118.36},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":2922.97,"10th_percentile":2628.61,"90th_percentile":2980.92,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"1 through 10","median_amount":9986.34,"10th_percentile":9986.34,"90th_percentile":10285.94,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":8407.02,"10th_percentile":7732.58,"90th_percentile":9883.19,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":2783.78,"10th_percentile":2783.78,"90th_percentile":2838.97,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"1 through 10","median_amount":5793.84,"10th_percentile":5793.84,"90th_percentile":5793.84,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"11","median_amount":7136.0,"10th_percentile":5760.8,"90th_percentile":7201.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"11","median_amount":2838.97,"10th_percentile":2503.44,"90th_percentile":2838.97,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Reticuloendothelial And Immunity Disorders With Mcc","code_information":[{"code":"814","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":11679.12,"maximum":43750.17,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15572.16,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":33170.14},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":38367.79},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":36728.11},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":34665.21},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15572.16,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23217.18},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27832.12},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15572.16,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15572.16,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11679.12,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15572.16,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":43750.17},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29077.54},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":42427.67},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37578.79},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15572.16,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32034.48},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15883.6,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36526.82}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Lymphoma And Leukemia With Major O.R. Procedures Without Cc/Mcc","code_information":[{"code":"822","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":6611.96,"maximum":24768.52,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8815.95,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":18778.79},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21721.36},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20793.08},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19625.2},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8815.95,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13144.07},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15756.75},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8815.95,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8815.95,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6611.96,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8815.95,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":24768.52},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16461.82},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24019.8},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21274.68},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8815.95,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18135.85},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8992.27,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20679.12}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":7877.24,"10th_percentile":7877.24,"90th_percentile":7877.24,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures Without Cc/Mcc","code_information":[{"code":"830","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":8264.95,"maximum":30960.65,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11019.93,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":23473.49},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27151.71},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25991.35},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24531.5},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11019.93,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16430.09},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19695.94},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11019.93,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11019.93,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8264.95,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11019.93,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":30960.65},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20577.28},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30024.75},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26593.35},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11019.93,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22669.82},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11240.33,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25848.9}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Chemotherapy With Acute Leukemia As Secondary Diagnosis With Cc Or High Dose Chemotherapy Agent","code_information":[{"code":"838","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":11463.29,"maximum":42941.7,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15284.39,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":32557.18},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":37658.78},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":36049.4},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":34024.62},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15284.39,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22788.15},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27317.8},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15284.39,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15284.39,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11463.29,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15284.39,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":42941.7},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28540.21},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":41643.63},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36884.36},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15284.39,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31442.51},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15590.08,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35851.83}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Mcc","code_information":[{"code":"846","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":14237.13,"maximum":53332.55,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18982.84,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":40435.22},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":46771.29},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":44772.48},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":42257.75},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18982.84,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28302.32},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33928.05},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18982.84,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18982.84,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14237.13,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18982.84,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":53332.55},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35446.24},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":51720.38},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":45809.48},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18982.84,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":39050.83},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19362.5,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":44527.09}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Postoperative Or Post-Traumatic Infections With O.R. Procedures With Mcc","code_information":[{"code":"856","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":24979.92,"maximum":93575.22,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":33306.56,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":70946.07},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":82063.1},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":78556.05},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":74143.81},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":33306.56,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":49658.16},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":59528.84},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":33306.56,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":33306.56,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":24979.92,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":33306.56,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":93575.22},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":62192.6},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":90746.57},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":80375.53},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":33306.56,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":68517.07},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":33972.69,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":78125.51}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":33669.91,"10th_percentile":33669.91,"90th_percentile":33669.91,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":36946.5,"10th_percentile":36946.5,"90th_percentile":36946.5,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Infectious And Parasitic Diseases Diagnoses With Mcc","code_information":[{"code":"867","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":11495.14,"maximum":43061.02,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15326.86,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":32647.64},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":37763.42},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":36149.56},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":34119.16},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15326.86,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22851.46},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27393.71},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15326.86,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15326.86,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11495.14,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15326.86,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":43061.02},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28619.51},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":41759.34},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36986.84},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15326.86,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31529.87},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15633.4,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35951.44}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"1 through 10","median_amount":33444.65,"10th_percentile":33444.65,"90th_percentile":33444.65,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Depressive Neuroses","code_information":[{"code":"881","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":5167.1,"maximum":19356.06,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6889.47,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":14675.22},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16974.78},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16249.34},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15336.67},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6889.47,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10271.81},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12313.56},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6889.47,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6889.47,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5167.1,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6889.47,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":19356.06},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12864.56},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18770.96},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16625.7},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6889.47,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14172.78},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7027.26,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16160.29}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":5452.1,"10th_percentile":5452.1,"90th_percentile":5452.1,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"1 through 10","median_amount":4414.6,"10th_percentile":4414.6,"90th_percentile":4414.6,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":6044.7,"10th_percentile":6044.7,"90th_percentile":10846.37,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"1 through 10","median_amount":8450.81,"10th_percentile":8450.81,"90th_percentile":8450.81,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":7101.51,"10th_percentile":7101.51,"90th_percentile":7101.51,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":4312.48,"10th_percentile":4312.48,"90th_percentile":4312.48,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"1 through 10","median_amount":9792.36,"10th_percentile":9792.36,"90th_percentile":9792.36,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":6430.0,"10th_percentile":6044.7,"90th_percentile":9418.41,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Alcohol, Drug Abuse Or Dependence With Rehabilitation Therapy","code_information":[{"code":"895","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":7774.0,"maximum":29121.53,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10365.33,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":22079.11},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25538.84},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24447.41},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23074.28},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10365.33,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15454.11},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18525.96},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10365.33,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10365.33,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7774.0,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10365.33,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":29121.53},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19354.95},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28241.22},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25013.65},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10365.33,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21323.18},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10572.64,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24313.43}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Hand Procedures For Injuries","code_information":[{"code":"906","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":10787.27,"maximum":40409.3,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14383.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":30637.19},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":35437.94},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":33923.46},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":32018.09},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14383.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21444.26},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25706.79},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14383.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14383.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10787.27,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14383.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":40409.3},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26857.11},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":39187.79},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34709.18},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14383.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29588.25},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14670.69,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33737.54}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Poisoning And Toxic Effects Of Drugs With Mcc","code_information":[{"code":"917","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":8613.12,"maximum":32264.91,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11484.16,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":24462.33},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28295.5},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27086.27},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25564.92},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11484.16,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17122.22},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20525.65},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11484.16,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11484.16,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8613.12,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11484.16,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":32264.91},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21444.12},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31289.58},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27713.63},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11484.16,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23624.81},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11713.84,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26937.82}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":11056.66,"10th_percentile":11056.66,"90th_percentile":11831.84,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"1 through 10","median_amount":18810.53,"10th_percentile":18810.53,"90th_percentile":18810.53,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"1 through 10","median_amount":14122.09,"10th_percentile":14122.09,"90th_percentile":14122.09,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":14699.0,"10th_percentile":14699.0,"90th_percentile":14699.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":14293.37,"10th_percentile":14293.37,"90th_percentile":14293.37,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":12948.94,"10th_percentile":12948.94,"90th_percentile":12948.94,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"1 through 10","median_amount":12911.0,"10th_percentile":12911.0,"90th_percentile":12911.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":10910.65,"10th_percentile":10910.65,"90th_percentile":12621.26,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":17712.65,"10th_percentile":13509.86,"90th_percentile":24323.77,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":6597.75,"10th_percentile":6597.75,"90th_percentile":6597.75,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":11375.33,"10th_percentile":11375.33,"90th_percentile":11375.33,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"1 through 10","median_amount":8174.48,"10th_percentile":8174.48,"90th_percentile":8174.48,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Full Thickness Burn With Skin Graft Or Inhalation Injury With Cc/Mcc","code_information":[{"code":"928","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":39390.04,"maximum":147555.78,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":52520.06,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":111872.6},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":129402.68},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":123872.53},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":116915.01},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":52520.06,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":78304.37},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":93869.12},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":52520.06,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":52520.06,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":39390.04,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":52520.06,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":147555.78},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":98069.53},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":143095.37},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":126741.61},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":52520.06,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":108042.38},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":53570.46,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":123193.63}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Rehabilitation With Cc/Mcc","code_information":[{"code":"945","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":8504.38,"maximum":31857.58,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11339.18,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":24153.51},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27938.29},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26744.32},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25242.18},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11339.18,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16906.07},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20266.53},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11339.18,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11339.18,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8504.38,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11339.18,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":31857.58},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21173.4},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30894.57},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27363.76},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11339.18,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23326.56},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11565.96,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26597.75}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Limb Reattachment, Hip And Femur Procedures For Multiple Significant Trauma","code_information":[{"code":"956","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":20665.12,"maximum":77411.91,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27553.5,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":58691.51},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":67888.28},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":64987.01},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":61336.9},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27553.5,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":41080.67},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":49246.38},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27553.5,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27553.5,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20665.12,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27553.5,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":77411.91},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":51450.03},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":75071.85},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":66492.21},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27553.5,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":56682.07},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":28104.57,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":64630.84}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":29194.93,"10th_percentile":29194.93,"90th_percentile":33463.92,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":28835.76,"10th_percentile":28835.76,"90th_percentile":28835.76,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Hiv With Extensive O.R. Procedures Without Mcc","code_information":[{"code":"970","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":14483.71,"maximum":54256.22,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19311.61,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":41135.53},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":47581.33},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":45547.9},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":42989.62},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19311.61,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28792.5},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34515.65},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19311.61,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19311.61,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14483.71,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19311.61,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":54256.22},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36060.14},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":52616.13},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":46602.86},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19311.61,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":39727.16},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19697.84,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":45298.27}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc","code_information":[{"code":"987","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":18827.61,"maximum":70528.56,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25103.48,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":53472.75},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":61851.76},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":59208.47},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":55882.92},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25103.48,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37427.84},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":44867.47},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25103.48,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25103.48,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18827.61,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25103.48,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":70528.56},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":46875.18},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":68396.58},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":60579.83},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25103.48,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":51641.99},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25605.55,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":58883.97}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":31895.72,"10th_percentile":31895.72,"90th_percentile":31895.72,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":23594.49,"10th_percentile":23594.49,"90th_percentile":23594.49,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Combined Anterior And Posterior Spinal Fusion Without Cc/Mcc","code_information":[{"code":"455","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":70401.2,"maximum":70401.2,"payers_information":[{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":70401.2}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Ketorolac tromethamine inj","code_information":[{"code":"0764","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1083.81,"10th_percentile":1083.81,"90th_percentile":1083.81,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"1 through 10","median_amount":7191.5,"10th_percentile":4106.0,"90th_percentile":12413.5,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"15","median_amount":3388.0,"10th_percentile":304.92,"90th_percentile":10987.43,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1152.14,"10th_percentile":1152.14,"90th_percentile":1171.29,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1111.88,"10th_percentile":1111.88,"90th_percentile":1111.88,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"1 through 10","median_amount":28674.26,"10th_percentile":28674.26,"90th_percentile":28674.26},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":14231.73,"10th_percentile":14231.73,"90th_percentile":14231.73,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":3570.25,"10th_percentile":3570.25,"90th_percentile":3570.25,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"1 through 10","median_amount":16825.53,"10th_percentile":16825.53,"90th_percentile":16825.53},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1152.14,"10th_percentile":1152.14,"90th_percentile":1152.14,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":3288.59,"10th_percentile":3288.59,"90th_percentile":7489.62,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"1 through 10","median_amount":10688.21,"10th_percentile":10688.21,"90th_percentile":10688.21,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"1 through 10","median_amount":7546.65,"10th_percentile":7546.65,"90th_percentile":7546.65,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"1 through 10","median_amount":18032.99,"10th_percentile":18032.99,"90th_percentile":18032.99,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":7006.5,"10th_percentile":3289.77,"90th_percentile":10543.08,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"15","median_amount":11139.38,"10th_percentile":5991.0,"90th_percentile":29888.57,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":806.81,"10th_percentile":742.85,"90th_percentile":1607.66,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"1 through 10","median_amount":42413.52,"10th_percentile":42413.52,"90th_percentile":42413.52,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Injection,onabotulinumtoxinA","code_information":[{"code":"0902","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"1 through 10","median_amount":2654.0,"10th_percentile":2654.0,"90th_percentile":2654.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"1 through 10","median_amount":3658.57,"10th_percentile":3658.57,"90th_percentile":3658.57},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cath coronary drug-delivery","code_information":[{"code":"2050","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":12998.76,"10th_percentile":12998.76,"90th_percentile":12998.76,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":12024.06,"10th_percentile":12024.06,"90th_percentile":12024.06,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Clinic Visits and Related Services","code_information":[{"code":"5012","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"1 through 10","median_amount":1075.0,"10th_percentile":1075.0,"90th_percentile":1075.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":130.35,"10th_percentile":130.35,"90th_percentile":130.35,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"12","median_amount":125.0,"10th_percentile":83.94,"90th_percentile":948.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"1 through 10","median_amount":202.23,"10th_percentile":202.23,"90th_percentile":202.23,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"1 through 10","median_amount":102.21,"10th_percentile":102.21,"90th_percentile":102.21,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":255.38,"10th_percentile":255.38,"90th_percentile":255.38,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"1 through 10","median_amount":93.0,"10th_percentile":93.0,"90th_percentile":93.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"1 through 10","median_amount":133.01,"10th_percentile":133.01,"90th_percentile":357.41,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":132.85,"10th_percentile":132.85,"90th_percentile":132.85,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"1 through 10","median_amount":108.75,"10th_percentile":108.75,"90th_percentile":108.75},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":128.96,"10th_percentile":128.96,"90th_percentile":128.96,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"1 through 10","median_amount":88.25,"10th_percentile":88.25,"90th_percentile":88.25,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":208.56,"10th_percentile":125.0,"90th_percentile":257.12,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"25","median_amount":86.88,"10th_percentile":69.5,"90th_percentile":192.52,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"1 through 10","median_amount":112.5,"10th_percentile":112.5,"90th_percentile":112.5,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 1 Type A ED Visits","code_information":[{"code":"5021","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"1 through 10","median_amount":45.37,"10th_percentile":45.37,"90th_percentile":45.37,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"1 through 10","median_amount":141.6,"10th_percentile":141.6,"90th_percentile":141.6,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":101.94,"10th_percentile":74.64,"90th_percentile":122.88,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":89.42,"10th_percentile":89.42,"90th_percentile":89.42,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":97.09,"10th_percentile":97.09,"90th_percentile":97.09,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":174.49,"10th_percentile":174.49,"90th_percentile":174.49,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":24.77,"10th_percentile":24.77,"90th_percentile":24.77,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":53.56,"10th_percentile":53.56,"90th_percentile":70.87,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":77.88,"10th_percentile":77.88,"90th_percentile":77.88,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":88.11,"10th_percentile":88.11,"90th_percentile":88.11,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"1 through 10","median_amount":157.17,"10th_percentile":157.17,"90th_percentile":157.17,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":216.8,"10th_percentile":216.8,"90th_percentile":216.8,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":53.56,"10th_percentile":53.56,"90th_percentile":53.56,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"1 through 10","median_amount":362.41,"10th_percentile":227.27,"90th_percentile":1098.76,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":82.5,"10th_percentile":64.69,"90th_percentile":518.73,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 2 Type A ED Visits","code_information":[{"code":"5022","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"1 through 10","median_amount":1079.2,"10th_percentile":1079.2,"90th_percentile":1079.2,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"84","median_amount":81.86,"10th_percentile":55.05,"90th_percentile":216.8,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"25","median_amount":159.05,"10th_percentile":71.09,"90th_percentile":161.97,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"56","median_amount":522.19,"10th_percentile":185.55,"90th_percentile":1191.52,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"71","median_amount":661.0,"10th_percentile":194.63,"90th_percentile":736.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"98","median_amount":77.88,"10th_percentile":56.24,"90th_percentile":180.47,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"1 through 10","median_amount":809.13,"10th_percentile":809.13,"90th_percentile":809.13,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"38","median_amount":81.24,"10th_percentile":49.39,"90th_percentile":230.7,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"1 through 10","median_amount":561.85,"10th_percentile":438.16,"90th_percentile":1054.0},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"22","median_amount":80.79,"10th_percentile":52.23,"90th_percentile":249.23,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"14","median_amount":313.82,"10th_percentile":294.54,"90th_percentile":488.31,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"16","median_amount":491.76,"10th_percentile":491.76,"90th_percentile":1330.99,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"1 through 10","median_amount":1139.95,"10th_percentile":644.65,"90th_percentile":1275.91,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"17","median_amount":161.45,"10th_percentile":52.37,"90th_percentile":270.53,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"47","median_amount":74.17,"10th_percentile":45.37,"90th_percentile":230.7,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":100.67,"10th_percentile":100.67,"90th_percentile":100.67,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":178.37,"10th_percentile":178.37,"90th_percentile":178.37,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"1 through 10","median_amount":587.03,"10th_percentile":73.06,"90th_percentile":600.56},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"114","median_amount":77.88,"10th_percentile":54.84,"90th_percentile":227.64,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"73","median_amount":160.17,"10th_percentile":51.25,"90th_percentile":163.27,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"21","median_amount":661.0,"10th_percentile":586.0,"90th_percentile":1253.98,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"11","median_amount":518.41,"10th_percentile":376.26,"90th_percentile":1057.88,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"51","median_amount":74.17,"10th_percentile":49.72,"90th_percentile":270.03,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"1 through 10","median_amount":499.31,"10th_percentile":77.0,"90th_percentile":1010.87,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"76","median_amount":125.0,"10th_percentile":52.37,"90th_percentile":249.23,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"204","median_amount":459.4,"10th_percentile":138.1,"90th_percentile":1106.13,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"300","median_amount":74.17,"10th_percentile":53.43,"90th_percentile":149.46,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":107.47,"10th_percentile":107.47,"90th_percentile":107.47,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"25","median_amount":55.58,"10th_percentile":44.75,"90th_percentile":163.38,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"53","median_amount":762.3,"10th_percentile":594.9,"90th_percentile":1307.7,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 3 Type A ED Visits","code_information":[{"code":"5023","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"14","median_amount":2522.25,"10th_percentile":723.12,"90th_percentile":5990.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"296","median_amount":107.48,"10th_percentile":66.43,"90th_percentile":272.35,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"137","median_amount":280.93,"10th_percentile":189.29,"90th_percentile":508.05,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"206","median_amount":1365.0,"10th_percentile":505.68,"90th_percentile":3073.01,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"374","median_amount":1367.0,"10th_percentile":736.97,"90th_percentile":3045.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"243","median_amount":122.19,"10th_percentile":66.44,"90th_percentile":282.87,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"1 through 10","median_amount":1494.0,"10th_percentile":1494.0,"90th_percentile":1494.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"1 through 10","median_amount":1257.0,"10th_percentile":910.16,"90th_percentile":2534.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"1 through 10","median_amount":2537.3,"10th_percentile":2537.3,"90th_percentile":2537.3,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"80","median_amount":133.77,"10th_percentile":72.32,"90th_percentile":304.73,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"45","median_amount":1464.04,"10th_percentile":705.21,"90th_percentile":3140.8},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"54","median_amount":216.8,"10th_percentile":80.79,"90th_percentile":345.97,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":282.57,"10th_percentile":246.64,"90th_percentile":559.52,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"139","median_amount":657.63,"10th_percentile":543.65,"90th_percentile":1079.95,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"59","median_amount":1543.01,"10th_percentile":736.54,"90th_percentile":2843.96,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"25","median_amount":1426.25,"10th_percentile":899.66,"90th_percentile":3654.26,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"192","median_amount":282.57,"10th_percentile":142.87,"90th_percentile":518.51,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"124","median_amount":125.48,"10th_percentile":63.47,"90th_percentile":267.67,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":438.7,"10th_percentile":257.0,"90th_percentile":669.89,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":184.6,"10th_percentile":70.92,"90th_percentile":631.77,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":310.11,"10th_percentile":224.06,"90th_percentile":421.38,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"13","median_amount":1703.03,"10th_percentile":550.17,"90th_percentile":3195.05},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"1 through 10","median_amount":353.94,"10th_percentile":353.94,"90th_percentile":353.94},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"259","median_amount":122.24,"10th_percentile":67.25,"90th_percentile":293.55,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"666","median_amount":295.31,"10th_percentile":221.99,"90th_percentile":548.71,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"156","median_amount":1940.0,"10th_percentile":999.5,"90th_percentile":2164.24,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"53","median_amount":1468.06,"10th_percentile":806.92,"90th_percentile":3471.05,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"81","median_amount":144.38,"10th_percentile":65.47,"90th_percentile":307.9,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"20","median_amount":1348.35,"10th_percentile":471.75,"90th_percentile":3877.11,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"516","median_amount":282.58,"10th_percentile":172.27,"90th_percentile":518.21,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"927","median_amount":1091.85,"10th_percentile":364.13,"90th_percentile":2567.22,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"721","median_amount":116.78,"10th_percentile":65.71,"90th_percentile":300.55,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":199.29,"10th_percentile":199.29,"90th_percentile":205.29,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":279.89,"10th_percentile":228.49,"90th_percentile":316.87,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"96","median_amount":268.73,"10th_percentile":177.88,"90th_percentile":491.9,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"182","median_amount":1327.05,"10th_percentile":891.0,"90th_percentile":2435.67,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"1 through 10","median_amount":1738.23,"10th_percentile":714.78,"90th_percentile":3717.45,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."}]}]},{"description":"Level 4 Type A ED Visits","code_information":[{"code":"5024","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"11","median_amount":4219.67,"10th_percentile":967.66,"90th_percentile":10000.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"115","median_amount":295.05,"10th_percentile":114.79,"90th_percentile":609.02,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"154","median_amount":734.68,"10th_percentile":419.6,"90th_percentile":1101.58,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"156","median_amount":3277.8,"10th_percentile":1640.0,"90th_percentile":6275.63,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"302","median_amount":2493.0,"10th_percentile":1720.07,"90th_percentile":5036.78,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"1 through 10","median_amount":2350.0,"10th_percentile":2350.0,"90th_percentile":5506.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"124","median_amount":313.14,"10th_percentile":142.83,"90th_percentile":533.07,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":433.38,"10th_percentile":258.39,"90th_percentile":514.86,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"1 through 10","median_amount":2522.07,"10th_percentile":2522.07,"90th_percentile":2522.07,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"1 through 10","median_amount":2456.88,"10th_percentile":2113.34,"90th_percentile":3934.95,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"32","median_amount":357.1,"10th_percentile":208.54,"90th_percentile":523.16,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"35","median_amount":3952.92,"10th_percentile":1974.19,"90th_percentile":7024.4},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"22","median_amount":317.71,"10th_percentile":191.84,"90th_percentile":492.85,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"12","median_amount":908.92,"10th_percentile":411.33,"90th_percentile":1112.02,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"170","median_amount":1435.85,"10th_percentile":848.24,"90th_percentile":2271.24,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"46","median_amount":3625.41,"10th_percentile":2272.84,"90th_percentile":6054.09,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"1 through 10","median_amount":4093.05,"10th_percentile":2003.34,"90th_percentile":9580.02,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"158","median_amount":727.87,"10th_percentile":282.27,"90th_percentile":1124.58,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"46","median_amount":318.27,"10th_percentile":109.93,"90th_percentile":629.48,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":1107.16,"10th_percentile":1107.16,"90th_percentile":1107.16,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":233.94,"10th_percentile":160.42,"90th_percentile":607.01,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":500.84,"10th_percentile":344.57,"90th_percentile":749.52,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"1 through 10","median_amount":7173.5,"10th_percentile":7173.5,"90th_percentile":7173.5},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"16","median_amount":3783.35,"10th_percentile":2241.99,"90th_percentile":9408.12},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"117","median_amount":335.24,"10th_percentile":122.62,"90th_percentile":612.52,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"703","median_amount":730.37,"10th_percentile":472.27,"90th_percentile":1125.95,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"84","median_amount":4266.0,"10th_percentile":2878.0,"90th_percentile":4455.78,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"46","median_amount":3675.9,"10th_percentile":1950.08,"90th_percentile":9682.22,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"31","median_amount":301.45,"10th_percentile":183.25,"90th_percentile":469.41,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"21","median_amount":1988.74,"10th_percentile":648.34,"90th_percentile":4705.02,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"539","median_amount":732.9,"10th_percentile":422.28,"90th_percentile":1124.29,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"730","median_amount":2865.55,"10th_percentile":1242.32,"90th_percentile":5897.88,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"1 through 10","median_amount":3516.81,"10th_percentile":3516.81,"90th_percentile":3516.81,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"374","median_amount":300.19,"10th_percentile":123.0,"90th_percentile":569.38,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":380.28,"10th_percentile":339.05,"90th_percentile":914.55,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"92","median_amount":639.74,"10th_percentile":387.22,"90th_percentile":1056.36,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"45","median_amount":3239.6,"10th_percentile":1859.23,"90th_percentile":8743.44,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"1 through 10","median_amount":3792.74,"10th_percentile":2306.98,"90th_percentile":6990.54,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."}]}]},{"description":"Level 5 Type A ED Visits","code_information":[{"code":"5025","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"1 through 10","median_amount":7461.08,"10th_percentile":7461.08,"90th_percentile":7461.08,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"32","median_amount":454.55,"10th_percentile":200.85,"90th_percentile":869.78,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"61","median_amount":1507.6,"10th_percentile":756.95,"90th_percentile":2768.12,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"57","median_amount":6614.53,"10th_percentile":2880.63,"90th_percentile":15377.1,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"79","median_amount":3928.0,"10th_percentile":1950.0,"90th_percentile":10237.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"37","median_amount":499.54,"10th_percentile":265.06,"90th_percentile":1022.82,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":602.22,"10th_percentile":433.57,"90th_percentile":1114.3,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"20","median_amount":7102.17,"10th_percentile":4251.06,"90th_percentile":14730.63},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":672.87,"10th_percentile":672.87,"90th_percentile":672.87,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":1394.4,"10th_percentile":1161.44,"90th_percentile":2687.12,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"60","median_amount":2292.0,"10th_percentile":1425.7,"90th_percentile":5246.94,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"18","median_amount":6680.54,"10th_percentile":3031.5,"90th_percentile":13043.34,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"1 through 10","median_amount":440.0,"10th_percentile":440.0,"90th_percentile":440.0},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"1 through 10","median_amount":12046.89,"10th_percentile":6859.01,"90th_percentile":13942.45,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"44","median_amount":1375.51,"10th_percentile":822.8,"90th_percentile":2686.09,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"18","median_amount":566.14,"10th_percentile":318.06,"90th_percentile":965.54,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1776.87,"10th_percentile":1776.87,"90th_percentile":1776.87,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":676.29,"10th_percentile":676.29,"90th_percentile":676.29,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"1 through 10","median_amount":9756.73,"10th_percentile":5080.02,"90th_percentile":21042.38},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"37","median_amount":472.55,"10th_percentile":195.74,"90th_percentile":763.49,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"254","median_amount":1377.05,"10th_percentile":835.34,"90th_percentile":2786.97,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"28","median_amount":4869.53,"10th_percentile":3981.0,"90th_percentile":11362.24,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"1 through 10","median_amount":4423.01,"10th_percentile":3308.48,"90th_percentile":9982.27,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":507.73,"10th_percentile":466.74,"90th_percentile":1254.58,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"1 through 10","median_amount":6428.68,"10th_percentile":2744.58,"90th_percentile":13399.26,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"189","median_amount":1408.38,"10th_percentile":713.07,"90th_percentile":2832.03,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"209","median_amount":5348.43,"10th_percentile":2404.92,"90th_percentile":14067.33,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"89","median_amount":438.04,"10th_percentile":168.38,"90th_percentile":924.38,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":244.18,"10th_percentile":244.18,"90th_percentile":244.18,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1246.11,"10th_percentile":1246.11,"90th_percentile":1246.11,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"29","median_amount":984.05,"10th_percentile":615.59,"90th_percentile":2561.62,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"1 through 10","median_amount":7215.41,"10th_percentile":7062.2,"90th_percentile":12998.1,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"1 through 10","median_amount":5267.9,"10th_percentile":5267.9,"90th_percentile":7694.77,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."}]}]},{"description":"Critical Care","code_information":[{"code":"5041","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":655.8,"10th_percentile":655.8,"90th_percentile":760.89,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":1764.32,"10th_percentile":1505.51,"90th_percentile":2937.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"1 through 10","median_amount":12802.94,"10th_percentile":11697.76,"90th_percentile":25453.67,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"15","median_amount":5139.0,"10th_percentile":3602.82,"90th_percentile":10283.59,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1241.62,"10th_percentile":1241.62,"90th_percentile":1241.62,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"1 through 10","median_amount":3971.75,"10th_percentile":3971.75,"90th_percentile":3971.75,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"1 through 10","median_amount":8390.2,"10th_percentile":8390.2,"90th_percentile":8390.2},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":945.77,"10th_percentile":945.77,"90th_percentile":945.77,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":4924.63,"10th_percentile":4924.63,"90th_percentile":6440.78,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"1 through 10","median_amount":14812.75,"10th_percentile":14812.75,"90th_percentile":14812.75,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"11","median_amount":1635.28,"10th_percentile":1295.2,"90th_percentile":7201.53,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1101.67,"10th_percentile":1101.67,"90th_percentile":1101.67,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":505.81,"10th_percentile":505.81,"90th_percentile":505.81,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"1 through 10","median_amount":5673.28,"10th_percentile":5673.28,"90th_percentile":5673.28},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":505.48,"10th_percentile":505.48,"90th_percentile":557.68,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"41","median_amount":2113.9,"10th_percentile":1209.22,"90th_percentile":9821.85,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"1 through 10","median_amount":11031.3,"10th_percentile":7495.73,"90th_percentile":11031.3,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"1 through 10","median_amount":17855.22,"10th_percentile":17855.22,"90th_percentile":17855.22,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":695.34,"10th_percentile":695.34,"90th_percentile":695.34,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"33","median_amount":1820.81,"10th_percentile":1250.49,"90th_percentile":2846.86,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"27","median_amount":12998.65,"10th_percentile":5212.9,"90th_percentile":18056.94,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1053.84,"10th_percentile":673.93,"90th_percentile":1692.3,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":1614.82,"10th_percentile":1614.82,"90th_percentile":1614.82,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Trauma Response with Critical Care","code_information":[{"code":"5045","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":3518.86,"10th_percentile":3518.86,"90th_percentile":3518.86,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"1 through 10","median_amount":11451.0,"10th_percentile":11451.0,"90th_percentile":11451.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":132.64,"10th_percentile":132.64,"90th_percentile":132.64,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1735.41,"10th_percentile":1735.41,"90th_percentile":1735.41,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"1 through 10","median_amount":5253.0,"10th_percentile":5253.0,"90th_percentile":5253.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"1 through 10","median_amount":20770.36,"10th_percentile":20770.36,"90th_percentile":20770.36,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":2677.59,"10th_percentile":2677.59,"90th_percentile":2677.59,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"1 through 10","median_amount":17286.16,"10th_percentile":15888.33,"90th_percentile":21467.72,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":546.17,"10th_percentile":546.17,"90th_percentile":546.17,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"1 through 10","median_amount":16918.28,"10th_percentile":16918.28,"90th_percentile":16918.28,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 1 Skin Procedures","code_information":[{"code":"5051","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":159.98,"10th_percentile":159.98,"90th_percentile":159.98,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"14","median_amount":482.34,"10th_percentile":247.49,"90th_percentile":777.22,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"1 through 10","median_amount":1617.38,"10th_percentile":1053.6,"90th_percentile":3585.43,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"21","median_amount":1467.0,"10th_percentile":538.02,"90th_percentile":2235.32,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":216.19,"10th_percentile":216.19,"90th_percentile":216.19,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"1 through 10","median_amount":3092.2,"10th_percentile":3092.2,"90th_percentile":3092.2,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":428.42,"10th_percentile":428.42,"90th_percentile":428.42,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"1 through 10","median_amount":1471.74,"10th_percentile":1471.74,"90th_percentile":1471.74},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":200.87,"10th_percentile":200.87,"90th_percentile":200.87,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":896.81,"10th_percentile":896.81,"90th_percentile":896.81,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":551.57,"10th_percentile":551.57,"90th_percentile":551.57,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"1 through 10","median_amount":1540.57,"10th_percentile":1272.18,"90th_percentile":2670.29,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"20","median_amount":310.17,"10th_percentile":159.05,"90th_percentile":753.84,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":287.77,"10th_percentile":287.77,"90th_percentile":287.77,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":167.98,"10th_percentile":163.06,"90th_percentile":176.43,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"71","median_amount":331.33,"10th_percentile":200.98,"90th_percentile":735.68,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"1 through 10","median_amount":2026.2,"10th_percentile":905.98,"90th_percentile":3750.79,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"1 through 10","median_amount":1299.83,"10th_percentile":1299.83,"90th_percentile":1299.83,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":159.98,"10th_percentile":159.98,"90th_percentile":159.98,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"1 through 10","median_amount":349.5,"10th_percentile":349.5,"90th_percentile":349.5,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"25","median_amount":331.93,"10th_percentile":159.89,"90th_percentile":726.48,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"29","median_amount":1460.0,"10th_percentile":399.44,"90th_percentile":1988.76,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":159.98,"10th_percentile":159.98,"90th_percentile":578.17,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":260.58,"10th_percentile":177.88,"90th_percentile":439.69,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"29","median_amount":1441.92,"10th_percentile":1232.97,"90th_percentile":2159.75,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 2 Skin Procedures","code_information":[{"code":"5052","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":164.58,"10th_percentile":143.07,"90th_percentile":495.35,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":949.59,"10th_percentile":493.86,"90th_percentile":1874.47,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"14","median_amount":3470.0,"10th_percentile":1887.6,"90th_percentile":4140.79,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"47","median_amount":3306.5,"10th_percentile":1467.0,"90th_percentile":7285.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":446.02,"10th_percentile":223.01,"90th_percentile":1242.26,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"1 through 10","median_amount":2091.0,"10th_percentile":2091.0,"90th_percentile":8399.09,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":240.63,"10th_percentile":240.63,"90th_percentile":240.63,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"1 through 10","median_amount":2071.67,"10th_percentile":2071.67,"90th_percentile":6095.34},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":605.96,"10th_percentile":605.96,"90th_percentile":605.96,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":1303.41,"10th_percentile":1071.38,"90th_percentile":2517.73,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"1 through 10","median_amount":2309.11,"10th_percentile":2309.11,"90th_percentile":5605.12,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"1 through 10","median_amount":2175.77,"10th_percentile":2175.77,"90th_percentile":2175.77,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"48","median_amount":905.36,"10th_percentile":404.92,"90th_percentile":1550.98,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":420.14,"10th_percentile":420.14,"90th_percentile":585.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":582.51,"10th_percentile":582.51,"90th_percentile":582.51,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":446.02,"10th_percentile":167.26,"90th_percentile":1115.05,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"150","median_amount":808.24,"10th_percentile":404.12,"90th_percentile":1728.07,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"1 through 10","median_amount":1964.72,"10th_percentile":1253.98,"90th_percentile":8266.25,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"1 through 10","median_amount":1651.39,"10th_percentile":1170.44,"90th_percentile":4112.68,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":72.2,"10th_percentile":72.2,"90th_percentile":72.2,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"1 through 10","median_amount":2472.76,"10th_percentile":1653.46,"90th_percentile":3709.14,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"115","median_amount":806.09,"10th_percentile":384.63,"90th_percentile":1781.48,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"47","median_amount":2932.73,"10th_percentile":1157.25,"90th_percentile":5680.18,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"12","median_amount":178.51,"10th_percentile":162.04,"90th_percentile":836.98,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":522.26,"10th_percentile":296.1,"90th_percentile":650.82,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":529.28,"10th_percentile":329.77,"90th_percentile":3810.5,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"12","median_amount":2419.44,"10th_percentile":1880.66,"90th_percentile":3510.76,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 3 Skin Procedures","code_information":[{"code":"5053","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":340.55,"10th_percentile":340.55,"90th_percentile":340.55,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":1608.43,"10th_percentile":1608.43,"90th_percentile":1608.43,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":334.5,"10th_percentile":334.5,"90th_percentile":334.5,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":1128.84,"10th_percentile":1128.84,"90th_percentile":1145.16,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"1 through 10","median_amount":3547.92,"10th_percentile":3547.92,"90th_percentile":3547.92,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":305.81,"10th_percentile":305.81,"90th_percentile":305.81,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"1 through 10","median_amount":3478.5,"10th_percentile":1582.74,"90th_percentile":3910.05,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 4 Skin Procedures","code_information":[{"code":"5054","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":431.86,"10th_percentile":431.86,"90th_percentile":1531.41,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":2220.28,"10th_percentile":2220.28,"90th_percentile":5751.67,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"1 through 10","median_amount":4311.3,"10th_percentile":4311.3,"90th_percentile":6159.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"1 through 10","median_amount":8885.84,"10th_percentile":8885.84,"90th_percentile":8885.84,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":3122.0,"10th_percentile":3122.0,"90th_percentile":3122.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"1 through 10","median_amount":13077.63,"10th_percentile":13077.63,"90th_percentile":13077.63},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":2671.75,"10th_percentile":2671.75,"90th_percentile":2671.75,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"1 through 10","median_amount":5074.47,"10th_percentile":5074.47,"90th_percentile":5074.47,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":2781.35,"10th_percentile":2781.35,"90th_percentile":2781.35,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"18","median_amount":2781.35,"10th_percentile":2597.36,"90th_percentile":3152.5,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"1 through 10","median_amount":7141.5,"10th_percentile":7141.5,"90th_percentile":7141.5,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"1 through 10","median_amount":6234.7,"10th_percentile":6234.7,"90th_percentile":6234.7,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":2709.16,"10th_percentile":2385.9,"90th_percentile":3211.2,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"1 through 10","median_amount":7295.62,"10th_percentile":6219.4,"90th_percentile":9270.89,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 5 Skin Procedures","code_information":[{"code":"5055","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"1 through 10","median_amount":21096.38,"10th_percentile":21096.38,"90th_percentile":21096.38},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":4012.58,"10th_percentile":4012.58,"90th_percentile":4012.58,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":3708.5,"10th_percentile":3708.5,"90th_percentile":3708.5,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 1 Excision/ Biopsy/ Incision and Drainage","code_information":[{"code":"5071","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":555.28,"10th_percentile":555.28,"90th_percentile":555.28,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"11","median_amount":670.49,"10th_percentile":417.67,"90th_percentile":717.67,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"1 through 10","median_amount":2660.28,"10th_percentile":346.02,"90th_percentile":3335.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"11","median_amount":2428.2,"10th_percentile":812.43,"90th_percentile":2654.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"1 through 10","median_amount":8763.16,"10th_percentile":8763.16,"90th_percentile":8763.16},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":277.64,"10th_percentile":277.64,"90th_percentile":277.64,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":843.08,"10th_percentile":843.08,"90th_percentile":843.08,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":1394.28,"10th_percentile":1340.6,"90th_percentile":1394.28,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"1 through 10","median_amount":3472.89,"10th_percentile":3472.89,"90th_percentile":3472.89,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":390.27,"10th_percentile":368.67,"90th_percentile":765.27,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":223.01,"10th_percentile":162.44,"90th_percentile":291.52,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"36","median_amount":711.67,"10th_percentile":684.27,"90th_percentile":786.93,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"1 through 10","median_amount":2752.0,"10th_percentile":2737.25,"90th_percentile":3030.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"1 through 10","median_amount":1787.2,"10th_percentile":1787.2,"90th_percentile":1787.2,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":277.64,"10th_percentile":277.64,"90th_percentile":277.64,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"1 through 10","median_amount":4165.31,"10th_percentile":4165.31,"90th_percentile":4165.31,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"19","median_amount":718.97,"10th_percentile":569.33,"90th_percentile":765.14,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"30","median_amount":1899.73,"10th_percentile":1678.98,"90th_percentile":4627.71,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":277.64,"10th_percentile":277.64,"90th_percentile":555.28,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":580.72,"10th_percentile":580.72,"90th_percentile":580.72,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 2 Excision/ Biopsy/ Incision and Drainage","code_information":[{"code":"5072","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":829.13,"10th_percentile":646.54,"90th_percentile":845.63,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"18","median_amount":1438.49,"10th_percentile":1237.0,"90th_percentile":1664.81,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"11","median_amount":4106.0,"10th_percentile":3227.72,"90th_percentile":4314.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"33","median_amount":3388.0,"10th_percentile":3049.2,"90th_percentile":4715.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"1 through 10","median_amount":5082.0,"10th_percentile":5082.0,"90th_percentile":5082.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":483.16,"10th_percentile":483.16,"90th_percentile":817.66,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":552.75,"10th_percentile":552.75,"90th_percentile":552.75,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"1 through 10","median_amount":6636.64,"10th_percentile":2382.48,"90th_percentile":11924.61},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":548.84,"10th_percentile":548.84,"90th_percentile":548.84,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":1735.6,"10th_percentile":1735.6,"90th_percentile":1735.6,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":3227.52,"10th_percentile":3210.8,"90th_percentile":3357.4,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"1 through 10","median_amount":6652.99,"10th_percentile":6006.73,"90th_percentile":17992.02,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"1 through 10","median_amount":4466.55,"10th_percentile":4466.55,"90th_percentile":4466.55,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"18","median_amount":1638.84,"10th_percentile":827.45,"90th_percentile":1738.49,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":432.62,"10th_percentile":432.62,"90th_percentile":432.62,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"1 through 10","median_amount":5409.97,"10th_percentile":5409.97,"90th_percentile":5409.97},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":483.16,"10th_percentile":483.16,"90th_percentile":503.5,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"126","median_amount":1638.84,"10th_percentile":1344.84,"90th_percentile":1724.23,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"11","median_amount":4761.0,"10th_percentile":4623.0,"90th_percentile":6934.5,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"1 through 10","median_amount":5897.36,"10th_percentile":4892.14,"90th_percentile":10583.7,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"1 through 10","median_amount":4787.07,"10th_percentile":4787.07,"90th_percentile":8134.27,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"58","median_amount":1582.7,"10th_percentile":1224.16,"90th_percentile":1682.41,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"95","median_amount":5768.72,"10th_percentile":3502.43,"90th_percentile":9898.34,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":552.75,"10th_percentile":323.26,"90th_percentile":754.84,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":1337.3,"10th_percentile":1248.65,"90th_percentile":1752.61,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"1 through 10","median_amount":7919.8,"10th_percentile":7919.8,"90th_percentile":7919.8,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 3 Excision/ Biopsy/ Incision and Drainage","code_information":[{"code":"5073","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":2894.91,"10th_percentile":2769.39,"90th_percentile":2894.91,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"1 through 10","median_amount":4589.0,"10th_percentile":4589.0,"90th_percentile":4589.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"1 through 10","median_amount":3735.0,"10th_percentile":3735.0,"90th_percentile":6777.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":829.03,"10th_percentile":829.03,"90th_percentile":829.03,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"1 through 10","median_amount":10259.11,"10th_percentile":10259.11,"90th_percentile":10259.11},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":705.96,"10th_percentile":705.96,"90th_percentile":705.96,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":5671.66,"10th_percentile":5671.66,"90th_percentile":5671.66,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"1 through 10","median_amount":11776.44,"10th_percentile":11776.44,"90th_percentile":11776.44,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":2894.91,"10th_percentile":2894.91,"90th_percentile":2894.91,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"1 through 10","median_amount":6043.15,"10th_percentile":6043.15,"90th_percentile":6043.15},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":780.5,"10th_percentile":780.5,"90th_percentile":780.5,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"20","median_amount":2767.99,"10th_percentile":2551.91,"90th_percentile":2901.91,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"1 through 10","median_amount":7791.0,"10th_percentile":7564.0,"90th_percentile":7791.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"1 through 10","median_amount":11178.88,"10th_percentile":11178.88,"90th_percentile":11178.88,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"1 through 10","median_amount":5979.37,"10th_percentile":5979.37,"90th_percentile":5979.37,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":2763.49,"10th_percentile":2507.82,"90th_percentile":2894.92,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"13","median_amount":10001.77,"10th_percentile":6161.11,"90th_percentile":12751.94,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":761.53,"10th_percentile":754.84,"90th_percentile":1597.03,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":2255.01,"10th_percentile":2255.01,"90th_percentile":2255.01,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"1 through 10","median_amount":13100.63,"10th_percentile":13100.63,"90th_percentile":13100.63,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 1 Breast/Lymphatic Surgery and Related Procedures","code_information":[{"code":"5091","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":5370.7,"10th_percentile":5370.7,"90th_percentile":5370.7,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"1 through 10","median_amount":6256.5,"10th_percentile":6074.61,"90th_percentile":14746.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"1 through 10","median_amount":3962.02,"10th_percentile":3174.83,"90th_percentile":13768.5,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"1 through 10","median_amount":12998.02,"10th_percentile":12998.02,"90th_percentile":31591.56},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"1 through 10","median_amount":11323.86,"10th_percentile":11323.86,"90th_percentile":11323.86,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"1 through 10","median_amount":13263.51,"10th_percentile":13263.51,"90th_percentile":13263.51,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":3885.19,"10th_percentile":3713.1,"90th_percentile":6695.97,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"1 through 10","median_amount":14967.44,"10th_percentile":14967.44,"90th_percentile":14967.44},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"27","median_amount":3879.24,"10th_percentile":3622.47,"90th_percentile":6609.55,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"1 through 10","median_amount":9306.0,"10th_percentile":9306.0,"90th_percentile":9306.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"1 through 10","median_amount":9823.21,"10th_percentile":9823.21,"90th_percentile":9823.21,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"14","median_amount":3880.25,"10th_percentile":3600.25,"90th_percentile":3973.9,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"21","median_amount":10931.08,"10th_percentile":8435.8,"90th_percentile":17837.33,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":557.74,"10th_percentile":557.74,"90th_percentile":561.65,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 2 Breast/Lymphatic Surgery and Related Procedures","code_information":[{"code":"5092","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":6052.99,"10th_percentile":6052.99,"90th_percentile":6052.99,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"1 through 10","median_amount":9577.5,"10th_percentile":9577.5,"90th_percentile":11973.97,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1152.14,"10th_percentile":1152.14,"90th_percentile":1152.14,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":12523.53,"10th_percentile":12523.53,"90th_percentile":12523.53,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"1 through 10","median_amount":20725.42,"10th_percentile":20725.42,"90th_percentile":20725.42,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1152.14,"10th_percentile":1152.14,"90th_percentile":1152.14,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":6602.32,"10th_percentile":6602.32,"90th_percentile":6701.28,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"1 through 10","median_amount":23536.5,"10th_percentile":23536.5,"90th_percentile":23536.5,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"1 through 10","median_amount":19098.83,"10th_percentile":19098.83,"90th_percentile":19098.83,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":6699.48,"10th_percentile":6699.48,"90th_percentile":6699.48,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"1 through 10","median_amount":21060.39,"10th_percentile":15954.59,"90th_percentile":23172.95,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":3085.31,"10th_percentile":3085.31,"90th_percentile":4501.78,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 3 Breast/Lymphatic Surgery and Related Procedures","code_information":[{"code":"5093","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"1 through 10","median_amount":1620.0,"10th_percentile":1620.0,"90th_percentile":1620.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"1 through 10","median_amount":17370.9,"10th_percentile":17370.9,"90th_percentile":17370.9,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"1 through 10","median_amount":19139.22,"10th_percentile":16541.75,"90th_percentile":59396.45,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 4 Breast/Lymphatic Surgery and Related Procedures","code_information":[{"code":"5094","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"1 through 10","median_amount":57320.5,"10th_percentile":57320.5,"90th_percentile":57320.5,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"1 through 10","median_amount":25082.78,"10th_percentile":21578.28,"90th_percentile":46766.58,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"1 through 10","median_amount":28943.29,"10th_percentile":28943.29,"90th_percentile":28943.29,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":33816.39,"10th_percentile":33816.39,"90th_percentile":33816.39,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"1 through 10","median_amount":53252.02,"10th_percentile":53252.02,"90th_percentile":53252.02,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":6178.64,"10th_percentile":6178.64,"90th_percentile":17700.11,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"1 through 10","median_amount":52453.07,"10th_percentile":52453.07,"90th_percentile":52453.07,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":17702.14,"10th_percentile":17702.14,"90th_percentile":17702.14,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"1 through 10","median_amount":64812.39,"10th_percentile":62403.57,"90th_percentile":66465.25,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":6759.33,"10th_percentile":6759.33,"90th_percentile":6759.33,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 1 Strapping and Cast Application","code_information":[{"code":"5101","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"1 through 10","median_amount":756.0,"10th_percentile":756.0,"90th_percentile":756.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":85.9,"10th_percentile":85.9,"90th_percentile":85.9,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":824.39,"10th_percentile":345.24,"90th_percentile":1191.86,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":260.7,"10th_percentile":260.7,"90th_percentile":441.3,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"1 through 10","median_amount":467.04,"10th_percentile":467.04,"90th_percentile":467.04,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 1 Musculoskeletal Procedures","code_information":[{"code":"5111","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":318.06,"10th_percentile":318.06,"90th_percentile":318.06,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":844.93,"10th_percentile":844.93,"90th_percentile":844.93,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"1 through 10","median_amount":1106.15,"10th_percentile":1106.15,"90th_percentile":1106.15,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":322.83,"10th_percentile":322.83,"90th_percentile":322.83,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":483.91,"10th_percentile":483.91,"90th_percentile":483.91,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":789.19,"10th_percentile":789.19,"90th_percentile":789.19,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"1 through 10","median_amount":1240.94,"10th_percentile":1240.94,"90th_percentile":1240.94,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":1226.12,"10th_percentile":1226.12,"90th_percentile":1226.12,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":1075.87,"10th_percentile":675.84,"90th_percentile":1889.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"1 through 10","median_amount":969.87,"10th_percentile":969.87,"90th_percentile":969.87,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":1100.74,"10th_percentile":1100.74,"90th_percentile":1100.74,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"1 through 10","median_amount":8684.32,"10th_percentile":2760.75,"90th_percentile":13275.38,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":318.06,"10th_percentile":318.06,"90th_percentile":318.06,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"1 through 10","median_amount":3587.8,"10th_percentile":3587.8,"90th_percentile":3587.8,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 2 Musculoskeletal Procedures","code_information":[{"code":"5112","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":898.15,"10th_percentile":898.15,"90th_percentile":1000.71,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":1517.47,"10th_percentile":1397.37,"90th_percentile":1618.78,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"1 through 10","median_amount":3803.7,"10th_percentile":3376.67,"90th_percentile":6159.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"23","median_amount":3388.0,"10th_percentile":2350.0,"90th_percentile":6776.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":780.5,"10th_percentile":610.32,"90th_percentile":780.5,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":211.35,"10th_percentile":211.35,"90th_percentile":211.35,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"1 through 10","median_amount":6920.45,"10th_percentile":6027.15,"90th_percentile":8148.83},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":3171.49,"10th_percentile":3062.38,"90th_percentile":3189.94,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"1 through 10","median_amount":3380.44,"10th_percentile":3380.44,"90th_percentile":3380.44,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"1 through 10","median_amount":4224.38,"10th_percentile":4224.38,"90th_percentile":4224.38,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"17","median_amount":1570.08,"10th_percentile":1226.78,"90th_percentile":1627.28,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1347.23,"10th_percentile":1347.23,"90th_percentile":1347.23,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"1 through 10","median_amount":9194.13,"10th_percentile":9194.13,"90th_percentile":9194.13},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":780.5,"10th_percentile":780.5,"90th_percentile":780.5,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"30","median_amount":1567.58,"10th_percentile":1324.78,"90th_percentile":1624.78,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"1 through 10","median_amount":7550.5,"10th_percentile":4455.78,"90th_percentile":9349.03,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"1 through 10","median_amount":5816.4,"10th_percentile":5756.33,"90th_percentile":7646.45,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"1 through 10","median_amount":6025.8,"10th_percentile":6025.8,"90th_percentile":6025.8,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"23","median_amount":1569.86,"10th_percentile":1250.46,"90th_percentile":1627.09,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"39","median_amount":5064.21,"10th_percentile":2954.37,"90th_percentile":6535.24,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":903.92,"10th_percentile":307.45,"90th_percentile":1347.23,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":1275.47,"10th_percentile":1275.47,"90th_percentile":1275.47,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 3 Musculoskeletal Procedures","code_information":[{"code":"5113","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1355.88,"10th_percentile":1347.23,"90th_percentile":1743.81,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"11","median_amount":3064.29,"10th_percentile":2668.38,"90th_percentile":3282.98,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"11","median_amount":4821.0,"10th_percentile":3212.3,"90th_percentile":8492.69,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"27","median_amount":3735.0,"10th_percentile":3169.6,"90th_percentile":6489.32,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1152.14,"10th_percentile":1152.14,"90th_percentile":2419.87,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"1 through 10","median_amount":14135.08,"10th_percentile":14135.08,"90th_percentile":16794.19},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":888.79,"10th_percentile":888.79,"90th_percentile":888.79,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":3289.86,"10th_percentile":3289.86,"90th_percentile":3289.86,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":6429.77,"10th_percentile":6429.77,"90th_percentile":6463.26,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"1 through 10","median_amount":11750.99,"10th_percentile":8687.0,"90th_percentile":12110.53,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":3287.86,"10th_percentile":3078.54,"90th_percentile":3287.86,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":3336.2,"10th_percentile":3336.2,"90th_percentile":3336.2,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"1 through 10","median_amount":19824.56,"10th_percentile":19824.56,"90th_percentile":19824.56},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"1 through 10","median_amount":20708.12,"10th_percentile":20708.12,"90th_percentile":20708.12},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1152.14,"10th_percentile":1152.14,"90th_percentile":1152.14,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"63","median_amount":3287.86,"10th_percentile":2988.54,"90th_percentile":3505.29,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"13","median_amount":10143.62,"10th_percentile":8153.71,"90th_percentile":19406.69,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"1 through 10","median_amount":8004.58,"10th_percentile":8004.58,"90th_percentile":8004.58,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"1 through 10","median_amount":12819.28,"10th_percentile":12819.28,"90th_percentile":12819.28,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"40","median_amount":3147.99,"10th_percentile":2625.49,"90th_percentile":3536.87,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"78","median_amount":9190.41,"10th_percentile":7379.93,"90th_percentile":16141.57,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1347.23,"10th_percentile":898.15,"90th_percentile":2191.85,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":2568.76,"10th_percentile":2500.47,"90th_percentile":2568.76,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"14","median_amount":14777.21,"10th_percentile":9930.85,"90th_percentile":21723.39,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 4 Musculoskeletal Procedures","code_information":[{"code":"5114","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"1 through 10","median_amount":11111.8,"10th_percentile":11111.8,"90th_percentile":11111.8,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":2856.53,"10th_percentile":2531.04,"90th_percentile":4552.31,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":7024.97,"10th_percentile":6663.69,"90th_percentile":9254.07,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"14","median_amount":13102.91,"10th_percentile":8048.81,"90th_percentile":23625.02,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"25","median_amount":9535.0,"10th_percentile":5639.85,"90th_percentile":17452.9,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"1 through 10","median_amount":7055.29,"10th_percentile":7055.29,"90th_percentile":7055.29,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1152.14,"10th_percentile":1152.14,"90th_percentile":2333.55,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":3538.83,"10th_percentile":3538.83,"90th_percentile":3538.83,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"1 through 10","median_amount":24225.9,"10th_percentile":19205.78,"90th_percentile":35798.14},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":2081.86,"10th_percentile":2081.86,"90th_percentile":2081.86,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":14156.56,"10th_percentile":13728.65,"90th_percentile":14157.9,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"1 through 10","median_amount":16112.52,"10th_percentile":16112.52,"90th_percentile":20269.81,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":6963.69,"10th_percentile":6833.74,"90th_percentile":7329.87,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"1 through 10","median_amount":26203.47,"10th_percentile":26203.47,"90th_percentile":26203.47},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"1 through 10","median_amount":7849.17,"10th_percentile":7849.17,"90th_percentile":7849.17},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1152.14,"10th_percentile":1152.14,"90th_percentile":1152.14,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"61","median_amount":7231.74,"10th_percentile":6931.74,"90th_percentile":7326.07,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"14","median_amount":23025.85,"10th_percentile":17314.0,"90th_percentile":28366.63,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"1 through 10","median_amount":17922.08,"10th_percentile":12820.62,"90th_percentile":27249.6,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":3611.47,"10th_percentile":3611.47,"90th_percentile":4022.01,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"1 through 10","median_amount":34077.79,"10th_percentile":34077.79,"90th_percentile":34077.79,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"36","median_amount":7005.52,"10th_percentile":5780.59,"90th_percentile":7322.77,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"79","median_amount":18702.09,"10th_percentile":13414.18,"90th_percentile":24441.86,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"14","median_amount":3004.37,"10th_percentile":2045.66,"90th_percentile":4327.77,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":5896.2,"10th_percentile":5505.94,"90th_percentile":7370.95,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"21","median_amount":22204.21,"10th_percentile":16801.17,"90th_percentile":30435.22,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 5 Musculoskeletal Procedures","code_information":[{"code":"5115","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":4006.95,"10th_percentile":3978.71,"90th_percentile":4134.16,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"17","median_amount":12895.18,"10th_percentile":12030.27,"90th_percentile":13188.39,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"1 through 10","median_amount":14089.95,"10th_percentile":12830.59,"90th_percentile":15863.88,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"25","median_amount":12049.48,"10th_percentile":10988.7,"90th_percentile":19052.2,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":4174.34,"10th_percentile":4174.34,"90th_percentile":4174.34,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":4740.03,"10th_percentile":4740.03,"90th_percentile":4740.03,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"1 through 10","median_amount":28875.91,"10th_percentile":28875.91,"90th_percentile":28875.91},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":13116.76,"10th_percentile":13116.76,"90th_percentile":13116.76,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":25825.33,"10th_percentile":25825.33,"90th_percentile":38948.29,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"1 through 10","median_amount":18558.68,"10th_percentile":18270.15,"90th_percentile":20456.58,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"1 through 10","median_amount":34724.82,"10th_percentile":34724.82,"90th_percentile":34724.82,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"12","median_amount":13108.44,"10th_percentile":12672.51,"90th_percentile":13192.17,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1337.17,"10th_percentile":1337.17,"90th_percentile":1337.17,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"80","median_amount":13115.46,"10th_percentile":12670.21,"90th_percentile":13193.53,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"1 through 10","median_amount":32473.79,"10th_percentile":31147.63,"90th_percentile":34611.09,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"1 through 10","median_amount":32927.66,"10th_percentile":32927.66,"90th_percentile":32927.66,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"1 through 10","median_amount":38510.02,"10th_percentile":38510.02,"90th_percentile":38510.02},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"1 through 10","median_amount":37243.72,"10th_percentile":33865.56,"90th_percentile":39396.18,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"41","median_amount":12975.42,"10th_percentile":10550.74,"90th_percentile":13190.29,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"60","median_amount":30532.94,"10th_percentile":25817.34,"90th_percentile":36503.23,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":9390.84,"10th_percentile":3991.0,"90th_percentile":9646.3,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":12983.48,"10th_percentile":10758.61,"90th_percentile":13202.02,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"1 through 10","median_amount":37797.68,"10th_percentile":37797.68,"90th_percentile":41817.47,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 6 Musculoskeletal Procedures","code_information":[{"code":"5116","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":4665.38,"10th_percentile":4665.38,"90th_percentile":4665.38,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":18865.97,"10th_percentile":18865.97,"90th_percentile":18865.97,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"1 through 10","median_amount":17461.75,"10th_percentile":17461.75,"90th_percentile":17461.75,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"1 through 10","median_amount":16442.88,"10th_percentile":15620.74,"90th_percentile":17553.22,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"1 through 10","median_amount":38222.59,"10th_percentile":38222.59,"90th_percentile":38222.59,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":18597.16,"10th_percentile":18308.61,"90th_percentile":18799.99,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"15","median_amount":18701.49,"10th_percentile":18299.84,"90th_percentile":19146.07,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"1 through 10","median_amount":38326.91,"10th_percentile":38326.91,"90th_percentile":38326.91,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":18068.36,"10th_percentile":17542.83,"90th_percentile":18774.51,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"1 through 10","median_amount":34782.17,"10th_percentile":33989.21,"90th_percentile":35593.28,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":12197.83,"10th_percentile":12197.83,"90th_percentile":12197.83,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":136.79,"10th_percentile":136.79,"90th_percentile":136.79,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"1 through 10","median_amount":46665.56,"10th_percentile":46665.56,"90th_percentile":46665.56,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 1 Airway Endoscopy","code_information":[{"code":"5151","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":308.8,"10th_percentile":308.8,"90th_percentile":308.8,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"1 through 10","median_amount":663.0,"10th_percentile":271.0,"90th_percentile":2654.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":326.71,"10th_percentile":32.71,"90th_percentile":332.71,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":293.84,"10th_percentile":293.84,"90th_percentile":293.84,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":326.71,"10th_percentile":261.37,"90th_percentile":326.71,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"1 through 10","median_amount":470.73,"10th_percentile":470.73,"90th_percentile":470.73,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"12","median_amount":308.8,"10th_percentile":130.35,"90th_percentile":330.72,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"1 through 10","median_amount":460.79,"10th_percentile":460.79,"90th_percentile":465.43,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 3 Airway Endoscopy","code_information":[{"code":"5153","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":3435.27,"10th_percentile":3435.27,"90th_percentile":3435.27,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"1 through 10","median_amount":3388.0,"10th_percentile":3388.0,"90th_percentile":3388.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":1744.27,"10th_percentile":1744.27,"90th_percentile":1744.27,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"13","median_amount":1750.27,"10th_percentile":1595.27,"90th_percentile":1751.27,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":1401.28,"10th_percentile":1386.58,"90th_percentile":3642.05,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":770.93,"10th_percentile":770.93,"90th_percentile":770.93,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 4 Airway Endoscopy","code_information":[{"code":"5154","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":3948.04,"10th_percentile":3948.04,"90th_percentile":3948.04,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"1 through 10","median_amount":4589.0,"10th_percentile":4589.0,"90th_percentile":4589.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"1 through 10","median_amount":72.0,"10th_percentile":72.0,"90th_percentile":72.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"1 through 10","median_amount":18310.2,"10th_percentile":18310.2,"90th_percentile":18310.2},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":7306.33,"10th_percentile":7306.33,"90th_percentile":7306.33,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":3648.04,"10th_percentile":3648.04,"90th_percentile":3648.04,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":3735.27,"10th_percentile":3646.54,"90th_percentile":3736.27,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"1 through 10","median_amount":7627.51,"10th_percentile":7627.51,"90th_percentile":13751.96,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":3489.35,"10th_percentile":2994.99,"90th_percentile":6269.32,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"1 through 10","median_amount":8090.93,"10th_percentile":7086.96,"90th_percentile":17510.76,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":790.72,"10th_percentile":790.72,"90th_percentile":790.72,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"1 through 10","median_amount":13235.7,"10th_percentile":13235.7,"90th_percentile":13235.7,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."}]}]},{"description":"Level 5 Airway Endoscopy","code_information":[{"code":"5155","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"1 through 10","median_amount":27210.5,"10th_percentile":21215.27,"90th_percentile":27861.41,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"1 through 10","median_amount":12831.61,"10th_percentile":12024.99,"90th_percentile":16196.18,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"1 through 10","median_amount":23143.5,"10th_percentile":23143.5,"90th_percentile":23143.5,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":7007.94,"10th_percentile":7007.94,"90th_percentile":7008.94,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"1 through 10","median_amount":27234.98,"10th_percentile":27234.98,"90th_percentile":27234.98,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"1 through 10","median_amount":21250.75,"10th_percentile":21250.75,"90th_percentile":21250.75,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"1 through 10","median_amount":20646.33,"10th_percentile":20646.33,"90th_percentile":20646.33,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":7008.95,"10th_percentile":7008.95,"90th_percentile":7008.95,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"16","median_amount":19599.67,"10th_percentile":14261.63,"90th_percentile":23649.93,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 1 ENT Procedures","code_information":[{"code":"5161","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":2287.84,"10th_percentile":2287.84,"90th_percentile":2287.84,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 2 ENT Procedures","code_information":[{"code":"5162","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":746.24,"10th_percentile":746.24,"90th_percentile":746.24,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":64.72,"10th_percentile":64.72,"90th_percentile":64.72,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":67.25,"10th_percentile":67.25,"90th_percentile":67.25,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"1 through 10","median_amount":3039.56,"10th_percentile":3039.56,"90th_percentile":3039.56,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":896.14,"10th_percentile":896.14,"90th_percentile":896.14,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"1 through 10","median_amount":2592.37,"10th_percentile":2592.37,"90th_percentile":2592.37,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 3 ENT Procedures","code_information":[{"code":"5163","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"13","median_amount":882.67,"10th_percentile":871.81,"90th_percentile":882.67,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"17","median_amount":5636.7,"10th_percentile":4837.2,"90th_percentile":6063.45,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"35","median_amount":4935.7,"10th_percentile":3218.6,"90th_percentile":5082.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":483.16,"10th_percentile":483.16,"90th_percentile":483.16,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"1 through 10","median_amount":5203.5,"10th_percentile":5203.5,"90th_percentile":5203.5,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"1 through 10","median_amount":5128.5,"10th_percentile":5128.5,"90th_percentile":5128.5,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":882.67,"10th_percentile":882.67,"90th_percentile":882.67,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"1 through 10","median_amount":4523.39,"10th_percentile":4523.39,"90th_percentile":4523.39},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":871.81,"10th_percentile":871.81,"90th_percentile":882.67,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"1 through 10","median_amount":4219.52,"10th_percentile":4219.51,"90th_percentile":4363.5,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"1 through 10","median_amount":4219.51,"10th_percentile":4219.51,"90th_percentile":4219.51,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":1498.37,"10th_percentile":1498.37,"90th_percentile":1498.37,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":871.81,"10th_percentile":871.81,"90th_percentile":871.81,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"1 through 10","median_amount":5210.86,"10th_percentile":5210.86,"90th_percentile":5210.86},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":483.16,"10th_percentile":483.16,"90th_percentile":483.16,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":1804.28,"10th_percentile":1804.28,"90th_percentile":1804.28,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"1 through 10","median_amount":5745.45,"10th_percentile":4409.45,"90th_percentile":6241.05,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"1 through 10","median_amount":3208.23,"10th_percentile":3005.76,"90th_percentile":3546.77,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":871.81,"10th_percentile":871.81,"90th_percentile":871.81,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"1 through 10","median_amount":4051.93,"10th_percentile":3997.0,"90th_percentile":4328.22,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":1498.29,"10th_percentile":1498.29,"90th_percentile":1498.29,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"77","median_amount":3698.72,"10th_percentile":2748.77,"90th_percentile":4331.9,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"12","median_amount":882.67,"10th_percentile":871.81,"90th_percentile":882.67,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"1 through 10","median_amount":4603.8,"10th_percentile":4603.8,"90th_percentile":4603.8,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."}]}]},{"description":"Level 4 ENT Procedures","code_information":[{"code":"5164","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1542.89,"10th_percentile":1542.89,"90th_percentile":1542.89,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"17","median_amount":7582.62,"10th_percentile":4106.0,"90th_percentile":8378.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"40","median_amount":5082.0,"10th_percentile":3388.0,"90th_percentile":6828.6,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":780.5,"10th_percentile":780.5,"90th_percentile":780.5,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"1 through 10","median_amount":4549.0,"10th_percentile":4549.0,"90th_percentile":4549.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"1 through 10","median_amount":10078.46,"10th_percentile":5333.71,"90th_percentile":14231.06},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1052.77,"10th_percentile":1052.77,"90th_percentile":1334.42,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":6460.19,"10th_percentile":6460.19,"90th_percentile":6460.19,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"13","median_amount":6476.51,"10th_percentile":6130.51,"90th_percentile":8451.97,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"1 through 10","median_amount":6567.79,"10th_percentile":6567.79,"90th_percentile":6567.79,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"1 through 10","median_amount":11807.58,"10th_percentile":11807.58,"90th_percentile":11807.58},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":780.5,"10th_percentile":780.5,"90th_percentile":780.5,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":3136.74,"10th_percentile":3136.74,"90th_percentile":3136.74,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"1 through 10","median_amount":13693.5,"10th_percentile":7791.0,"90th_percentile":15582.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"1 through 10","median_amount":9157.38,"10th_percentile":6551.29,"90th_percentile":10378.76,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":2091.07,"10th_percentile":2091.07,"90th_percentile":2091.07,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"1 through 10","median_amount":9721.46,"10th_percentile":5836.04,"90th_percentile":22593.6,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":3285.31,"10th_percentile":3285.31,"90th_percentile":3285.31,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"107","median_amount":8293.93,"10th_percentile":4855.86,"90th_percentile":12202.09,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":893.08,"10th_percentile":824.68,"90th_percentile":1542.89,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"1 through 10","median_amount":6777.19,"10th_percentile":6777.19,"90th_percentile":6777.19,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."}]}]},{"description":"Level 5 ENT Procedures","code_information":[{"code":"5165","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1334.42,"10th_percentile":1334.42,"90th_percentile":1542.89,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"1 through 10","median_amount":5441.0,"10th_percentile":5441.0,"90th_percentile":5441.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"1 through 10","median_amount":4428.0,"10th_percentile":4142.46,"90th_percentile":7816.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"1 through 10","median_amount":8939.25,"10th_percentile":8939.25,"90th_percentile":8939.25,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"1 through 10","median_amount":24426.26,"10th_percentile":24426.26,"90th_percentile":24426.26},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"1 through 10","median_amount":6048.88,"10th_percentile":4226.0,"90th_percentile":27213.07,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":824.68,"10th_percentile":824.68,"90th_percentile":824.68,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"1 through 10","median_amount":10319.8,"10th_percentile":10319.8,"90th_percentile":10319.8,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1542.89,"10th_percentile":1542.89,"90th_percentile":1542.89,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"1 through 10","median_amount":9172.74,"10th_percentile":9172.74,"90th_percentile":9172.74,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"22","median_amount":6841.67,"10th_percentile":6275.51,"90th_percentile":7914.6,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":893.08,"10th_percentile":893.08,"90th_percentile":893.08,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 1 Vascular Procedures","code_information":[{"code":"5181","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":305.43,"10th_percentile":305.43,"90th_percentile":305.43,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":625.36,"10th_percentile":500.29,"90th_percentile":625.36,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"1 through 10","median_amount":2815.0,"10th_percentile":2815.0,"90th_percentile":2815.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":334.5,"10th_percentile":334.5,"90th_percentile":334.5,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"1 through 10","median_amount":4064.7,"10th_percentile":4064.7,"90th_percentile":4064.7},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":1149.93,"10th_percentile":1149.93,"90th_percentile":1149.93,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":316.96,"10th_percentile":316.96,"90th_percentile":572.63,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":1498.35,"10th_percentile":1498.35,"90th_percentile":1498.35,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"91","median_amount":625.36,"10th_percentile":610.96,"90th_percentile":717.34,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"1 through 10","median_amount":3030.0,"10th_percentile":3030.0,"90th_percentile":3030.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"1 through 10","median_amount":1413.26,"10th_percentile":1413.26,"90th_percentile":1413.26,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":306.26,"10th_percentile":306.26,"90th_percentile":306.26,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"23","median_amount":610.97,"10th_percentile":488.77,"90th_percentile":888.46,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"1 through 10","median_amount":1894.92,"10th_percentile":1330.93,"90th_percentile":3260.25,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":417.85,"10th_percentile":306.26,"90th_percentile":417.85,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":623.18,"10th_percentile":623.18,"90th_percentile":623.18,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 2 Vascular Procedures","code_information":[{"code":"5182","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":3389.8,"10th_percentile":1563.57,"90th_percentile":21015.2,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"1 through 10","median_amount":2654.0,"10th_percentile":2654.0,"90th_percentile":4135.24,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":1214.57,"10th_percentile":1214.57,"90th_percentile":1214.57,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":3078.41,"10th_percentile":3078.41,"90th_percentile":3078.41,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":1571.27,"10th_percentile":1571.27,"90th_percentile":1709.62,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"14","median_amount":1571.27,"10th_percentile":1296.59,"90th_percentile":3183.63,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"1 through 10","median_amount":3030.0,"10th_percentile":3030.0,"90th_percentile":3030.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"1 through 10","median_amount":2549.92,"10th_percentile":2549.92,"90th_percentile":2549.92,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":1578.58,"10th_percentile":1439.41,"90th_percentile":4357.83,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"1 through 10","median_amount":3591.05,"10th_percentile":3046.17,"90th_percentile":5143.11,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1343.85,"10th_percentile":1343.85,"90th_percentile":1343.85,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":1583.66,"10th_percentile":1583.66,"90th_percentile":1583.66,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 3 Vascular Procedures","code_information":[{"code":"5183","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":2972.58,"10th_percentile":2805.99,"90th_percentile":3183.63,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"1 through 10","median_amount":5602.5,"10th_percentile":5602.5,"90th_percentile":9114.93,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"1 through 10","median_amount":4222.2,"10th_percentile":4162.2,"90th_percentile":4449.2,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1152.14,"10th_percentile":1152.14,"90th_percentile":1152.14,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":888.73,"10th_percentile":888.73,"90th_percentile":888.73,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":2742.63,"10th_percentile":2742.63,"90th_percentile":2742.63,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":6073.46,"10th_percentile":6073.46,"90th_percentile":6237.33,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"1 through 10","median_amount":10226.42,"10th_percentile":10226.42,"90th_percentile":10226.42,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"1 through 10","median_amount":21509.71,"10th_percentile":21509.71,"90th_percentile":21509.71,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"14","median_amount":3183.63,"10th_percentile":2889.63,"90th_percentile":3191.63,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1063.78,"10th_percentile":1063.78,"90th_percentile":1063.78,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"62","median_amount":3183.63,"10th_percentile":2889.63,"90th_percentile":3189.63,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"1 through 10","median_amount":8405.0,"10th_percentile":8405.0,"90th_percentile":12985.5,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"1 through 10","median_amount":11810.34,"10th_percentile":8197.93,"90th_percentile":17477.42,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"29","median_amount":2978.09,"10th_percentile":2546.9,"90th_percentile":3183.63,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"16","median_amount":10024.89,"10th_percentile":7565.01,"90th_percentile":18597.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":880.46,"10th_percentile":880.46,"90th_percentile":880.46,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":2597.84,"10th_percentile":2529.6,"90th_percentile":2597.84,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 4 Vascular Procedures","code_information":[{"code":"5184","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":5111.28,"10th_percentile":5111.28,"90th_percentile":5111.28,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1152.14,"10th_percentile":1152.14,"90th_percentile":1152.14,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":10054.28,"10th_percentile":10054.28,"90th_percentile":10054.28,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":5344.5,"10th_percentile":5344.5,"90th_percentile":5405.28,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":5344.5,"10th_percentile":5344.5,"90th_percentile":5344.5,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":5055.4,"10th_percentile":5055.4,"90th_percentile":5055.4,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 1 Endovascular Procedures","code_information":[{"code":"5191","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1051.33,"10th_percentile":1045.12,"90th_percentile":1579.13,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"25","median_amount":3253.34,"10th_percentile":2602.66,"90th_percentile":3319.73,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"1 through 10","median_amount":16297.59,"10th_percentile":12766.14,"90th_percentile":27503.18,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"20","median_amount":10639.46,"10th_percentile":7290.7,"90th_percentile":18282.11,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1522.33,"10th_percentile":1522.33,"90th_percentile":1522.33,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"1 through 10","median_amount":15872.83,"10th_percentile":15872.83,"90th_percentile":15872.83,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"1 through 10","median_amount":13670.15,"10th_percentile":13670.15,"90th_percentile":14554.36},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":3169.11,"10th_percentile":3169.11,"90th_percentile":3169.11,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"23","median_amount":6373.88,"10th_percentile":6208.88,"90th_percentile":6407.08,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"1 through 10","median_amount":13422.05,"10th_percentile":13422.05,"90th_percentile":16372.58,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"19","median_amount":3259.34,"10th_percentile":2910.34,"90th_percentile":3343.66,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1029.77,"10th_percentile":1029.77,"90th_percentile":1029.77,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"1 through 10","median_amount":14039.65,"10th_percentile":14039.65,"90th_percentile":14039.65},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"113","median_amount":3175.11,"10th_percentile":2959.34,"90th_percentile":3260.34,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"1 through 10","median_amount":15691.0,"10th_percentile":15691.0,"90th_percentile":17467.81,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"1 through 10","median_amount":12156.51,"10th_percentile":12156.51,"90th_percentile":12156.51,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1481.29,"10th_percentile":1481.29,"90th_percentile":1481.29,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"1 through 10","median_amount":13407.62,"10th_percentile":13407.62,"90th_percentile":17618.39,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"86","median_amount":3253.34,"10th_percentile":2650.56,"90th_percentile":3261.64,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"44","median_amount":12189.22,"10th_percentile":10359.16,"90th_percentile":23827.27,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1055.22,"10th_percentile":1055.22,"90th_percentile":1055.22,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":3232.5,"10th_percentile":2685.11,"90th_percentile":3318.4,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"1 through 10","median_amount":13520.66,"10th_percentile":13520.66,"90th_percentile":13520.66,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."}]}]},{"description":"Level 2 Endovascular Procedures","code_information":[{"code":"5192","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":5766.98,"10th_percentile":5472.98,"90th_percentile":11491.98,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"1 through 10","median_amount":7755.0,"10th_percentile":7755.0,"90th_percentile":7755.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"1 through 10","median_amount":9724.67,"10th_percentile":9724.67,"90th_percentile":9724.67,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":11357.41,"10th_percentile":11357.41,"90th_percentile":22473.33,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":5772.98,"10th_percentile":5766.98,"90th_percentile":6066.98,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"17","median_amount":5565.77,"10th_percentile":5390.66,"90th_percentile":5772.98,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"1 through 10","median_amount":30477.25,"10th_percentile":30477.25,"90th_percentile":30477.25,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":5558.77,"10th_percentile":4613.59,"90th_percentile":5773.98,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"1 through 10","median_amount":33614.44,"10th_percentile":33614.44,"90th_percentile":33614.44,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1586.17,"10th_percentile":1586.17,"90th_percentile":1586.17,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":5775.28,"10th_percentile":5775.28,"90th_percentile":5775.28,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 3 Endovascular Procedures","code_information":[{"code":"5193","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":8288.46,"10th_percentile":8288.46,"90th_percentile":8288.46,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"14","median_amount":10886.6,"10th_percentile":9176.61,"90th_percentile":17053.78,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"1 through 10","median_amount":26104.75,"10th_percentile":19340.18,"90th_percentile":29716.92,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"1 through 10","median_amount":18462.89,"10th_percentile":13764.07,"90th_percentile":36000.47,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":2690.52,"10th_percentile":2690.52,"90th_percentile":2690.52,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":16517.79,"10th_percentile":16517.79,"90th_percentile":16517.79,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":22473.33,"10th_percentile":20961.66,"90th_percentile":22473.33,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"1 through 10","median_amount":26449.54,"10th_percentile":26449.54,"90th_percentile":26449.54,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":11176.76,"10th_percentile":9063.37,"90th_percentile":11517.58,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"1 through 10","median_amount":28224.98,"10th_percentile":28224.98,"90th_percentile":28224.98},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":4698.35,"10th_percentile":4698.35,"90th_percentile":4698.35,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"60","median_amount":11176.76,"10th_percentile":10416.33,"90th_percentile":11476.76,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"1 through 10","median_amount":26201.74,"10th_percentile":18365.0,"90th_percentile":40501.04,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"1 through 10","median_amount":25855.45,"10th_percentile":25855.45,"90th_percentile":40726.22,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"52","median_amount":11127.77,"10th_percentile":9176.61,"90th_percentile":11479.07,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"13","median_amount":29315.45,"10th_percentile":22507.31,"90th_percentile":37845.94,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":4567.83,"10th_percentile":4567.83,"90th_percentile":4567.83,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":14820.9,"10th_percentile":14820.9,"90th_percentile":14820.9,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 4 Endovascular Procedures","code_information":[{"code":"5194","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":17059.78,"10th_percentile":17059.78,"90th_percentile":17059.78,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"1 through 10","median_amount":17834.03,"10th_percentile":17834.03,"90th_percentile":17834.03,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"1 through 10","median_amount":30197.7,"10th_percentile":30197.7,"90th_percentile":30197.7},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":17053.78,"10th_percentile":17053.78,"90th_percentile":17053.78,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":7365.82,"10th_percentile":7365.82,"90th_percentile":7365.82,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":18162.87,"10th_percentile":17868.87,"90th_percentile":18181.99,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":18169.87,"10th_percentile":18162.87,"90th_percentile":18170.77,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"1 through 10","median_amount":55717.31,"10th_percentile":55717.31,"90th_percentile":55717.31,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":6259.67,"10th_percentile":6259.67,"90th_percentile":6259.67,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Implantation Wireless PA Pressure Monitor","code_information":[{"code":"5200","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":28754.69,"10th_percentile":28754.69,"90th_percentile":28754.69,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":28754.69,"10th_percentile":28754.69,"90th_percentile":28754.69,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":7790.71,"10th_percentile":7790.71,"90th_percentile":7790.71,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":28411.69,"10th_percentile":28411.69,"90th_percentile":28411.69,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 2 Electrophysiologic Procedures","code_information":[{"code":"5212","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":2858.05,"10th_percentile":2858.05,"90th_percentile":2858.05,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"1 through 10","median_amount":12729.97,"10th_percentile":12729.97,"90th_percentile":12729.97,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":7675.22,"10th_percentile":7675.22,"90th_percentile":7675.22,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":7681.21,"10th_percentile":7681.21,"90th_percentile":7681.21,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"1 through 10","median_amount":40790.04,"10th_percentile":40790.04,"90th_percentile":40790.04,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":7991.22,"10th_percentile":7991.22,"90th_percentile":7991.22,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"1 through 10","median_amount":18467.99,"10th_percentile":18467.99,"90th_percentile":18467.99,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":5847.78,"10th_percentile":5847.78,"90th_percentile":5847.78,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 3 Electrophysiologic Procedures","code_information":[{"code":"5213","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":23399.36,"10th_percentile":22804.46,"90th_percentile":24915.21,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"1 through 10","median_amount":84776.42,"10th_percentile":65044.25,"90th_percentile":99727.8,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"1 through 10","median_amount":51978.28,"10th_percentile":48216.26,"90th_percentile":68285.29,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":7432.76,"10th_percentile":7432.76,"90th_percentile":7432.76,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"1 through 10","median_amount":51150.67,"10th_percentile":51150.67,"90th_percentile":51150.67},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":48615.05,"10th_percentile":48615.05,"90th_percentile":48868.26,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"1 through 10","median_amount":70486.1,"10th_percentile":70486.1,"90th_percentile":70486.1,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":24818.71,"10th_percentile":24519.93,"90th_percentile":24819.93,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":10994.46,"10th_percentile":10994.46,"90th_percentile":10994.46,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"78","median_amount":24819.93,"10th_percentile":23102.96,"90th_percentile":24819.93,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"1 through 10","median_amount":43095.74,"10th_percentile":42902.74,"90th_percentile":44069.74,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"1 through 10","median_amount":83252.97,"10th_percentile":83252.97,"90th_percentile":83355.62,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":10298.69,"10th_percentile":10298.69,"90th_percentile":10298.69,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"33","median_amount":24739.59,"10th_percentile":22755.47,"90th_percentile":24821.84,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"21","median_amount":65224.12,"10th_percentile":57084.22,"90th_percentile":75676.05,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":8502.31,"10th_percentile":8502.31,"90th_percentile":10952.7,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":18848.35,"10th_percentile":18848.35,"90th_percentile":18848.35,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 1 Pacemaker and Similar Procedures","code_information":[{"code":"5221","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":3779.14,"10th_percentile":3779.14,"90th_percentile":3779.14,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 2 Pacemaker and Similar Procedures","code_information":[{"code":"5222","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":696.26,"10th_percentile":696.26,"90th_percentile":696.26,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":8076.98,"10th_percentile":8076.98,"90th_percentile":8076.98,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":16400.31,"10th_percentile":16400.31,"90th_percentile":16400.31,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":8268.48,"10th_percentile":8268.48,"90th_percentile":8268.48,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1436.35,"10th_percentile":1436.35,"90th_percentile":1436.35,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":8260.14,"10th_percentile":8076.98,"90th_percentile":8376.48,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"1 through 10","median_amount":16810.0,"10th_percentile":16810.0,"90th_percentile":16810.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":3273.68,"10th_percentile":3273.68,"90th_percentile":3273.68,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":8377.45,"10th_percentile":8268.38,"90th_percentile":10198.38,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"1 through 10","median_amount":15714.06,"10th_percentile":15714.06,"90th_percentile":15714.06,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 3 Pacemaker and Similar Procedures","code_information":[{"code":"5223","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"1 through 10","median_amount":12918.51,"10th_percentile":12918.51,"90th_percentile":12918.51,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":10585.48,"10th_percentile":10585.48,"90th_percentile":10585.48,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":20346.41,"10th_percentile":20346.41,"90th_percentile":20346.41,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":10591.48,"10th_percentile":9889.73,"90th_percentile":10591.48,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"34","median_amount":10526.48,"10th_percentile":10164.65,"90th_percentile":10591.48,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"14","median_amount":10592.48,"10th_percentile":10228.52,"90th_percentile":19299.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"1 through 10","median_amount":15937.65,"10th_percentile":15937.65,"90th_percentile":15937.65,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":10797.19,"10th_percentile":10797.19,"90th_percentile":10797.19,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 4 Pacemaker and Similar Procedures","code_information":[{"code":"5224","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":19296.09,"10th_percentile":19296.09,"90th_percentile":19296.09,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":19296.09,"10th_percentile":18996.09,"90th_percentile":19296.09,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"1 through 10","median_amount":22760.68,"10th_percentile":22760.68,"90th_percentile":22760.68,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":7785.82,"10th_percentile":7785.82,"90th_percentile":7785.82,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"1 through 10","median_amount":38503.86,"10th_percentile":38503.86,"90th_percentile":38503.86,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 1 ICD and Similar Procedures","code_information":[{"code":"5231","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"1 through 10","median_amount":25607.5,"10th_percentile":25607.5,"90th_percentile":25607.5,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":9289.52,"10th_percentile":9289.52,"90th_percentile":9289.52,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":22928.89,"10th_percentile":22928.89,"90th_percentile":22928.89,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"1 through 10","median_amount":49024.46,"10th_percentile":49024.46,"90th_percentile":49024.46,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."}]}]},{"description":"Level 2 ICD and Similar Procedures","code_information":[{"code":"5232","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":32429.65,"10th_percentile":32429.65,"90th_percentile":32429.65,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"1 through 10","median_amount":25389.85,"10th_percentile":25389.85,"90th_percentile":25389.85,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":62686.06,"10th_percentile":62686.06,"90th_percentile":62686.06,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":32429.65,"10th_percentile":32429.65,"90th_percentile":32429.65,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":32000.51,"10th_percentile":31996.01,"90th_percentile":32735.65,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":89.47,"10th_percentile":89.47,"90th_percentile":89.47,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"1 through 10","median_amount":65506.25,"10th_percentile":55946.83,"90th_percentile":93624.25,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":9301.08,"10th_percentile":9301.08,"90th_percentile":9301.08,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":27122.4,"10th_percentile":27122.4,"90th_percentile":27122.4,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 1 Blood Product Exchange and Related Services","code_information":[{"code":"5241","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":633.22,"10th_percentile":633.22,"90th_percentile":1266.44,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"1 through 10","median_amount":2664.67,"10th_percentile":2664.67,"90th_percentile":2664.67,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"1 through 10","median_amount":1249.51,"10th_percentile":1249.51,"90th_percentile":1249.51,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":2605.73,"10th_percentile":2605.73,"90th_percentile":2605.73,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"11","median_amount":665.37,"10th_percentile":635.02,"90th_percentile":824.24,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"33","median_amount":802.16,"10th_percentile":633.22,"90th_percentile":1017.75,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"14","median_amount":633.23,"10th_percentile":542.56,"90th_percentile":1254.72,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"1 through 10","median_amount":1359.15,"10th_percentile":1343.4,"90th_percentile":2496.3,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":683.45,"10th_percentile":683.45,"90th_percentile":1088.96,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 1 Upper GI Procedures","code_information":[{"code":"5301","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"28","median_amount":351.84,"10th_percentile":310.38,"90th_percentile":424.54,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"58","median_amount":948.33,"10th_percentile":758.66,"90th_percentile":1168.7,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"39","median_amount":3335.0,"10th_percentile":1693.02,"90th_percentile":3585.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"99","median_amount":2654.0,"10th_percentile":515.45,"90th_percentile":3781.95,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":445.77,"10th_percentile":343.85,"90th_percentile":870.11,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"1 through 10","median_amount":3431.21,"10th_percentile":3431.21,"90th_percentile":3938.57,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":445.78,"10th_percentile":445.78,"90th_percentile":445.78,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"11","median_amount":5184.38,"10th_percentile":3677.95,"90th_percentile":7925.47},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":415.64,"10th_percentile":415.64,"90th_percentile":415.64,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":957.33,"10th_percentile":957.33,"90th_percentile":957.33,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"59","median_amount":1857.95,"10th_percentile":1727.21,"90th_percentile":2775.69,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"15","median_amount":2285.01,"10th_percentile":1484.0,"90th_percentile":2965.62,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"1 through 10","median_amount":4383.76,"10th_percentile":2285.01,"90th_percentile":5342.05,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"23","median_amount":893.77,"10th_percentile":587.6,"90th_percentile":1350.31,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"13","median_amount":304.59,"10th_percentile":304.59,"90th_percentile":415.64,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":705.28,"10th_percentile":705.28,"90th_percentile":705.28,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"1 through 10","median_amount":4973.14,"10th_percentile":4973.14,"90th_percentile":6284.01},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"15","median_amount":436.42,"10th_percentile":430.12,"90th_percentile":670.18,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"230","median_amount":948.33,"10th_percentile":881.6,"90th_percentile":1409.42,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"31","median_amount":4743.5,"10th_percentile":2590.0,"90th_percentile":6478.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"1 through 10","median_amount":4214.56,"10th_percentile":854.18,"90th_percentile":6954.27,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":360.96,"10th_percentile":304.59,"90th_percentile":692.99,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"1 through 10","median_amount":4686.89,"10th_percentile":3676.27,"90th_percentile":4692.63,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"108","median_amount":895.36,"10th_percentile":590.63,"90th_percentile":1319.98,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"224","median_amount":3788.67,"10th_percentile":1837.88,"90th_percentile":7048.49,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"75","median_amount":400.73,"10th_percentile":304.59,"90th_percentile":784.6,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":955.83,"10th_percentile":955.83,"90th_percentile":955.83,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":888.6,"10th_percentile":888.6,"90th_percentile":888.6,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"18","median_amount":903.17,"10th_percentile":773.83,"90th_percentile":1450.94,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 2 Upper GI Procedures","code_information":[{"code":"5302","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":831.28,"10th_percentile":831.28,"90th_percentile":1210.94,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"13","median_amount":1797.57,"10th_percentile":1624.77,"90th_percentile":1924.77,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"11","median_amount":5773.5,"10th_percentile":4106.0,"90th_percentile":8222.99,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"34","median_amount":4715.0,"10th_percentile":3275.19,"90th_percentile":6042.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":872.84,"10th_percentile":872.84,"90th_percentile":1306.53,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":882.21,"10th_percentile":882.21,"90th_percentile":882.21,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"1 through 10","median_amount":9428.42,"10th_percentile":4741.92,"90th_percentile":11758.92},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":801.46,"10th_percentile":801.46,"90th_percentile":801.46,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":1926.57,"10th_percentile":1859.58,"90th_percentile":3407.21,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":3759.23,"10th_percentile":3625.63,"90th_percentile":3778.8,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"1 through 10","median_amount":2965.62,"10th_percentile":2152.49,"90th_percentile":4043.29,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"1 through 10","median_amount":1931.43,"10th_percentile":1931.43,"90th_percentile":1931.43},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"17","median_amount":1850.58,"10th_percentile":1624.77,"90th_percentile":2033.82,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1244.32,"10th_percentile":801.46,"90th_percentile":1659.96,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":2475.57,"10th_percentile":2475.57,"90th_percentile":2475.57,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"1 through 10","median_amount":2159.97,"10th_percentile":2159.97,"90th_percentile":2159.97},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":872.84,"10th_percentile":483.16,"90th_percentile":872.84,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"124","median_amount":1918.77,"10th_percentile":1535.01,"90th_percentile":1924.77,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"13","median_amount":6934.5,"10th_percentile":4761.0,"90th_percentile":8090.25,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"1 through 10","median_amount":7321.02,"10th_percentile":6356.76,"90th_percentile":8644.72,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":801.46,"10th_percentile":801.46,"90th_percentile":801.46,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"1 through 10","median_amount":2940.26,"10th_percentile":2940.26,"90th_percentile":2940.26,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"72","median_amount":1799.47,"10th_percentile":1480.47,"90th_percentile":2114.57,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"84","median_amount":4491.55,"10th_percentile":3416.86,"90th_percentile":8940.58,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":831.28,"10th_percentile":415.64,"90th_percentile":1244.32,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1856.49,"10th_percentile":1856.49,"90th_percentile":1856.49,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":1510.08,"10th_percentile":1461.91,"90th_percentile":1565.72,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 3 Upper GI Procedures","code_information":[{"code":"5303","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":3554.21,"10th_percentile":3554.21,"90th_percentile":3554.21,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":3848.21,"10th_percentile":3848.21,"90th_percentile":3854.21,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":3854.21,"10th_percentile":3554.21,"90th_percentile":3855.21,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1114.17,"10th_percentile":1114.17,"90th_percentile":1114.17,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":3593.11,"10th_percentile":3593.11,"90th_percentile":3593.11,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"1 through 10","median_amount":13391.44,"10th_percentile":13391.44,"90th_percentile":13391.44,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 1 Lower GI Procedures","code_information":[{"code":"5311","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":413.04,"10th_percentile":413.04,"90th_percentile":421.94,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"18","median_amount":922.18,"10th_percentile":861.04,"90th_percentile":1883.58,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"34","median_amount":3335.0,"10th_percentile":3174.0,"90th_percentile":3504.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"115","median_amount":2654.0,"10th_percentile":2654.0,"90th_percentile":2815.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":443.04,"10th_percentile":433.69,"90th_percentile":859.9,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"1 through 10","median_amount":4547.8,"10th_percentile":4547.8,"90th_percentile":4547.8,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"1 through 10","median_amount":3743.17,"10th_percentile":3743.17,"90th_percentile":3743.17,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":413.04,"10th_percentile":413.04,"90th_percentile":413.04,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"1 through 10","median_amount":5132.3,"10th_percentile":4098.71,"90th_percentile":5344.81},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":888.87,"10th_percentile":870.04,"90th_percentile":922.18,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"41","median_amount":1806.72,"10th_percentile":1695.72,"90th_percentile":1816.13,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"30","median_amount":1543.0,"10th_percentile":1492.0,"90th_percentile":2209.52,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"1 through 10","median_amount":4633.84,"10th_percentile":4633.84,"90th_percentile":4633.84,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"25","median_amount":922.18,"10th_percentile":888.87,"90th_percentile":922.18,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":711.1,"10th_percentile":711.1,"90th_percentile":711.1,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"1 through 10","median_amount":5527.1,"10th_percentile":5302.65,"90th_percentile":6362.76},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":433.69,"10th_percentile":433.69,"90th_percentile":483.16,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"186","median_amount":922.18,"10th_percentile":861.04,"90th_percentile":1031.94,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"42","median_amount":4761.0,"10th_percentile":4623.0,"90th_percentile":4761.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"22","median_amount":4479.92,"10th_percentile":4095.1,"90th_percentile":5388.55,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":418.38,"10th_percentile":418.38,"90th_percentile":418.38,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"1 through 10","median_amount":4646.23,"10th_percentile":4192.63,"90th_percentile":6637.35,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"96","median_amount":922.18,"10th_percentile":888.87,"90th_percentile":922.18,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"258","median_amount":4200.18,"10th_percentile":3683.12,"90th_percentile":4623.74,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"16","median_amount":413.04,"10th_percentile":409.48,"90th_percentile":819.11,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":940.62,"10th_percentile":879.46,"90th_percentile":1266.35,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"1 through 10","median_amount":4395.36,"10th_percentile":4395.36,"90th_percentile":4395.36,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."}]}]},{"description":"Level 2 Lower GI Procedures","code_information":[{"code":"5312","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":409.98,"10th_percentile":409.48,"90th_percentile":828.68,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"47","median_amount":1192.61,"10th_percentile":1113.55,"90th_percentile":1788.92,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"73","median_amount":4106.0,"10th_percentile":4041.48,"90th_percentile":5773.5,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"192","median_amount":3388.0,"10th_percentile":3388.0,"90th_percentile":5082.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"11","median_amount":867.38,"10th_percentile":433.69,"90th_percentile":870.11,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"1 through 10","median_amount":4287.66,"10th_percentile":3331.15,"90th_percentile":4746.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1228.59,"10th_percentile":1228.59,"90th_percentile":1228.59,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"14","median_amount":5953.83,"10th_percentile":5421.47,"90th_percentile":7506.73},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":837.58,"10th_percentile":837.58,"90th_percentile":1241.72,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":1192.61,"10th_percentile":1147.68,"90th_percentile":2238.92,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"66","median_amount":2336.56,"10th_percentile":2193.02,"90th_percentile":3289.53,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"41","median_amount":1543.0,"10th_percentile":1492.0,"90th_percentile":3197.25,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"13","median_amount":2908.91,"10th_percentile":1543.0,"90th_percentile":5953.12,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"56","median_amount":1192.61,"10th_percentile":1113.55,"90th_percentile":1788.92,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":826.08,"10th_percentile":413.04,"90th_percentile":828.68,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":918.14,"10th_percentile":918.14,"90th_percentile":1315.87,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":422.29,"10th_percentile":422.29,"90th_percentile":422.29,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"15","median_amount":5943.84,"10th_percentile":5521.45,"90th_percentile":7040.69},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":867.38,"10th_percentile":443.04,"90th_percentile":1348.28,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"341","median_amount":1192.61,"10th_percentile":1147.68,"90th_percentile":1788.92,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"61","median_amount":4761.0,"10th_percentile":4623.0,"90th_percentile":7141.5,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"19","median_amount":5408.25,"10th_percentile":4681.27,"90th_percentile":8002.27,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":826.08,"10th_percentile":810.21,"90th_percentile":828.68,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"1 through 10","median_amount":4864.29,"10th_percentile":4251.66,"90th_percentile":6496.54,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"207","median_amount":1192.62,"10th_percentile":1147.68,"90th_percentile":1788.94,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"423","median_amount":4834.43,"10th_percentile":4287.39,"90th_percentile":7630.02,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"34","median_amount":413.04,"10th_percentile":413.04,"90th_percentile":837.58,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"16","median_amount":1218.29,"10th_percentile":1135.83,"90th_percentile":1755.94,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"1 through 10","median_amount":5116.64,"10th_percentile":5116.64,"90th_percentile":5116.64,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."}]}]},{"description":"Level 3 Lower GI Procedures","code_information":[{"code":"5313","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":2779.87,"10th_percentile":2779.87,"90th_percentile":2779.87,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"1 through 10","median_amount":4314.0,"10th_percentile":4314.0,"90th_percentile":4314.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"1 through 10","median_amount":2116.78,"10th_percentile":2116.78,"90th_percentile":2116.78,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":5349.96,"10th_percentile":5349.96,"90th_percentile":5434.52,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1161.49,"10th_percentile":1161.49,"90th_percentile":1161.49,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":2773.87,"10th_percentile":2773.87,"90th_percentile":2773.87,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"1 through 10","median_amount":6903.45,"10th_percentile":6903.45,"90th_percentile":6903.45,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"1 through 10","median_amount":5684.78,"10th_percentile":5684.78,"90th_percentile":5684.78,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"1 through 10","median_amount":8934.35,"10th_percentile":8934.35,"90th_percentile":8934.35,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":2594.99,"10th_percentile":2210.92,"90th_percentile":2738.62,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"13","median_amount":7803.61,"10th_percentile":4508.76,"90th_percentile":10815.01,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Complex GI Procedures","code_information":[{"code":"5331","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":5727.15,"10th_percentile":5727.15,"90th_percentile":5727.15,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"1 through 10","median_amount":5613.28,"10th_percentile":5613.28,"90th_percentile":5613.28,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"1 through 10","median_amount":9593.54,"10th_percentile":9593.54,"90th_percentile":9593.54,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1559.21,"10th_percentile":1559.21,"90th_percentile":1559.21,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":11796.54,"10th_percentile":11796.54,"90th_percentile":11796.54,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":6027.15,"10th_percentile":6027.15,"90th_percentile":6027.15,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":5542.79,"10th_percentile":5542.79,"90th_percentile":5542.79,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":5663.45,"10th_percentile":5663.45,"90th_percentile":6028.45,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"1 through 10","median_amount":19229.93,"10th_percentile":14391.51,"90th_percentile":20349.7,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 1 Abdominal/Peritoneal/Biliary and Related Procedures","code_information":[{"code":"5341","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"1 through 10","median_amount":7352.88,"10th_percentile":7352.88,"90th_percentile":7352.88,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"1 through 10","median_amount":3735.0,"10th_percentile":3735.0,"90th_percentile":4186.08,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"1 through 10","median_amount":15908.73,"10th_percentile":15908.73,"90th_percentile":15908.73},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":7029.87,"10th_percentile":7029.87,"90th_percentile":7029.87,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"1 through 10","median_amount":12786.93,"10th_percentile":12786.93,"90th_percentile":14131.4,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"1 through 10","median_amount":18463.76,"10th_percentile":18463.76,"90th_percentile":18463.76,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":3338.94,"10th_percentile":3332.94,"90th_percentile":3364.7,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1928.43,"10th_percentile":1928.43,"90th_percentile":1928.43,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":3369.2,"10th_percentile":3275.57,"90th_percentile":3902.93,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"1 through 10","median_amount":8657.0,"10th_percentile":8657.0,"90th_percentile":8657.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"1 through 10","median_amount":41706.01,"10th_percentile":41706.01,"90th_percentile":41706.01,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":3569.58,"10th_percentile":3175.18,"90th_percentile":3577.88,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"15","median_amount":9807.81,"10th_percentile":6655.5,"90th_percentile":21178.48,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 2 Abdominal/Peritoneal/Biliary and Related Procedures","code_information":[{"code":"5342","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"1 through 10","median_amount":4716.75,"10th_percentile":4716.75,"90th_percentile":4716.75,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"1 through 10","median_amount":3313.03,"10th_percentile":3313.03,"90th_percentile":3313.03,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1928.43,"10th_percentile":1928.43,"90th_percentile":1928.43,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1937.78,"10th_percentile":1937.78,"90th_percentile":1937.78,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"1 through 10","median_amount":28405.93,"10th_percentile":28405.93,"90th_percentile":28405.93},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":6687.82,"10th_percentile":6687.82,"90th_percentile":6687.82,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1937.78,"10th_percentile":1937.78,"90th_percentile":1937.78,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":6319.75,"10th_percentile":6319.75,"90th_percentile":6319.75,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":6318.69,"10th_percentile":6318.69,"90th_percentile":6318.69,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"1 through 10","median_amount":20217.27,"10th_percentile":20217.27,"90th_percentile":20217.27,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":2099.25,"10th_percentile":2099.25,"90th_percentile":2099.25,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"1 through 10","median_amount":29317.4,"10th_percentile":29317.4,"90th_percentile":29317.4,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 1 Laparoscopy and Related Services","code_information":[{"code":"5361","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1934.9,"10th_percentile":1513.22,"90th_percentile":2108.73,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":5781.84,"10th_percentile":4722.05,"90th_percentile":5907.34,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"28","median_amount":6546.36,"10th_percentile":5822.74,"90th_percentile":9693.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"51","median_amount":5257.03,"10th_percentile":4610.42,"90th_percentile":8422.85,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"1 through 10","median_amount":4617.05,"10th_percentile":4617.05,"90th_percentile":4617.05,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1152.14,"10th_percentile":1152.14,"90th_percentile":1937.78,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"1 through 10","median_amount":25897.42,"10th_percentile":25897.42,"90th_percentile":25897.42,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"1 through 10","median_amount":17100.67,"10th_percentile":17100.67,"90th_percentile":17100.67,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"1 through 10","median_amount":13539.7,"10th_percentile":13539.7,"90th_percentile":13539.7},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1815.49,"10th_percentile":1815.49,"90th_percentile":1815.49,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"15","median_amount":11561.82,"10th_percentile":10994.15,"90th_percentile":11564.48,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"1 through 10","median_amount":13350.96,"10th_percentile":7926.0,"90th_percentile":21704.75,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"1 through 10","median_amount":16747.98,"10th_percentile":16747.98,"90th_percentile":18048.24,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":5903.84,"10th_percentile":5614.3,"90th_percentile":5908.97,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1832.16,"10th_percentile":1832.16,"90th_percentile":1832.16,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"1 through 10","median_amount":20501.38,"10th_percentile":20501.38,"90th_percentile":20501.38},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1161.49,"10th_percentile":1152.14,"90th_percentile":2177.35,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"64","median_amount":5907.34,"10th_percentile":5516.12,"90th_percentile":6034.9,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"14","median_amount":17314.0,"10th_percentile":16810.0,"90th_percentile":24950.12,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"1 through 10","median_amount":22327.08,"10th_percentile":18405.29,"90th_percentile":24321.15,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1554.0,"10th_percentile":1554.0,"90th_percentile":1554.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"1 through 10","median_amount":25222.19,"10th_percentile":25222.19,"90th_percentile":29289.15,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"17","median_amount":5866.23,"10th_percentile":4721.61,"90th_percentile":5993.85,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"113","median_amount":16624.91,"10th_percentile":11120.42,"90th_percentile":21122.39,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"19","median_amount":1824.84,"10th_percentile":1513.22,"90th_percentile":2658.55,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":4816.13,"10th_percentile":4816.13,"90th_percentile":4816.13,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"1 through 10","median_amount":25321.15,"10th_percentile":25321.15,"90th_percentile":25321.15,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"1 through 10","median_amount":16626.55,"10th_percentile":16626.55,"90th_percentile":16626.55,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."}]}]},{"description":"Level 2 Laparoscopy and Related Services","code_information":[{"code":"5362","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":2917.59,"10th_percentile":2917.59,"90th_percentile":2917.59,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":10011.15,"10th_percentile":10011.15,"90th_percentile":10011.15,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"13","median_amount":9563.81,"10th_percentile":9356.0,"90th_percentile":14034.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"27","median_amount":7808.5,"10th_percentile":7609.0,"90th_percentile":12417.01,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1152.14,"10th_percentile":1152.14,"90th_percentile":1152.14,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":2097.63,"10th_percentile":2097.63,"90th_percentile":2097.63,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"1 through 10","median_amount":27299.49,"10th_percentile":27299.49,"90th_percentile":37851.26},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":3.0,"10th_percentile":3.0,"90th_percentile":3.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":20632.99,"10th_percentile":20632.63,"90th_percentile":20638.92,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"1 through 10","median_amount":25217.73,"10th_percentile":22462.03,"90th_percentile":37211.95,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"1 through 10","median_amount":20917.18,"10th_percentile":20917.18,"90th_percentile":20917.18,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":10538.73,"10th_percentile":10538.73,"90th_percentile":10540.77,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":2445.15,"10th_percentile":2445.15,"90th_percentile":2451.78,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"1 through 10","median_amount":23204.78,"10th_percentile":23204.78,"90th_percentile":23204.78},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1152.14,"10th_percentile":1152.14,"90th_percentile":1152.14,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"15","median_amount":10537.64,"10th_percentile":10536.72,"90th_percentile":10540.14,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"1 through 10","median_amount":20592.0,"10th_percentile":17314.0,"90th_percentile":36787.65,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"1 through 10","median_amount":25181.44,"10th_percentile":18732.36,"90th_percentile":31245.06,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"1 through 10","median_amount":23779.18,"10th_percentile":23779.18,"90th_percentile":23779.18,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"11","median_amount":10538.95,"10th_percentile":8425.14,"90th_percentile":10540.02,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"44","median_amount":25752.42,"10th_percentile":20261.1,"90th_percentile":40525.7,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":2504.46,"10th_percentile":2430.25,"90th_percentile":3351.79,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":8169.1,"10th_percentile":0.8,"90th_percentile":8594.2,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"1 through 10","median_amount":21853.62,"10th_percentile":21853.62,"90th_percentile":21853.62,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."}]}]},{"description":"Level 1 Urology and Related Services","code_information":[{"code":"5371","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":146.87,"10th_percentile":146.87,"90th_percentile":146.87,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":1985.41,"10th_percentile":1985.41,"90th_percentile":1985.41,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":381.75,"10th_percentile":381.75,"90th_percentile":381.75,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 2 Urology and Related Services","code_information":[{"code":"5372","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":675.13,"10th_percentile":675.13,"90th_percentile":675.13,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":1322.71,"10th_percentile":1322.71,"90th_percentile":1322.71,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":681.13,"10th_percentile":681.13,"90th_percentile":681.13,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":675.13,"10th_percentile":675.13,"90th_percentile":675.13,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":522.58,"10th_percentile":522.58,"90th_percentile":522.58,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 3 Urology and Related Services","code_information":[{"code":"5373","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":707.36,"10th_percentile":707.36,"90th_percentile":707.36,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":2072.02,"10th_percentile":1980.9,"90th_percentile":3488.56,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"1 through 10","median_amount":6159.0,"10th_percentile":6159.0,"90th_percentile":6159.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"1 through 10","median_amount":3388.0,"10th_percentile":2973.38,"90th_percentile":5082.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":780.5,"10th_percentile":780.5,"90th_percentile":780.5,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":709.83,"10th_percentile":709.83,"90th_percentile":709.83,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":2081.02,"10th_percentile":2081.02,"90th_percentile":2081.02,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"11","median_amount":3880.95,"10th_percentile":3880.95,"90th_percentile":4083.52,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"1 through 10","median_amount":10083.85,"10th_percentile":10083.85,"90th_percentile":10083.85,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":1980.9,"10th_percentile":1657.62,"90th_percentile":2080.02,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"68","median_amount":2074.52,"10th_percentile":1778.02,"90th_percentile":2078.02,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"1 through 10","median_amount":7791.0,"10th_percentile":7791.0,"90th_percentile":7791.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"1 through 10","median_amount":10514.15,"10th_percentile":10514.15,"90th_percentile":10514.15,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"23","median_amount":1987.91,"10th_percentile":1665.33,"90th_percentile":2080.33,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"15","median_amount":8630.81,"10th_percentile":4778.49,"90th_percentile":11000.94,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":1527.31,"10th_percentile":1527.31,"90th_percentile":1527.31,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 4 Urology and Related Services","code_information":[{"code":"5374","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1166.97,"10th_percentile":1166.97,"90th_percentile":1166.97,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"16","median_amount":3488.56,"10th_percentile":3390.46,"90th_percentile":4559.08,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"1 through 10","median_amount":6642.0,"10th_percentile":4821.0,"90th_percentile":8392.7,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"19","median_amount":4246.1,"10th_percentile":3734.97,"90th_percentile":5602.5,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1152.14,"10th_percentile":1152.14,"90th_percentile":1152.14,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"1 through 10","median_amount":7587.45,"10th_percentile":7587.45,"90th_percentile":7587.45,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"1 through 10","median_amount":18658.37,"10th_percentile":18658.37,"90th_percentile":18658.37},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":6642.53,"10th_percentile":6642.53,"90th_percentile":6854.05,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"1 through 10","median_amount":15892.65,"10th_percentile":13063.6,"90th_percentile":21360.67,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"14","median_amount":3390.46,"10th_percentile":3220.04,"90th_percentile":3494.56,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":650.37,"10th_percentile":650.37,"90th_percentile":650.37,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1152.14,"10th_percentile":1152.14,"90th_percentile":1164.93,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"80","median_amount":3397.46,"10th_percentile":3194.56,"90th_percentile":3494.56,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"1 through 10","median_amount":18822.3,"10th_percentile":18822.3,"90th_percentile":18822.3,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"1 through 10","median_amount":13747.27,"10th_percentile":13747.27,"90th_percentile":13747.27,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1141.29,"10th_percentile":1141.29,"90th_percentile":1141.29,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"47","median_amount":3416.85,"10th_percentile":3081.87,"90th_percentile":3496.55,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"32","median_amount":9280.99,"10th_percentile":7618.37,"90th_percentile":16003.61,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":979.34,"10th_percentile":649.28,"90th_percentile":1715.76,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":2766.61,"10th_percentile":2766.61,"90th_percentile":3558.34,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 5 Urology and Related Services","code_information":[{"code":"5375","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1768.62,"10th_percentile":1768.62,"90th_percentile":1768.62,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"15","median_amount":5141.98,"10th_percentile":4847.98,"90th_percentile":5716.77,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"1 through 10","median_amount":5982.2,"10th_percentile":4457.28,"90th_percentile":9788.5,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"22","median_amount":4574.13,"10th_percentile":3985.2,"90th_percentile":6003.91,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1152.14,"10th_percentile":1152.14,"90th_percentile":1152.14,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"1 through 10","median_amount":15014.38,"10th_percentile":15014.38,"90th_percentile":15014.38,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"1 through 10","median_amount":19060.75,"10th_percentile":19060.75,"90th_percentile":23644.81},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":2530.27,"10th_percentile":2530.27,"90th_percentile":2530.27,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"11","median_amount":10074.09,"10th_percentile":9859.24,"90th_percentile":10076.99,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"1 through 10","median_amount":19798.02,"10th_percentile":18450.18,"90th_percentile":20263.2,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"13","median_amount":5141.98,"10th_percentile":4738.32,"90th_percentile":5661.43,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1733.64,"10th_percentile":1733.64,"90th_percentile":1733.64,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":3840.87,"10th_percentile":3840.87,"90th_percentile":3840.87,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":7482.65,"10th_percentile":7482.65,"90th_percentile":7482.65,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"1 through 10","median_amount":46877.92,"10th_percentile":46877.92,"90th_percentile":46877.92},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1152.14,"10th_percentile":1152.14,"90th_percentile":1152.14,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"73","median_amount":5147.98,"10th_percentile":4847.98,"90th_percentile":5923.52,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"1 through 10","median_amount":15234.0,"10th_percentile":14864.73,"90th_percentile":15691.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"1 through 10","median_amount":16645.19,"10th_percentile":14869.92,"90th_percentile":18283.2,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1772.64,"10th_percentile":1772.64,"90th_percentile":1772.64,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"1 through 10","median_amount":14208.49,"10th_percentile":14208.49,"90th_percentile":14208.49,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"38","median_amount":5038.22,"10th_percentile":4689.32,"90th_percentile":5609.72,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"52","median_amount":15914.3,"10th_percentile":12286.42,"90th_percentile":22029.48,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"11","median_amount":1746.97,"10th_percentile":1539.83,"90th_percentile":1891.04,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":5032.32,"10th_percentile":5032.32,"90th_percentile":5032.32,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":4106.38,"10th_percentile":4106.38,"90th_percentile":4106.38,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 6 Urology and Related Services","code_information":[{"code":"5376","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":9011.11,"10th_percentile":9011.11,"90th_percentile":9011.11,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"1 through 10","median_amount":17036.36,"10th_percentile":17036.36,"90th_percentile":17036.36,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 1 Gynecologic Procedures","code_information":[{"code":"5411","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"61","median_amount":81.72,"10th_percentile":81.72,"90th_percentile":184.97,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"15","median_amount":820.98,"10th_percentile":578.99,"90th_percentile":1484.2,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"61","median_amount":425.83,"10th_percentile":339.88,"90th_percentile":565.31,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"42","median_amount":85.81,"10th_percentile":84.44,"90th_percentile":235.84,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"18","median_amount":1063.13,"10th_percentile":588.0,"90th_percentile":1365.91,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"13","median_amount":85.81,"10th_percentile":80.42,"90th_percentile":120.79,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"1 through 10","median_amount":898.66,"10th_percentile":606.05,"90th_percentile":1210.54},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":81.72,"10th_percentile":81.72,"90th_percentile":250.3,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":654.03,"10th_percentile":398.65,"90th_percentile":658.03,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"1 through 10","median_amount":966.42,"10th_percentile":530.45,"90th_percentile":1510.28,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"1 through 10","median_amount":999.9,"10th_percentile":999.9,"90th_percentile":999.9,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":81.72,"10th_percentile":81.72,"90th_percentile":172.29,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":267.06,"10th_percentile":267.06,"90th_percentile":267.06,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"1 through 10","median_amount":1169.1,"10th_percentile":1169.1,"90th_percentile":1800.03},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"28","median_amount":105.7,"10th_percentile":85.81,"90th_percentile":235.09,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"25","median_amount":913.28,"10th_percentile":503.38,"90th_percentile":1428.78,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"15","median_amount":954.24,"10th_percentile":490.69,"90th_percentile":1706.72,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"19","median_amount":81.72,"10th_percentile":80.42,"90th_percentile":233.18,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"1 through 10","median_amount":481.28,"10th_percentile":439.5,"90th_percentile":1057.4,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":260.28,"10th_percentile":155.04,"90th_percentile":267.06,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"167","median_amount":500.53,"10th_percentile":396.43,"90th_percentile":902.81,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"101","median_amount":81.72,"10th_percentile":80.42,"90th_percentile":206.89,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":317.93,"10th_percentile":193.79,"90th_percentile":340.5,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 2 Gynecologic Procedures","code_information":[{"code":"5412","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":591.68,"10th_percentile":591.68,"90th_percentile":591.68,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"1 through 10","median_amount":1096.95,"10th_percentile":1096.95,"90th_percentile":1096.95,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 3 Gynecologic Procedures","code_information":[{"code":"5413","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"1 through 10","median_amount":6363.25,"10th_percentile":6363.25,"90th_percentile":6363.25,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 4 Gynecologic Procedures","code_information":[{"code":"5414","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":988.74,"10th_percentile":920.81,"90th_percentile":995.43,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":3222.04,"10th_percentile":3222.04,"90th_percentile":3222.04,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"1 through 10","median_amount":3451.26,"10th_percentile":3284.8,"90th_percentile":4106.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"14","median_amount":3388.0,"10th_percentile":2786.27,"90th_percentile":3786.12,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1152.14,"10th_percentile":1152.14,"90th_percentile":1152.14,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"1 through 10","median_amount":7262.62,"10th_percentile":7262.62,"90th_percentile":7262.62,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":6301.97,"10th_percentile":5956.97,"90th_percentile":6336.52,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"1 through 10","median_amount":3824.0,"10th_percentile":3823.99,"90th_percentile":8375.64,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":2361.96,"10th_percentile":2361.96,"90th_percentile":2361.96,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":124.18,"10th_percentile":124.18,"90th_percentile":124.18,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1152.14,"10th_percentile":1152.14,"90th_percentile":1152.14,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":3222.04,"10th_percentile":2922.04,"90th_percentile":3223.04,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"1 through 10","median_amount":7791.0,"10th_percentile":7791.0,"90th_percentile":7791.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"1 through 10","median_amount":7491.87,"10th_percentile":7491.87,"90th_percentile":8251.63,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":3216.04,"10th_percentile":2858.34,"90th_percentile":3417.08,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"39","median_amount":8811.02,"10th_percentile":4729.63,"90th_percentile":11502.95,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":989.87,"10th_percentile":742.85,"90th_percentile":2309.42,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":2481.08,"10th_percentile":2481.08,"90th_percentile":2481.08,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"1 through 10","median_amount":15913.78,"10th_percentile":15913.78,"90th_percentile":15913.78,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."}]}]},{"description":"Level 5 Gynecologic Procedures","code_information":[{"code":"5415","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":4999.12,"10th_percentile":4999.12,"90th_percentile":4999.12,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"1 through 10","median_amount":13039.51,"10th_percentile":13039.51,"90th_percentile":13039.51,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"1 through 10","median_amount":4428.0,"10th_percentile":3757.6,"90th_percentile":6642.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1152.14,"10th_percentile":1152.14,"90th_percentile":1152.14,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":9782.44,"10th_percentile":9782.44,"90th_percentile":9782.44,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"1 through 10","median_amount":13133.19,"10th_percentile":13133.19,"90th_percentile":13133.19,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"1 through 10","median_amount":15163.48,"10th_percentile":15163.48,"90th_percentile":15163.48},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1152.14,"10th_percentile":1152.14,"90th_percentile":1152.14,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":4999.12,"10th_percentile":4699.12,"90th_percentile":4999.85,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"1 through 10","median_amount":14962.74,"10th_percentile":8405.0,"90th_percentile":17115.7,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"1 through 10","median_amount":9017.35,"10th_percentile":9017.35,"90th_percentile":9017.35,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"1 through 10","median_amount":5854.66,"10th_percentile":5854.66,"90th_percentile":5854.66,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":4993.82,"10th_percentile":4844.38,"90th_percentile":5000.42,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"28","median_amount":9956.85,"10th_percentile":8393.34,"90th_percentile":12198.42,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1952.97,"10th_percentile":1952.97,"90th_percentile":1952.97,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 6 Gynecologic Procedures","code_information":[{"code":"5416","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":7479.7,"10th_percentile":7479.7,"90th_percentile":7479.7,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"1 through 10","median_amount":15872.11,"10th_percentile":15872.11,"90th_percentile":15872.11,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":7356.11,"10th_percentile":7356.11,"90th_percentile":7356.11,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":7479.71,"10th_percentile":7479.71,"90th_percentile":7480.91,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":5700.03,"10th_percentile":5700.03,"90th_percentile":5700.03,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 1 Nerve Procedures","code_information":[{"code":"5431","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":563.23,"10th_percentile":559.46,"90th_percentile":563.23,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"21","median_amount":1705.69,"10th_percentile":1475.39,"90th_percentile":1981.19,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"19","median_amount":4106.0,"10th_percentile":2470.14,"90th_percentile":14339.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"46","median_amount":3388.0,"10th_percentile":2938.36,"90th_percentile":9962.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":780.5,"10th_percentile":780.5,"90th_percentile":780.5,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"1 through 10","median_amount":10489.5,"10th_percentile":10489.5,"90th_percentile":10489.5,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":591.4,"10th_percentile":591.4,"90th_percentile":591.4,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"1 through 10","median_amount":6357.07,"10th_percentile":5852.6,"90th_percentile":8452.04},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":844.84,"10th_percentile":844.84,"90th_percentile":844.84,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"12","median_amount":3678.91,"10th_percentile":3678.91,"90th_percentile":3871.68,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"11","median_amount":3170.0,"10th_percentile":3170.0,"90th_percentile":7361.04,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"1 through 10","median_amount":7268.09,"10th_percentile":7268.09,"90th_percentile":7268.09,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"23","median_amount":1877.78,"10th_percentile":1583.19,"90th_percentile":1981.19,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"1 through 10","median_amount":7558.21,"10th_percentile":7558.21,"90th_percentile":7558.21},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":780.5,"10th_percentile":780.5,"90th_percentile":780.5,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"119","median_amount":1882.28,"10th_percentile":1681.19,"90th_percentile":1981.19,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"18","median_amount":7791.21,"10th_percentile":7564.0,"90th_percentile":12479.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"1 through 10","median_amount":7109.56,"10th_percentile":5829.88,"90th_percentile":12604.81,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":563.23,"10th_percentile":563.23,"90th_percentile":563.23,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"1 through 10","median_amount":7467.34,"10th_percentile":7467.34,"90th_percentile":7467.34,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"77","median_amount":1885.68,"10th_percentile":1580.15,"90th_percentile":1983.49,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"101","median_amount":6860.07,"10th_percentile":5433.77,"90th_percentile":12251.28,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"13","median_amount":563.23,"10th_percentile":563.23,"90th_percentile":1188.66,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":1611.76,"10th_percentile":1611.76,"90th_percentile":1611.76,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"14","median_amount":8835.35,"10th_percentile":6517.56,"90th_percentile":12275.27,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"1 through 10","median_amount":7167.15,"10th_percentile":7167.15,"90th_percentile":7167.15,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."}]}]},{"description":"Level 1 Nerve Injections","code_information":[{"code":"5441","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":102.56,"10th_percentile":102.56,"90th_percentile":102.56,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"12","median_amount":304.08,"10th_percentile":238.87,"90th_percentile":1687.66,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"11","median_amount":2013.96,"10th_percentile":1344.18,"90th_percentile":3335.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"25","median_amount":2411.25,"10th_percentile":1282.52,"90th_percentile":3981.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"1 through 10","median_amount":1445.25,"10th_percentile":1445.25,"90th_percentile":1445.25,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":483.16,"10th_percentile":334.5,"90th_percentile":483.16,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"1 through 10","median_amount":3374.71,"10th_percentile":3374.71,"90th_percentile":3374.71},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":102.56,"10th_percentile":102.56,"90th_percentile":102.56,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":304.67,"10th_percentile":304.67,"90th_percentile":304.67,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"16","median_amount":588.01,"10th_percentile":564.35,"90th_percentile":3353.57,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"1 through 10","median_amount":2662.09,"10th_percentile":1781.08,"90th_percentile":3007.33,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"24","median_amount":304.58,"10th_percentile":185.0,"90th_percentile":1277.99,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":235.14,"10th_percentile":235.14,"90th_percentile":235.14,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"1 through 10","median_amount":1936.84,"10th_percentile":1936.84,"90th_percentile":3669.88},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":483.16,"10th_percentile":483.16,"90th_percentile":483.16,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"107","median_amount":298.58,"10th_percentile":278.78,"90th_percentile":853.43,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"1 through 10","median_amount":2039.25,"10th_percentile":1457.25,"90th_percentile":2505.47,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"1 through 10","median_amount":2806.1,"10th_percentile":2775.29,"90th_percentile":3083.67,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":102.56,"10th_percentile":102.56,"90th_percentile":102.56,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"60","median_amount":304.67,"10th_percentile":238.87,"90th_percentile":1549.51,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"55","median_amount":1574.16,"10th_percentile":958.2,"90th_percentile":3270.33,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":221.54,"10th_percentile":221.54,"90th_percentile":221.54,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":304.54,"10th_percentile":304.54,"90th_percentile":304.54,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"1 through 10","median_amount":2133.46,"10th_percentile":2133.46,"90th_percentile":2186.69,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"1 through 10","median_amount":845.64,"10th_percentile":845.64,"90th_percentile":845.64,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."}]}]},{"description":"Level 2 Nerve Injections","code_information":[{"code":"5442","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":315.65,"10th_percentile":184.56,"90th_percentile":406.01,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"35","median_amount":560.38,"10th_percentile":406.47,"90th_percentile":700.47,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"28","median_amount":3335.0,"10th_percentile":2644.25,"90th_percentile":5002.5,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"46","median_amount":2654.0,"10th_percentile":2581.66,"90th_percentile":2815.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"12","median_amount":334.5,"10th_percentile":223.01,"90th_percentile":334.5,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"1 through 10","median_amount":2537.65,"10th_percentile":2537.65,"90th_percentile":2755.71,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"1 through 10","median_amount":3155.84,"10th_percentile":3155.84,"90th_percentile":5636.57},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":317.41,"10th_percentile":315.65,"90th_percentile":326.31,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":259.47,"10th_percentile":259.47,"90th_percentile":709.47,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"32","median_amount":1372.36,"10th_percentile":1317.68,"90th_percentile":1837.07,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"1 through 10","median_amount":2865.78,"10th_percentile":2546.81,"90th_percentile":5678.35,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"1 through 10","median_amount":2865.78,"10th_percentile":2865.78,"90th_percentile":2865.78,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"30","median_amount":678.56,"10th_percentile":406.47,"90th_percentile":706.47,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":324.71,"10th_percentile":315.65,"90th_percentile":324.71,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"1 through 10","median_amount":3351.39,"10th_percentile":3187.03,"90th_percentile":6175.81},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"1 through 10","median_amount":1200.0,"10th_percentile":1200.0,"90th_percentile":1200.0},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":232.52,"10th_percentile":223.01,"90th_percentile":334.5,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"232","median_amount":700.47,"10th_percentile":654.03,"90th_percentile":706.47,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"18","median_amount":3030.0,"10th_percentile":2942.0,"90th_percentile":3030.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"12","median_amount":2627.89,"10th_percentile":2474.0,"90th_percentile":2734.92,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":276.84,"10th_percentile":276.84,"90th_percentile":276.84,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"1 through 10","median_amount":2665.22,"10th_percentile":2454.98,"90th_percentile":4930.53,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"159","median_amount":678.47,"10th_percentile":357.48,"90th_percentile":707.78,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"174","median_amount":2501.84,"10th_percentile":1992.89,"90th_percentile":3815.06,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"34","median_amount":315.65,"10th_percentile":190.65,"90th_percentile":555.84,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"13","median_amount":571.59,"10th_percentile":571.59,"90th_percentile":686.02,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"14","median_amount":3242.7,"10th_percentile":2943.0,"90th_percentile":4613.83,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 3 Nerve Injections","code_information":[{"code":"5443","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":946.94,"10th_percentile":946.94,"90th_percentile":946.94,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"22","median_amount":1256.77,"10th_percentile":906.51,"90th_percentile":1350.77,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"17","median_amount":3504.0,"10th_percentile":3185.0,"90th_percentile":13568.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"37","median_amount":5816.61,"10th_percentile":2423.2,"90th_percentile":11585.5,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"1 through 10","median_amount":4222.5,"10th_percentile":4222.5,"90th_percentile":4222.5,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":334.5,"10th_percentile":334.5,"90th_percentile":334.5,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"1 through 10","median_amount":2576.05,"10th_percentile":2576.05,"90th_percentile":2576.05,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"1 through 10","median_amount":16273.59,"10th_percentile":16273.59,"90th_percentile":16273.59},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":315.65,"10th_percentile":315.65,"90th_percentile":315.65,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":893.46,"10th_percentile":459.51,"90th_percentile":1358.76,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"36","median_amount":2646.39,"10th_percentile":1665.08,"90th_percentile":2901.77,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"1 through 10","median_amount":2399.99,"10th_percentile":1221.0,"90th_percentile":2556.08,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"1 through 10","median_amount":3343.9,"10th_percentile":3343.9,"90th_percentile":11659.19,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"31","median_amount":1054.58,"10th_percentile":676.45,"90th_percentile":1357.14,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":789.12,"10th_percentile":317.41,"90th_percentile":789.12,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"1 through 10","median_amount":13439.29,"10th_percentile":9938.6,"90th_percentile":14380.67},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":334.5,"10th_percentile":334.5,"90th_percentile":334.5,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"206","median_amount":1019.97,"10th_percentile":886.46,"90th_percentile":1350.77,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"15","median_amount":4075.0,"10th_percentile":2942.0,"90th_percentile":5712.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"1 through 10","median_amount":5841.35,"10th_percentile":3346.77,"90th_percentile":8865.42,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"143","median_amount":908.42,"10th_percentile":672.65,"90th_percentile":1357.78,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"107","median_amount":6170.85,"10th_percentile":2977.09,"90th_percentile":11705.79,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":789.12,"10th_percentile":315.65,"90th_percentile":1110.94,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":597.36,"10th_percentile":597.36,"90th_percentile":597.36,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"12","median_amount":1102.24,"10th_percentile":1080.62,"90th_percentile":1102.24,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"1 through 10","median_amount":8092.66,"10th_percentile":3365.1,"90th_percentile":11757.55,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 1 Neurostimulator and Related Procedures","code_information":[{"code":"5461","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":2953.89,"10th_percentile":2953.89,"90th_percentile":2953.89,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1319.63,"10th_percentile":1319.63,"90th_percentile":1319.63,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 4 Neurostimulator and Related Procedures","code_information":[{"code":"5464","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":21696.58,"10th_percentile":21696.58,"90th_percentile":21696.58,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":22062.88,"10th_percentile":22062.88,"90th_percentile":22062.88,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"1 through 10","median_amount":31106.69,"10th_percentile":31106.69,"90th_percentile":31106.69,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":9304.99,"10th_percentile":9304.99,"90th_percentile":9304.99,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 5 Neurostimulator and Related Procedures","code_information":[{"code":"5465","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"1 through 10","median_amount":30578.2,"10th_percentile":30578.2,"90th_percentile":30578.2,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":60388.77,"10th_percentile":60388.77,"90th_percentile":60388.77,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 1 Intraocular Procedures","code_information":[{"code":"5491","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":709.18,"10th_percentile":709.18,"90th_percentile":714.93,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"55","median_amount":2197.94,"10th_percentile":1814.64,"90th_percentile":2312.91,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"11","median_amount":4106.0,"10th_percentile":3284.8,"90th_percentile":4523.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"27","median_amount":3588.64,"10th_percentile":3229.4,"90th_percentile":3794.64,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1152.14,"10th_percentile":1152.14,"90th_percentile":1152.14,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"1 through 10","median_amount":3219.12,"10th_percentile":3219.12,"90th_percentile":3219.12,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":1712.98,"10th_percentile":1712.98,"90th_percentile":2471.36,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":4242.02,"10th_percentile":4242.02,"90th_percentile":4519.66,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"1 through 10","median_amount":4384.28,"10th_percentile":519.0,"90th_percentile":4519.8,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"87","median_amount":2272.39,"10th_percentile":1963.91,"90th_percentile":2482.91,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"1 through 10","median_amount":8107.14,"10th_percentile":7266.97,"90th_percentile":8779.01},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1152.14,"10th_percentile":1152.14,"90th_percentile":1152.14,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"388","median_amount":2306.91,"10th_percentile":2012.91,"90th_percentile":2541.91,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"1 through 10","median_amount":7564.0,"10th_percentile":7564.0,"90th_percentile":7791.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"1 through 10","median_amount":6917.15,"10th_percentile":6593.01,"90th_percentile":7381.35,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"1 through 10","median_amount":7161.15,"10th_percentile":7161.15,"90th_percentile":7161.15},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"205","median_amount":2274.29,"10th_percentile":1845.53,"90th_percentile":2316.82,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"55","median_amount":5896.02,"10th_percentile":4665.31,"90th_percentile":6949.83,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"15","median_amount":714.93,"10th_percentile":714.93,"90th_percentile":1429.86,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":2274.29,"10th_percentile":2274.29,"90th_percentile":2274.29,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"14","median_amount":2108.05,"10th_percentile":1882.44,"90th_percentile":2362.65,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"1 through 10","median_amount":6954.26,"10th_percentile":6954.26,"90th_percentile":7539.88,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."}]}]},{"description":"Level 2 Intraocular Procedures","code_information":[{"code":"5492","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":3775.04,"10th_percentile":3775.04,"90th_percentile":3775.04,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 3 Extraocular, Repair, and Plastic Eye Procedures","code_information":[{"code":"5503","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":2359.74,"10th_percentile":2359.74,"90th_percentile":2359.74,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"1 through 10","median_amount":8470.0,"10th_percentile":8470.0,"90th_percentile":8470.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":1978.65,"10th_percentile":1978.65,"90th_percentile":1978.65,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":111.49,"10th_percentile":111.49,"90th_percentile":111.49,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":2303.58,"10th_percentile":2278.65,"90th_percentile":2365.74,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":2279.65,"10th_percentile":2213.21,"90th_percentile":2367.05,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":1925.54,"10th_percentile":1925.54,"90th_percentile":1925.54,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 1 Imaging without Contrast","code_information":[{"code":"5521","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"1 through 10","median_amount":1967.25,"10th_percentile":1967.25,"90th_percentile":1967.25,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"60","median_amount":23.0,"10th_percentile":23.0,"90th_percentile":263.53,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"184","median_amount":89.06,"10th_percentile":71.25,"90th_percentile":168.77,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"172","median_amount":70.88,"10th_percentile":55.89,"90th_percentile":718.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"371","median_amount":67.33,"10th_percentile":53.99,"90th_percentile":776.3,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"97","median_amount":24.5,"10th_percentile":24.15,"90th_percentile":218.76,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"1 through 10","median_amount":456.29,"10th_percentile":456.29,"90th_percentile":456.29,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"15","median_amount":456.0,"10th_percentile":361.0,"90th_percentile":708.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"19","median_amount":24.16,"10th_percentile":23.33,"90th_percentile":241.16,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"42","median_amount":427.55,"10th_percentile":403.75,"90th_percentile":970.7},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"24","median_amount":45.11,"10th_percentile":23.0,"90th_percentile":171.61,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"14","median_amount":83.75,"10th_percentile":58.98,"90th_percentile":89.66,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"58","median_amount":175.4,"10th_percentile":173.15,"90th_percentile":402.85,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"131","median_amount":353.39,"10th_percentile":353.39,"90th_percentile":706.78,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"14","median_amount":353.39,"10th_percentile":339.88,"90th_percentile":706.78,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"142","median_amount":90.88,"10th_percentile":84.85,"90th_percentile":204.55,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"33","median_amount":34.5,"10th_percentile":23.0,"90th_percentile":208.34,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":70.7,"10th_percentile":70.7,"90th_percentile":70.7,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":36.09,"10th_percentile":36.09,"90th_percentile":36.09,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":89.43,"10th_percentile":71.25,"90th_percentile":707.14,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"25","median_amount":413.25,"10th_percentile":330.6,"90th_percentile":1033.13},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"81","median_amount":24.15,"10th_percentile":24.15,"90th_percentile":101.55,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1019","median_amount":89.66,"10th_percentile":49.86,"90th_percentile":128.56,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"172","median_amount":475.0,"10th_percentile":440.0,"90th_percentile":816.79,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"51","median_amount":399.08,"10th_percentile":177.11,"90th_percentile":895.98,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"21","median_amount":23.0,"10th_percentile":23.0,"90th_percentile":46.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"1 through 10","median_amount":356.25,"10th_percentile":356.25,"90th_percentile":356.25},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"33","median_amount":356.25,"10th_percentile":285.0,"90th_percentile":712.5,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"682","median_amount":88.88,"10th_percentile":69.47,"90th_percentile":176.81,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"938","median_amount":244.0,"10th_percentile":195.2,"90th_percentile":608.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"239","median_amount":23.33,"10th_percentile":23.0,"90th_percentile":124.28,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":88.38,"10th_percentile":88.38,"90th_percentile":88.38,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":88.68,"10th_percentile":88.38,"90th_percentile":89.57,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"40","median_amount":72.68,"10th_percentile":72.11,"90th_percentile":197.15,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"127","median_amount":427.5,"10th_percentile":427.5,"90th_percentile":855.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"1 through 10","median_amount":381.69,"10th_percentile":381.69,"90th_percentile":442.54,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."}]}]},{"description":"Level 2 Imaging without Contrast","code_information":[{"code":"5522","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"1 through 10","median_amount":7535.46,"10th_percentile":7535.46,"90th_percentile":7611.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"76","median_amount":45.11,"10th_percentile":23.0,"90th_percentile":115.37,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"342","median_amount":107.56,"10th_percentile":85.54,"90th_percentile":215.68,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"284","median_amount":663.56,"10th_percentile":106.57,"90th_percentile":2244.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"525","median_amount":551.0,"10th_percentile":93.39,"90th_percentile":1578.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"1 through 10","median_amount":585.0,"10th_percentile":585.0,"90th_percentile":585.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"123","median_amount":47.37,"10th_percentile":36.23,"90th_percentile":129.31,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":47.68,"10th_percentile":47.68,"90th_percentile":47.68,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"1 through 10","median_amount":518.0,"10th_percentile":518.0,"90th_percentile":518.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"1 through 10","median_amount":470.0,"10th_percentile":456.29,"90th_percentile":1399.65,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"1 through 10","median_amount":1205.0,"10th_percentile":1205.0,"90th_percentile":1205.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"19","median_amount":49.19,"10th_percentile":43.43,"90th_percentile":119.12,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"52","median_amount":756.5,"10th_percentile":403.75,"90th_percentile":2310.3},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"19","median_amount":45.41,"10th_percentile":23.33,"90th_percentile":132.72,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"28","median_amount":107.56,"10th_percentile":100.43,"90th_percentile":197.22,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"104","median_amount":210.74,"10th_percentile":174.49,"90th_percentile":361.55,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"166","median_amount":468.0,"10th_percentile":353.39,"90th_percentile":1767.09,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"13","median_amount":636.83,"10th_percentile":468.0,"90th_percentile":1778.12,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"363","median_amount":109.76,"10th_percentile":101.23,"90th_percentile":291.07,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"37","median_amount":45.11,"10th_percentile":34.5,"90th_percentile":132.67,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":106.93,"10th_percentile":106.93,"90th_percentile":177.63,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":69.96,"10th_percentile":69.96,"90th_percentile":69.96,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":86.05,"10th_percentile":86.05,"90th_percentile":109.76,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"35","median_amount":642.06,"10th_percentile":289.27,"90th_percentile":1690.56},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"114","median_amount":47.37,"10th_percentile":24.5,"90th_percentile":83.25,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"2373","median_amount":108.36,"10th_percentile":86.05,"90th_percentile":250.26,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"218","median_amount":597.29,"10th_percentile":427.5,"90th_percentile":2029.1,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"88","median_amount":877.56,"10th_percentile":399.08,"90th_percentile":2660.58,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"33","median_amount":44.04,"10th_percentile":23.33,"90th_percentile":113.44,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"1 through 10","median_amount":546.75,"10th_percentile":546.75,"90th_percentile":546.75},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"28","median_amount":667.5,"10th_percentile":350.0,"90th_percentile":1863.75,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"1293","median_amount":108.0,"10th_percentile":86.05,"90th_percentile":215.44,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"1462","median_amount":430.0,"10th_percentile":206.0,"90th_percentile":1774.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"274","median_amount":45.11,"10th_percentile":23.0,"90th_percentile":113.44,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":109.03,"10th_percentile":109.03,"90th_percentile":109.03,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"125","median_amount":109.06,"10th_percentile":87.25,"90th_percentile":199.51,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"82","median_amount":465.5,"10th_percentile":427.5,"90th_percentile":2544.3,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"16","median_amount":1533.37,"10th_percentile":500.0,"90th_percentile":2544.56,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."}]}]},{"description":"Level 3 Imaging without Contrast","code_information":[{"code":"5523","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"34","median_amount":99.15,"10th_percentile":99.15,"90th_percentile":137.1,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"118","median_amount":225.49,"10th_percentile":53.39,"90th_percentile":323.39,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"102","median_amount":3200.0,"10th_percentile":1203.5,"90th_percentile":3730.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"250","median_amount":2641.0,"10th_percentile":1276.52,"90th_percentile":2802.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"1 through 10","median_amount":2688.77,"10th_percentile":2688.77,"90th_percentile":2688.77,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"45","median_amount":104.11,"10th_percentile":104.11,"90th_percentile":210.54,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"1 through 10","median_amount":2814.0,"10th_percentile":2814.0,"90th_percentile":2814.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"1 through 10","median_amount":2814.0,"10th_percentile":1951.0,"90th_percentile":2898.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":104.11,"10th_percentile":100.26,"90th_percentile":256.48,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"17","median_amount":2528.0,"10th_percentile":1808.8,"90th_percentile":3254.65},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":100.26,"10th_percentile":99.15,"90th_percentile":126.32,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"12","median_amount":238.32,"10th_percentile":231.79,"90th_percentile":498.96,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"121","median_amount":466.91,"10th_percentile":449.59,"90th_percentile":1004.87,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"58","median_amount":2130.0,"10th_percentile":1826.0,"90th_percentile":2598.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"1 through 10","median_amount":1302.7,"10th_percentile":1302.7,"90th_percentile":2130.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"142","median_amount":245.29,"10th_percentile":203.48,"90th_percentile":352.75,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"23","median_amount":99.15,"10th_percentile":99.15,"90th_percentile":231.81,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":182.63,"10th_percentile":182.63,"90th_percentile":182.63,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":244.49,"10th_percentile":244.49,"90th_percentile":419.28,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"18","median_amount":3005.85,"10th_percentile":2168.91,"90th_percentile":5768.1},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"46","median_amount":104.11,"10th_percentile":104.11,"90th_percentile":189.68,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"794","median_amount":245.29,"10th_percentile":224.89,"90th_percentile":278.86,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"114","median_amount":2652.25,"10th_percentile":1479.48,"90th_percentile":2652.25,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"30","median_amount":3718.36,"10th_percentile":1457.66,"90th_percentile":5716.26,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"15","median_amount":99.15,"10th_percentile":99.15,"90th_percentile":297.45,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"1 through 10","median_amount":2433.0,"10th_percentile":2433.0,"90th_percentile":2433.0},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"17","median_amount":2565.0,"10th_percentile":2225.25,"90th_percentile":2764.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"493","median_amount":244.5,"10th_percentile":190.65,"90th_percentile":350.18,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"730","median_amount":2528.0,"10th_percentile":1229.2,"90th_percentile":2826.83,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"118","median_amount":99.15,"10th_percentile":99.15,"90th_percentile":132.67,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":238.32,"10th_percentile":238.32,"90th_percentile":238.32,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"42","median_amount":199.51,"10th_percentile":186.29,"90th_percentile":433.17,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"83","median_amount":3109.5,"10th_percentile":2591.25,"90th_percentile":3500.4,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"1 through 10","median_amount":3040.0,"10th_percentile":2035.65,"90th_percentile":3743.78,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."}]}]},{"description":"Level 4 Imaging without Contrast","code_information":[{"code":"5524","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":194.2,"10th_percentile":179.94,"90th_percentile":388.4,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"68","median_amount":528.4,"10th_percentile":424.73,"90th_percentile":560.59,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"26","median_amount":2434.78,"10th_percentile":1947.82,"90th_percentile":3160.99,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"84","median_amount":1787.56,"10th_percentile":1264.4,"90th_percentile":2735.32,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"13","median_amount":203.91,"10th_percentile":188.94,"90th_percentile":407.82,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"1 through 10","median_amount":2183.0,"10th_percentile":2183.0,"90th_percentile":2248.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":203.91,"10th_percentile":203.91,"90th_percentile":203.91,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"1 through 10","median_amount":2619.7,"10th_percentile":2072.38,"90th_percentile":4931.52},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":234.4,"10th_percentile":234.4,"90th_percentile":234.4,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":536.53,"10th_percentile":517.83,"90th_percentile":555.09,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"22","median_amount":1086.55,"10th_percentile":1019.81,"90th_percentile":1092.21,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"17","median_amount":2292.93,"10th_percentile":2292.93,"90th_percentile":2496.77,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"1 through 10","median_amount":2398.38,"10th_percentile":2292.93,"90th_percentile":2504.39,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"99","median_amount":539.03,"10th_percentile":407.59,"90th_percentile":621.27,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":357.68,"10th_percentile":357.68,"90th_percentile":527.87,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":429.22,"10th_percentile":429.22,"90th_percentile":429.22,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"1 through 10","median_amount":2681.34,"10th_percentile":2681.34,"90th_percentile":3573.9},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"1 through 10","median_amount":9787.68,"10th_percentile":9787.68,"90th_percentile":9787.68},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"14","median_amount":203.91,"10th_percentile":188.94,"90th_percentile":203.91,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"541","median_amount":555.39,"10th_percentile":515.39,"90th_percentile":601.35,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"32","median_amount":2175.89,"10th_percentile":1733.3,"90th_percentile":3445.93,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"15","median_amount":2188.22,"10th_percentile":2068.19,"90th_percentile":2188.22,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":262.53,"10th_percentile":262.53,"90th_percentile":433.51,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"1 through 10","median_amount":2311.5,"10th_percentile":2311.5,"90th_percentile":5940.84,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"315","median_amount":554.6,"10th_percentile":339.0,"90th_percentile":649.07,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"195","median_amount":2141.99,"10th_percentile":1515.1,"90th_percentile":2606.45,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"30","median_amount":194.2,"10th_percentile":179.94,"90th_percentile":433.51,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"25","median_amount":452.54,"10th_percentile":422.56,"90th_percentile":565.69,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"1 through 10","median_amount":2225.2,"10th_percentile":2225.2,"90th_percentile":5772.27,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."}]}]},{"description":"Level 1 Imaging with Contrast","code_information":[{"code":"5571","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"11","median_amount":132.67,"10th_percentile":48.08,"90th_percentile":265.34,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"81","median_amount":183.74,"10th_percentile":144.05,"90th_percentile":444.61,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"30","median_amount":2690.59,"10th_percentile":858.2,"90th_percentile":4976.12,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"93","median_amount":1891.15,"10th_percentile":562.73,"90th_percentile":3227.69,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"1 through 10","median_amount":1707.93,"10th_percentile":1707.93,"90th_percentile":1707.93,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"18","median_amount":278.6,"10th_percentile":132.64,"90th_percentile":343.3,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"11","median_amount":2666.88,"10th_percentile":2442.27,"90th_percentile":5547.32},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":126.32,"10th_percentile":126.32,"90th_percentile":154.34,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":183.74,"10th_percentile":182.34,"90th_percentile":395.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"56","median_amount":352.78,"10th_percentile":331.11,"90th_percentile":862.27,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"19","median_amount":2085.47,"10th_percentile":2000.17,"90th_percentile":4121.94,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"1 through 10","median_amount":2397.59,"10th_percentile":2122.67,"90th_percentile":6485.49,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"95","median_amount":267.33,"10th_percentile":142.8,"90th_percentile":447.11,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":132.67,"10th_percentile":126.32,"90th_percentile":813.09,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":436.47,"10th_percentile":436.47,"90th_percentile":436.47,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":134.5,"10th_percentile":134.5,"90th_percentile":134.5,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"1 through 10","median_amount":2661.51,"10th_percentile":1449.36,"90th_percentile":6228.8},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"20","median_amount":139.3,"10th_percentile":50.48,"90th_percentile":278.6,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"508","median_amount":183.74,"10th_percentile":171.56,"90th_percentile":446.11,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"35","median_amount":2318.36,"10th_percentile":582.95,"90th_percentile":2426.2,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"15","median_amount":2891.34,"10th_percentile":1322.0,"90th_percentile":5479.36,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":154.34,"10th_percentile":23.33,"90th_percentile":498.3,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"1 through 10","median_amount":7823.06,"10th_percentile":7823.06,"90th_percentile":7823.06},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"1 through 10","median_amount":2747.38,"10th_percentile":2320.12,"90th_percentile":4660.87,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"283","median_amount":183.74,"10th_percentile":151.34,"90th_percentile":441.13,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"220","median_amount":1810.4,"10th_percentile":309.85,"90th_percentile":4435.46,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"59","median_amount":163.48,"10th_percentile":126.32,"90th_percentile":326.96,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":436.48,"10th_percentile":436.48,"90th_percentile":436.48,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"28","median_amount":183.66,"10th_percentile":145.81,"90th_percentile":359.13,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"1 through 10","median_amount":2987.11,"10th_percentile":2987.11,"90th_percentile":2987.11,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"1 through 10","median_amount":4168.0,"10th_percentile":4168.0,"90th_percentile":4168.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."}]}]},{"description":"Level 2 Imaging with Contrast","code_information":[{"code":"5572","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"1 through 10","median_amount":452.14,"10th_percentile":452.14,"90th_percentile":452.14,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"31","median_amount":166.77,"10th_percentile":132.67,"90th_percentile":507.42,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"115","median_amount":365.14,"10th_percentile":269.83,"90th_percentile":691.71,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"86","median_amount":3728.04,"10th_percentile":2072.04,"90th_percentile":5335.92,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"201","median_amount":2827.47,"10th_percentile":1242.14,"90th_percentile":3386.79,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"1 through 10","median_amount":3098.24,"10th_percentile":3098.24,"90th_percentile":3098.24,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"26","median_amount":175.11,"10th_percentile":139.3,"90th_percentile":177.6,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"1 through 10","median_amount":2152.32,"10th_percentile":2025.94,"90th_percentile":3064.35,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":214.06,"10th_percentile":204.3,"90th_percentile":535.88,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"31","median_amount":2849.2,"10th_percentile":1265.64,"90th_percentile":6004.19},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":166.77,"10th_percentile":132.67,"90th_percentile":333.54,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"13","median_amount":366.24,"10th_percentile":182.86,"90th_percentile":539.74,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"125","median_amount":707.71,"10th_percentile":664.25,"90th_percentile":1662.74,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"55","median_amount":2498.09,"10th_percentile":2104.63,"90th_percentile":2658.95,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"14","median_amount":2683.27,"10th_percentile":2226.94,"90th_percentile":4639.98,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"139","median_amount":368.24,"10th_percentile":125.8,"90th_percentile":548.3,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"18","median_amount":166.77,"10th_percentile":132.67,"90th_percentile":416.08,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":299.22,"10th_percentile":299.22,"90th_percentile":374.03,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"13","median_amount":3094.81,"10th_percentile":2471.53,"90th_percentile":3768.63},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"38","median_amount":175.11,"10th_percentile":132.64,"90th_percentile":458.29,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"813","median_amount":367.24,"10th_percentile":115.16,"90th_percentile":575.54,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"61","median_amount":2457.27,"10th_percentile":2164.24,"90th_percentile":3074.96,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"30","median_amount":4025.24,"10th_percentile":2872.17,"90th_percentile":7479.19,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":163.48,"10th_percentile":132.67,"90th_percentile":338.28,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"1 through 10","median_amount":2812.5,"10th_percentile":2812.5,"90th_percentile":2812.5},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"16","median_amount":2765.65,"10th_percentile":2434.12,"90th_percentile":5380.72,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"425","median_amount":365.64,"10th_percentile":220.64,"90th_percentile":757.29,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"589","median_amount":2576.63,"10th_percentile":1333.66,"90th_percentile":4345.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"97","median_amount":166.77,"10th_percentile":132.67,"90th_percentile":333.54,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":376.23,"10th_percentile":376.23,"90th_percentile":376.23,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":653.92,"10th_percentile":653.92,"90th_percentile":653.92,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"25","median_amount":294.76,"10th_percentile":275.22,"90th_percentile":692.53,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"11","median_amount":3685.73,"10th_percentile":2542.58,"90th_percentile":5108.3,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"1 through 10","median_amount":3695.67,"10th_percentile":2628.91,"90th_percentile":7481.52,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."}]}]},{"description":"Level 3 Imaging with Contrast","code_information":[{"code":"5573","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":194.2,"10th_percentile":194.2,"90th_percentile":389.25,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"22","median_amount":799.12,"10th_percentile":639.29,"90th_percentile":1017.02,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"15","median_amount":3398.38,"10th_percentile":1996.02,"90th_percentile":5891.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"43","median_amount":2495.02,"10th_percentile":1870.04,"90th_percentile":5417.25,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":203.91,"10th_percentile":203.91,"90th_percentile":747.07,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"1 through 10","median_amount":351.79,"10th_percentile":351.79,"90th_percentile":351.79,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"1 through 10","median_amount":4104.65,"10th_percentile":3478.84,"90th_percentile":4605.73},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":394.42,"10th_percentile":394.42,"90th_percentile":683.13,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":799.12,"10th_percentile":799.12,"90th_percentile":799.12,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":1565.64,"10th_percentile":1469.46,"90th_percentile":5260.33,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"14","median_amount":3654.77,"10th_percentile":3044.9,"90th_percentile":4010.77,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"1 through 10","median_amount":3389.6,"10th_percentile":3389.6,"90th_percentile":3389.6,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"30","median_amount":799.12,"10th_percentile":652.12,"90th_percentile":945.1,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":389.25,"10th_percentile":194.2,"90th_percentile":424.24,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":1205.57,"10th_percentile":1205.57,"90th_percentile":1205.57,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":483.16,"10th_percentile":203.91,"90th_percentile":748.97,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"173","median_amount":799.72,"10th_percentile":746.95,"90th_percentile":839.92,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"12","median_amount":3036.37,"10th_percentile":2334.0,"90th_percentile":4632.25,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"1 through 10","median_amount":3257.96,"10th_percentile":3054.24,"90th_percentile":6002.2,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":394.42,"10th_percentile":394.42,"90th_percentile":394.42,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"1 through 10","median_amount":7330.68,"10th_percentile":7330.68,"90th_percentile":10033.29,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"95","median_amount":799.13,"10th_percentile":639.29,"90th_percentile":909.89,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"111","median_amount":2989.2,"10th_percentile":1948.51,"90th_percentile":3690.7,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"14","median_amount":389.25,"10th_percentile":194.2,"90th_percentile":394.42,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":652.08,"10th_percentile":652.08,"90th_percentile":815.11,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"13","median_amount":4418.11,"10th_percentile":4412.26,"90th_percentile":4885.44,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 1 Nuclear Medicine and Related Services","code_information":[{"code":"5591","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":152.7,"10th_percentile":152.7,"90th_percentile":418.04,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":410.95,"10th_percentile":401.11,"90th_percentile":771.59,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"13","median_amount":1120.58,"10th_percentile":890.35,"90th_percentile":5968.06,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"1 through 10","median_amount":1020.48,"10th_percentile":829.56,"90th_percentile":4260.03,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":160.34,"10th_percentile":160.34,"90th_percentile":160.34,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"1 through 10","median_amount":3393.37,"10th_percentile":3393.37,"90th_percentile":3393.37,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":796.3,"10th_percentile":796.3,"90th_percentile":800.45,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":411.45,"10th_percentile":384.5,"90th_percentile":634.5,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":152.7,"10th_percentile":152.7,"90th_percentile":152.7,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":320.89,"10th_percentile":320.89,"90th_percentile":320.89,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"1 through 10","median_amount":3276.42,"10th_percentile":3276.42,"90th_percentile":3276.42},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":425.62,"10th_percentile":160.34,"90th_percentile":438.94,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"63","median_amount":412.35,"10th_percentile":179.69,"90th_percentile":846.56,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"1 through 10","median_amount":3646.2,"10th_percentile":3567.48,"90th_percentile":6973.01,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"1 through 10","median_amount":9334.3,"10th_percentile":3972.58,"90th_percentile":9734.12,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":152.7,"10th_percentile":152.7,"90th_percentile":152.7,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"35","median_amount":771.09,"10th_percentile":325.15,"90th_percentile":1212.2,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"26","median_amount":3588.75,"10th_percentile":2666.66,"90th_percentile":6332.33,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":152.7,"10th_percentile":152.7,"90th_percentile":152.7,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":777.25,"10th_percentile":777.25,"90th_percentile":777.25,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":414.57,"10th_percentile":331.65,"90th_percentile":690.78,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 2 Nuclear Medicine and Related Services","code_information":[{"code":"5592","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":196.86,"10th_percentile":196.86,"90th_percentile":196.86,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":406.68,"10th_percentile":406.68,"90th_percentile":406.68,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"1 through 10","median_amount":1675.75,"10th_percentile":1675.75,"90th_percentile":1675.75,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"1 through 10","median_amount":892.95,"10th_percentile":647.75,"90th_percentile":1660.64,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":160.34,"10th_percentile":160.34,"90th_percentile":202.64,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"1 through 10","median_amount":3199.4,"10th_percentile":3199.4,"90th_percentile":3199.4},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":597.11,"10th_percentile":597.11,"90th_percentile":597.11,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":1066.68,"10th_percentile":1066.68,"90th_percentile":1066.68,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"1 through 10","median_amount":3073.9,"10th_percentile":3073.9,"90th_percentile":3073.9,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"1 through 10","median_amount":3412.79,"10th_percentile":3412.79,"90th_percentile":3412.79,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":530.66,"10th_percentile":530.66,"90th_percentile":977.96,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":206.71,"10th_percentile":206.71,"90th_percentile":206.71,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"13","median_amount":544.45,"10th_percentile":514.26,"90th_percentile":618.64,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"1 through 10","median_amount":3893.3,"10th_percentile":3849.7,"90th_percentile":3975.89,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"1 through 10","median_amount":4222.15,"10th_percentile":4222.15,"90th_percentile":4222.15,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":399.36,"10th_percentile":399.36,"90th_percentile":399.36,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"1 through 10","median_amount":2996.1,"10th_percentile":2996.1,"90th_percentile":2996.1,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":547.85,"10th_percentile":435.56,"90th_percentile":678.2,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"23","median_amount":2922.37,"10th_percentile":2346.7,"90th_percentile":3795.83,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":192.99,"10th_percentile":192.99,"90th_percentile":196.86,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 3 Nuclear Medicine and Related Services","code_information":[{"code":"5593","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":447.05,"10th_percentile":447.05,"90th_percentile":447.05,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"43","median_amount":1237.43,"10th_percentile":1056.38,"90th_percentile":1384.89,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"20","median_amount":3659.04,"10th_percentile":2414.39,"90th_percentile":4116.25,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"42","median_amount":2954.12,"10th_percentile":2074.85,"90th_percentile":3009.23,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":469.4,"10th_percentile":469.4,"90th_percentile":673.31,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"1 through 10","median_amount":5333.28,"10th_percentile":4277.25,"90th_percentile":7125.14},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":447.05,"10th_percentile":447.05,"90th_percentile":447.05,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":1384.99,"10th_percentile":1237.93,"90th_percentile":1559.49,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"27","median_amount":2587.05,"10th_percentile":2428.11,"90th_percentile":2705.61,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"1 through 10","median_amount":5474.16,"10th_percentile":5474.16,"90th_percentile":5854.14,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"1 through 10","median_amount":5854.14,"10th_percentile":5854.14,"90th_percentile":5854.15,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"53","median_amount":1325.47,"10th_percentile":1075.47,"90th_percentile":1453.66,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":447.05,"10th_percentile":447.05,"90th_percentile":447.05,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":1160.66,"10th_percentile":1160.66,"90th_percentile":1160.66,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":434.57,"10th_percentile":434.57,"90th_percentile":434.57,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"1 through 10","median_amount":6845.82,"10th_percentile":6294.02,"90th_percentile":10143.35},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"1 through 10","median_amount":6254.31,"10th_percentile":6254.31,"90th_percentile":6254.31},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":469.4,"10th_percentile":469.4,"90th_percentile":469.4,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"316","median_amount":1326.37,"10th_percentile":531.78,"90th_percentile":1386.89,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"12","median_amount":6174.93,"10th_percentile":5927.09,"90th_percentile":7431.55,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"1 through 10","median_amount":6222.44,"10th_percentile":6222.44,"90th_percentile":6222.44,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":447.05,"10th_percentile":447.05,"90th_percentile":447.05,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"1 through 10","median_amount":5458.51,"10th_percentile":5458.51,"90th_percentile":5458.51,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"189","median_amount":1323.88,"10th_percentile":1056.38,"90th_percentile":1384.09,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"103","median_amount":5124.08,"10th_percentile":3365.61,"90th_percentile":5153.04,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":447.05,"10th_percentile":447.05,"90th_percentile":447.05,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1075.48,"10th_percentile":1075.48,"90th_percentile":1075.48,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"17","median_amount":1077.51,"10th_percentile":1077.51,"90th_percentile":1165.29,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"1 through 10","median_amount":5901.56,"10th_percentile":5901.56,"90th_percentile":5901.56,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 4 Nuclear Medicine and Related Services","code_information":[{"code":"5594","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":577.29,"10th_percentile":577.29,"90th_percentile":600.29,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"31","median_amount":1381.43,"10th_percentile":1180.26,"90th_percentile":1525.41,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"1 through 10","median_amount":9342.29,"10th_percentile":9342.29,"90th_percentile":15402.09,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"23","median_amount":5803.22,"10th_percentile":5176.96,"90th_percentile":9198.6,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":606.15,"10th_percentile":606.15,"90th_percentile":606.15,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":554.37,"10th_percentile":554.37,"90th_percentile":554.37,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"1 through 10","median_amount":5952.5,"10th_percentile":5652.5,"90th_percentile":7700.15},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":577.29,"10th_percentile":577.29,"90th_percentile":577.29,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":1405.51,"10th_percentile":1230.33,"90th_percentile":6665.09,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"19","median_amount":2980.92,"10th_percentile":2712.89,"90th_percentile":8679.98,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"1 through 10","median_amount":6739.65,"10th_percentile":6739.65,"90th_percentile":6739.65,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"1 through 10","median_amount":6482.09,"10th_percentile":6482.09,"90th_percentile":6482.09,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"34","median_amount":1482.33,"10th_percentile":1132.33,"90th_percentile":3420.72,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":577.29,"10th_percentile":577.29,"90th_percentile":577.29,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":577.29,"10th_percentile":577.29,"90th_percentile":577.29,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":1407.86,"10th_percentile":1407.86,"90th_percentile":1407.86,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"1 through 10","median_amount":16464.76,"10th_percentile":16464.76,"90th_percentile":16464.76},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":606.15,"10th_percentile":606.15,"90th_percentile":606.15,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"173","median_amount":1481.33,"10th_percentile":1186.23,"90th_percentile":4413.35,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"1 through 10","median_amount":8350.75,"10th_percentile":8000.25,"90th_percentile":8469.75,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"1 through 10","median_amount":9027.01,"10th_percentile":7989.91,"90th_percentile":11687.59,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"1 through 10","median_amount":6114.83,"10th_percentile":6114.83,"90th_percentile":6114.83,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"90","median_amount":1475.34,"10th_percentile":1180.26,"90th_percentile":4411.87,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"56","median_amount":5772.02,"10th_percentile":5691.55,"90th_percentile":10019.77,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":554.37,"10th_percentile":554.37,"90th_percentile":744.06,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":4412.47,"10th_percentile":4412.47,"90th_percentile":4412.47,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":1223.82,"10th_percentile":1203.87,"90th_percentile":1504.84,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"1 through 10","median_amount":8389.3,"10th_percentile":8389.3,"90th_percentile":8389.3,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."}]}]},{"description":"Level 1 Therapeutic Radiation Treatment Preparation","code_information":[{"code":"5611","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":5244.79,"10th_percentile":5244.79,"90th_percentile":5244.79,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 2 Therapeutic Radiation Treatment Preparation","code_information":[{"code":"5612","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":700.24,"10th_percentile":700.24,"90th_percentile":870.89,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"1 through 10","median_amount":1811.79,"10th_percentile":1811.79,"90th_percentile":19146.09,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"1 through 10","median_amount":8640.71,"10th_percentile":8640.71,"90th_percentile":8640.71,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1098.68,"10th_percentile":1098.68,"90th_percentile":1098.68,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":722.77,"10th_percentile":722.77,"90th_percentile":722.77,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":12702.52,"10th_percentile":12702.52,"90th_percentile":12702.52,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":1184.86,"10th_percentile":371.78,"90th_percentile":8871.4,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"1 through 10","median_amount":1619.94,"10th_percentile":1619.94,"90th_percentile":1619.94},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"27","median_amount":1989.26,"10th_percentile":502.13,"90th_percentile":7210.03,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"1 through 10","median_amount":17144.73,"10th_percentile":17144.73,"90th_percentile":32568.41,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"20","median_amount":1128.74,"10th_percentile":371.79,"90th_percentile":8348.66,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"15","median_amount":12193.04,"10th_percentile":1089.5,"90th_percentile":37121.43,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1177.42,"10th_percentile":1177.42,"90th_percentile":2190.76,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 3 Therapeutic Radiation Treatment Preparation","code_information":[{"code":"5613","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":2661.72,"10th_percentile":2086.35,"90th_percentile":5271.96,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"1 through 10","median_amount":3845.7,"10th_percentile":3845.7,"90th_percentile":3845.7,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"1 through 10","median_amount":8463.26,"10th_percentile":8463.26,"90th_percentile":8463.26,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":4688.51,"10th_percentile":4400.51,"90th_percentile":5963.06,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"1 through 10","median_amount":15169.6,"10th_percentile":15169.6,"90th_percentile":15169.6,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":3146.44,"10th_percentile":2339.73,"90th_percentile":3577.87,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"1 through 10","median_amount":16319.46,"10th_percentile":16319.46,"90th_percentile":16319.46},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":652.72,"10th_percentile":652.72,"90th_percentile":652.72,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"20","median_amount":3146.44,"10th_percentile":1385.7,"90th_percentile":4136.46,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"1 through 10","median_amount":13100.67,"10th_percentile":13100.67,"90th_percentile":13100.67,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"15","median_amount":2672.6,"10th_percentile":2129.39,"90th_percentile":3968.16,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"1 through 10","median_amount":13378.76,"10th_percentile":13378.76,"90th_percentile":16623.02,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":1952.78,"10th_percentile":1952.78,"90th_percentile":1952.78,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 2 Radiation Therapy","code_information":[{"code":"5622","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1410.48,"10th_percentile":1410.48,"90th_percentile":1458.89,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":3928.23,"10th_percentile":3531.55,"90th_percentile":4576.62,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"1 through 10","median_amount":14087.9,"10th_percentile":4040.5,"90th_percentile":22224.09,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"1 through 10","median_amount":18193.79,"10th_percentile":11503.17,"90th_percentile":23924.87,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1544.41,"10th_percentile":1544.41,"90th_percentile":1544.41,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":697.5,"10th_percentile":697.5,"90th_percentile":697.5,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"1 through 10","median_amount":27473.7,"10th_percentile":27473.7,"90th_percentile":27473.7},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":9933.24,"10th_percentile":9933.24,"90th_percentile":10954.25,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":4712.41,"10th_percentile":932.3,"90th_percentile":10109.24,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"1 through 10","median_amount":25510.14,"10th_percentile":25510.14,"90th_percentile":25510.14},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"54","median_amount":4135.34,"10th_percentile":1171.44,"90th_percentile":8879.68,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"1 through 10","median_amount":26668.34,"10th_percentile":26668.34,"90th_percentile":26668.34,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"1 through 10","median_amount":34097.04,"10th_percentile":4458.09,"90th_percentile":37728.69,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"23","median_amount":3640.22,"10th_percentile":919.68,"90th_percentile":8149.9,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"24","median_amount":18177.73,"10th_percentile":7103.64,"90th_percentile":36219.93,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":2323.24,"10th_percentile":2323.24,"90th_percentile":2323.24,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":6405.99,"10th_percentile":6405.99,"90th_percentile":6405.99,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"1 through 10","median_amount":14224.11,"10th_percentile":14224.11,"90th_percentile":14224.11,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."}]}]},{"description":"Level 3 Radiation Therapy","code_information":[{"code":"5623","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"18","median_amount":7838.41,"10th_percentile":1037.82,"90th_percentile":13409.62,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"1 through 10","median_amount":26069.4,"10th_percentile":26069.4,"90th_percentile":26069.4,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"1 through 10","median_amount":14595.39,"10th_percentile":4188.54,"90th_percentile":24580.79,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":4717.07,"10th_percentile":4717.07,"90th_percentile":4717.07,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":12958.81,"10th_percentile":12958.81,"90th_percentile":12958.81,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":13748.69,"10th_percentile":11989.6,"90th_percentile":26673.17,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"18","median_amount":7665.11,"10th_percentile":3533.63,"90th_percentile":12856.21,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"1 through 10","median_amount":80311.44,"10th_percentile":80311.44,"90th_percentile":98482.26},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":4079.52,"10th_percentile":4079.52,"90th_percentile":4079.52,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"123","median_amount":8257.24,"10th_percentile":1833.14,"90th_percentile":12958.81,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"1 through 10","median_amount":57193.43,"10th_percentile":57193.43,"90th_percentile":69625.44,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"76","median_amount":8122.17,"10th_percentile":1889.63,"90th_percentile":13464.4,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"30","median_amount":51853.35,"10th_percentile":19444.0,"90th_percentile":74364.45,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":2705.2,"10th_percentile":2705.2,"90th_percentile":2705.2,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":8554.97,"10th_percentile":1909.8,"90th_percentile":8813.26,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 6 Radiation Therapy","code_information":[{"code":"5626","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":5790.84,"10th_percentile":5683.4,"90th_percentile":9171.03,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"1 through 10","median_amount":13030.23,"10th_percentile":13030.23,"90th_percentile":13030.23,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"1 through 10","median_amount":42753.2,"10th_percentile":42753.2,"90th_percentile":42753.2,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":9014.6,"10th_percentile":9014.6,"90th_percentile":9014.6,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1826.5,"10th_percentile":1826.5,"90th_percentile":1826.5,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":7073.45,"10th_percentile":4553.51,"90th_percentile":11762.34,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":6941.52,"10th_percentile":3980.01,"90th_percentile":9014.65,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"1 through 10","median_amount":33345.56,"10th_percentile":33345.56,"90th_percentile":33345.56,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."}]}]},{"description":"Level 7 Radiation Therapy","code_information":[{"code":"5627","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":14096.52,"10th_percentile":14096.52,"90th_percentile":14096.52,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 1 Pathology","code_information":[{"code":"5671","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":55.14,"10th_percentile":55.14,"90th_percentile":55.14,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"1 through 10","median_amount":109.81,"10th_percentile":109.81,"90th_percentile":109.81,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"1 through 10","median_amount":61.28,"10th_percentile":61.28,"90th_percentile":61.28,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":34.44,"10th_percentile":34.44,"90th_percentile":54.44,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":52.71,"10th_percentile":52.71,"90th_percentile":52.71,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"1 through 10","median_amount":49.47,"10th_percentile":49.47,"90th_percentile":49.47,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 2 Pathology","code_information":[{"code":"5672","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":173.33,"10th_percentile":173.33,"90th_percentile":173.33,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"1 through 10","median_amount":22819.24,"10th_percentile":22819.24,"90th_percentile":22819.24,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":173.73,"10th_percentile":173.73,"90th_percentile":173.73,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"1 through 10","median_amount":369.05,"10th_percentile":369.05,"90th_percentile":369.05,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":173.34,"10th_percentile":173.34,"90th_percentile":173.34,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"1 through 10","median_amount":232.48,"10th_percentile":232.48,"90th_percentile":232.48,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."}]}]},{"description":"Level 3 Pathology","code_information":[{"code":"5673","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"1 through 10","median_amount":294.0,"10th_percentile":294.0,"90th_percentile":294.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":363.85,"10th_percentile":363.85,"90th_percentile":363.85,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":296.91,"10th_percentile":296.91,"90th_percentile":296.91,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 1 Drug Administration","code_information":[{"code":"5691","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"1 through 10","median_amount":55.33,"10th_percentile":55.33,"90th_percentile":55.33,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":5345.31,"10th_percentile":5345.31,"90th_percentile":5345.31,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":446.5,"10th_percentile":446.5,"90th_percentile":446.5,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":7390.17,"10th_percentile":7390.17,"90th_percentile":7390.17,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"1 through 10","median_amount":415.3,"10th_percentile":415.3,"90th_percentile":491.59,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 2 Drug Administration","code_information":[{"code":"5692","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"19","median_amount":204.01,"10th_percentile":21.36,"90th_percentile":535.79,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"30","median_amount":260.7,"10th_percentile":71.98,"90th_percentile":1714.62,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"1 through 10","median_amount":907.08,"10th_percentile":706.26,"90th_percentile":7162.54,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"21","median_amount":2667.28,"10th_percentile":85.27,"90th_percentile":7134.54,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":96.39,"10th_percentile":60.6,"90th_percentile":238.85,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":86.98,"10th_percentile":86.98,"90th_percentile":86.98,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"1 through 10","median_amount":161.7,"10th_percentile":161.7,"90th_percentile":277.31},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":2440.74,"10th_percentile":2285.61,"90th_percentile":2916.57,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":543.65,"10th_percentile":543.65,"90th_percentile":548.7,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"1 through 10","median_amount":137.45,"10th_percentile":132.98,"90th_percentile":2299.81,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"28","median_amount":486.82,"10th_percentile":88.11,"90th_percentile":2654.36,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":92.38,"10th_percentile":92.38,"90th_percentile":92.38,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"1 through 10","median_amount":1222.56,"10th_percentile":1222.56,"90th_percentile":1222.56},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":67.29,"10th_percentile":67.29,"90th_percentile":211.89,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"153","median_amount":282.57,"10th_percentile":71.98,"90th_percentile":2542.4,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"1 through 10","median_amount":483.28,"10th_percentile":483.28,"90th_percentile":483.28,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"1 through 10","median_amount":820.94,"10th_percentile":820.94,"90th_percentile":820.94,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"12","median_amount":204.01,"10th_percentile":122.03,"90th_percentile":327.01,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"1 through 10","median_amount":1003.38,"10th_percentile":1003.38,"90th_percentile":1003.38,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"112","median_amount":1419.63,"10th_percentile":139.82,"90th_percentile":2547.88,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"61","median_amount":132.6,"10th_percentile":63.12,"90th_percentile":1733.04,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":117.12,"10th_percentile":19.24,"90th_percentile":306.97,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":21.34,"10th_percentile":10.67,"90th_percentile":523.94,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"13","median_amount":398.88,"10th_percentile":132.96,"90th_percentile":1441.08,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"13","median_amount":992.15,"10th_percentile":505.81,"90th_percentile":1269.23,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"1 through 10","median_amount":8421.76,"10th_percentile":8421.76,"90th_percentile":8421.76,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."}]}]},{"description":"Level 3 Drug Administration","code_information":[{"code":"5693","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"1 through 10","median_amount":5983.09,"10th_percentile":5983.09,"90th_percentile":5983.09,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"38","median_amount":450.56,"10th_percentile":161.49,"90th_percentile":1317.8,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"58","median_amount":928.65,"10th_percentile":213.11,"90th_percentile":6354.71,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"25","median_amount":1322.07,"10th_percentile":520.81,"90th_percentile":3181.73,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"77","median_amount":884.32,"10th_percentile":347.23,"90th_percentile":4923.15,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"42","median_amount":815.81,"10th_percentile":201.32,"90th_percentile":2204.78,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"1 through 10","median_amount":6561.63,"10th_percentile":5908.66,"90th_percentile":19195.41,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":521.62,"10th_percentile":521.62,"90th_percentile":521.62,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"1 through 10","median_amount":848.52,"10th_percentile":762.03,"90th_percentile":3705.68},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":457.64,"10th_percentile":457.64,"90th_percentile":516.74,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":213.11,"10th_percentile":208.46,"90th_percentile":962.4,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"19","median_amount":10369.07,"10th_percentile":1367.12,"90th_percentile":113783.67,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"17","median_amount":2059.12,"10th_percentile":424.08,"90th_percentile":14135.85,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"1 through 10","median_amount":1517.31,"10th_percentile":1517.31,"90th_percentile":1517.31,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"98","median_amount":2354.81,"10th_percentile":213.55,"90th_percentile":27757.6,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":329.45,"10th_percentile":234.66,"90th_percentile":564.11,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":274.77,"10th_percentile":274.77,"90th_percentile":274.77,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":170.49,"10th_percentile":170.49,"90th_percentile":170.49,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"1 through 10","median_amount":2966.7,"10th_percentile":2966.7,"90th_percentile":2966.7},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"29","median_amount":301.07,"10th_percentile":123.2,"90th_percentile":2004.57,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"282","median_amount":761.18,"10th_percentile":208.46,"90th_percentile":4864.4,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"24","median_amount":2105.92,"10th_percentile":654.98,"90th_percentile":4455.78,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"1 through 10","median_amount":1786.84,"10th_percentile":1079.33,"90th_percentile":4456.61,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":343.09,"10th_percentile":343.09,"90th_percentile":499.45,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"1 through 10","median_amount":5724.92,"10th_percentile":2605.13,"90th_percentile":17301.87,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"208","median_amount":976.88,"10th_percentile":212.71,"90th_percentile":5378.44,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"179","median_amount":1684.38,"10th_percentile":327.16,"90th_percentile":6668.91,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"91","median_amount":908.93,"10th_percentile":212.12,"90th_percentile":2292.38,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"19","median_amount":646.22,"10th_percentile":217.37,"90th_percentile":3686.19,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"1 through 10","median_amount":2861.42,"10th_percentile":1720.51,"90th_percentile":6295.31,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"1 through 10","median_amount":5227.91,"10th_percentile":5227.91,"90th_percentile":5227.91,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."}]}]},{"description":"Level 4 Drug Administration","code_information":[{"code":"5694","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":513.13,"10th_percentile":513.13,"90th_percentile":524.24,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"15","median_amount":931.14,"10th_percentile":670.99,"90th_percentile":1339.8,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"1 through 10","median_amount":2994.71,"10th_percentile":2612.34,"90th_percentile":17123.45,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"1 through 10","median_amount":2395.68,"10th_percentile":1610.41,"90th_percentile":3795.38,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":751.77,"10th_percentile":538.79,"90th_percentile":1503.54,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":524.24,"10th_percentile":524.24,"90th_percentile":524.24,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":3062.38,"10th_percentile":2644.19,"90th_percentile":3347.76,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"23","median_amount":4455.49,"10th_percentile":3841.52,"90th_percentile":4937.76,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"17","median_amount":1971.63,"10th_percentile":834.94,"90th_percentile":2397.67,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":738.37,"10th_percentile":738.37,"90th_percentile":738.37,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":554.74,"10th_percentile":332.01,"90th_percentile":1109.48,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"83","median_amount":962.38,"10th_percentile":335.49,"90th_percentile":1914.74,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"1 through 10","median_amount":3620.01,"10th_percentile":2824.18,"90th_percentile":5484.22,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"1 through 10","median_amount":1235.37,"10th_percentile":1235.37,"90th_percentile":1235.37,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"30","median_amount":1111.44,"10th_percentile":477.04,"90th_percentile":1350.75,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"55","median_amount":2877.26,"10th_percentile":1384.89,"90th_percentile":6323.12,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"18","median_amount":513.13,"10th_percentile":513.13,"90th_percentile":524.24,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 1 Diagnostic Tests and Related Services","code_information":[{"code":"5721","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"19","median_amount":63.4,"10th_percentile":28.05,"90th_percentile":63.4,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"21","median_amount":130.0,"10th_percentile":65.16,"90th_percentile":158.91,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"33","median_amount":790.0,"10th_percentile":609.25,"90th_percentile":1000.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"71","median_amount":1000.0,"10th_percentile":447.3,"90th_percentile":1000.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"1 through 10","median_amount":770.0,"10th_percentile":770.0,"90th_percentile":770.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"11","median_amount":66.57,"10th_percentile":25.2,"90th_percentile":66.57,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"1 through 10","median_amount":830.0,"10th_percentile":830.0,"90th_percentile":830.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"1 through 10","median_amount":850.0,"10th_percentile":850.0,"90th_percentile":850.0},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":63.08,"10th_percentile":63.08,"90th_percentile":63.08,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":151.92,"10th_percentile":151.92,"90th_percentile":158.26,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":297.64,"10th_percentile":297.64,"90th_percentile":297.64,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"18","median_amount":743.97,"10th_percentile":743.97,"90th_percentile":866.09,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"1 through 10","median_amount":717.19,"10th_percentile":717.19,"90th_percentile":743.97,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"24","median_amount":153.62,"10th_percentile":126.61,"90th_percentile":161.49,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":63.4,"10th_percentile":63.4,"90th_percentile":63.4,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"1 through 10","median_amount":870.0,"10th_percentile":188.79,"90th_percentile":900.0},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"12","median_amount":66.57,"10th_percentile":25.2,"90th_percentile":66.57,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"78","median_amount":158.36,"10th_percentile":126.61,"90th_percentile":159.06,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"45","median_amount":706.0,"10th_percentile":635.4,"90th_percentile":964.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"1 through 10","median_amount":710.0,"10th_percentile":710.0,"90th_percentile":888.51,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":63.08,"10th_percentile":63.08,"90th_percentile":63.08,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"1 through 10","median_amount":750.0,"10th_percentile":325.5,"90th_percentile":873.11,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"109","median_amount":152.62,"10th_percentile":121.54,"90th_percentile":159.27,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"208","median_amount":695.0,"10th_percentile":301.63,"90th_percentile":811.71,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"18","median_amount":63.08,"10th_percentile":23.15,"90th_percentile":63.4,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":129.14,"10th_percentile":120.58,"90th_percentile":150.72,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 2 Diagnostic Tests and Related Services","code_information":[{"code":"5722","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"11","median_amount":89.69,"10th_percentile":79.79,"90th_percentile":508.1,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"29","median_amount":314.97,"10th_percentile":244.21,"90th_percentile":314.97,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"16","median_amount":1264.0,"10th_percentile":781.38,"90th_percentile":1607.26,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"48","median_amount":1013.84,"10th_percentile":605.82,"90th_percentile":1244.75,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":92.68,"10th_percentile":74.22,"90th_percentile":94.18,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":736.0,"10th_percentile":736.0,"90th_percentile":736.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"1 through 10","median_amount":1141.0,"10th_percentile":866.0,"90th_percentile":1293.69,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"1 through 10","median_amount":1674.7,"10th_percentile":1360.0,"90th_percentile":2833.95},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":485.22,"10th_percentile":89.69,"90th_percentile":485.22,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":305.26,"10th_percentile":305.26,"90th_percentile":305.26,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"34","median_amount":617.09,"10th_percentile":579.19,"90th_percentile":620.3,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"16","median_amount":1513.62,"10th_percentile":1190.36,"90th_percentile":2022.12,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"1 through 10","median_amount":1250.76,"10th_percentile":1250.76,"90th_percentile":1250.76,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"40","median_amount":314.97,"10th_percentile":270.96,"90th_percentile":315.87,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":79.79,"10th_percentile":79.79,"90th_percentile":1016.2,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"1 through 10","median_amount":1520.76,"10th_percentile":1252.8,"90th_percentile":1836.13},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"12","median_amount":83.78,"10th_percentile":74.22,"90th_percentile":94.18,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"209","median_amount":306.06,"10th_percentile":294.5,"90th_percentile":315.77,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"19","median_amount":1306.1,"10th_percentile":1016.64,"90th_percentile":2067.17,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"12","median_amount":1241.08,"10th_percentile":1096.02,"90th_percentile":1822.89,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":89.69,"10th_percentile":89.69,"90th_percentile":1016.2,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"1 through 10","median_amount":1400.79,"10th_percentile":1400.79,"90th_percentile":1574.25,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"134","median_amount":305.27,"10th_percentile":244.21,"90th_percentile":315.98,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"120","median_amount":1214.87,"10th_percentile":895.52,"90th_percentile":1539.64,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"25","median_amount":85.79,"10th_percentile":70.69,"90th_percentile":89.69,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":235.28,"10th_percentile":235.28,"90th_percentile":235.28,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"12","median_amount":257.01,"10th_percentile":239.98,"90th_percentile":257.01,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"1 through 10","median_amount":1831.05,"10th_percentile":1831.05,"90th_percentile":1985.35,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"1 through 10","median_amount":1262.06,"10th_percentile":1262.06,"90th_percentile":1262.06,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."}]}]},{"description":"Level 3 Diagnostic Tests and Related Services","code_information":[{"code":"5723","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":68.86,"10th_percentile":68.86,"90th_percentile":68.86,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":417.02,"10th_percentile":417.02,"90th_percentile":417.02,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"1 through 10","median_amount":1615.55,"10th_percentile":1615.55,"90th_percentile":1667.3,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"1 through 10","median_amount":1225.11,"10th_percentile":1225.11,"90th_percentile":1225.11,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"1 through 10","median_amount":519.36,"10th_percentile":519.36,"90th_percentile":519.36,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":161.62,"10th_percentile":161.62,"90th_percentile":161.62,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"1 through 10","median_amount":1795.41,"10th_percentile":1795.41,"90th_percentile":1795.41},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":68.86,"10th_percentile":68.86,"90th_percentile":68.86,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":544.49,"10th_percentile":544.49,"90th_percentile":544.49,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":1021.27,"10th_percentile":1021.27,"90th_percentile":1051.47,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"1 through 10","median_amount":2321.84,"10th_percentile":2321.84,"90th_percentile":2321.84,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":527.27,"10th_percentile":527.27,"90th_percentile":527.27,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":155.86,"10th_percentile":155.86,"90th_percentile":155.86,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":537.09,"10th_percentile":521.51,"90th_percentile":726.67,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"1 through 10","median_amount":2110.5,"10th_percentile":2105.0,"90th_percentile":2650.93,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"1 through 10","median_amount":1499.7,"10th_percentile":1499.7,"90th_percentile":1499.7,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"1 through 10","median_amount":1584.19,"10th_percentile":1584.19,"90th_percentile":1584.19,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"11","median_amount":492.59,"10th_percentile":429.35,"90th_percentile":521.28,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"14","median_amount":1468.01,"10th_percentile":1462.98,"90th_percentile":2172.16,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":437.93,"10th_percentile":437.93,"90th_percentile":437.93,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"1 through 10","median_amount":2243.35,"10th_percentile":2243.35,"90th_percentile":2243.35,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."}]}]},{"description":"Level 4 Diagnostic Tests and Related Services","code_information":[{"code":"5724","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":317.31,"10th_percentile":317.31,"90th_percentile":317.31,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"16","median_amount":964.75,"10th_percentile":823.26,"90th_percentile":1033.57,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"17","median_amount":5044.94,"10th_percentile":5014.94,"90th_percentile":5434.41,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"26","median_amount":3555.0,"10th_percentile":3021.75,"90th_percentile":3771.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":333.18,"10th_percentile":333.18,"90th_percentile":333.18,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"1 through 10","median_amount":4657.66,"10th_percentile":4657.66,"90th_percentile":4657.66,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"1 through 10","median_amount":5564.74,"10th_percentile":5546.47,"90th_percentile":5821.65},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":328.43,"10th_percentile":328.43,"90th_percentile":328.43,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":1029.07,"10th_percentile":1029.07,"90th_percentile":1395.31,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"1 through 10","median_amount":5095.47,"10th_percentile":4751.01,"90th_percentile":5095.47,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"21","median_amount":962.65,"10th_percentile":800.3,"90th_percentile":1030.97,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":333.18,"10th_percentile":333.18,"90th_percentile":344.85,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"96","median_amount":1017.24,"10th_percentile":343.29,"90th_percentile":1029.87,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"11","median_amount":4553.22,"10th_percentile":3832.67,"90th_percentile":4835.39,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"1 through 10","median_amount":4862.79,"10th_percentile":4534.06,"90th_percentile":5469.2,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":317.31,"10th_percentile":317.31,"90th_percentile":328.43,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"1 through 10","median_amount":1169.22,"10th_percentile":1169.22,"90th_percentile":5136.75,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"72","median_amount":984.97,"10th_percentile":768.68,"90th_percentile":1030.07,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"44","median_amount":4482.97,"10th_percentile":3599.0,"90th_percentile":4808.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"13","median_amount":317.31,"10th_percentile":317.31,"90th_percentile":328.43,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1017.54,"10th_percentile":1017.54,"90th_percentile":1017.54,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":839.72,"10th_percentile":839.72,"90th_percentile":839.72,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"1 through 10","median_amount":4191.73,"10th_percentile":4191.73,"90th_percentile":4191.73,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."}]}]},{"description":"Level 1 Minor Procedures","code_information":[{"code":"5731","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":19.82,"10th_percentile":19.82,"90th_percentile":19.82,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"1 through 10","median_amount":114.28,"10th_percentile":114.28,"90th_percentile":114.28,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":24.77,"10th_percentile":24.77,"90th_percentile":24.77,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":14.84,"10th_percentile":14.84,"90th_percentile":14.84,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":28.96,"10th_percentile":28.96,"90th_percentile":28.96,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"1 through 10","median_amount":243.25,"10th_percentile":243.25,"90th_percentile":243.25,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 2 Minor Procedures","code_information":[{"code":"5732","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":24.28,"10th_percentile":24.28,"90th_percentile":24.28,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":39.86,"10th_percentile":29.65,"90th_percentile":75.66,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"1 through 10","median_amount":161.95,"10th_percentile":161.95,"90th_percentile":161.95,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"18","median_amount":118.9,"10th_percentile":95.12,"90th_percentile":118.9,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":26.94,"10th_percentile":26.94,"90th_percentile":26.94,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":25.66,"10th_percentile":25.66,"90th_percentile":25.66,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"1 through 10","median_amount":174.25,"10th_percentile":174.25,"90th_percentile":174.25},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":77.78,"10th_percentile":77.78,"90th_percentile":78.18,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"11","median_amount":152.51,"10th_percentile":152.51,"90th_percentile":152.51,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":40.51,"10th_percentile":37.83,"90th_percentile":40.51,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":24.28,"10th_percentile":24.28,"90th_percentile":24.28,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":298.77,"10th_percentile":298.77,"90th_percentile":298.77,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":25.49,"10th_percentile":25.49,"90th_percentile":25.49,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"62","median_amount":40.2,"10th_percentile":37.83,"90th_percentile":40.51,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"1 through 10","median_amount":144.73,"10th_percentile":144.73,"90th_percentile":144.73,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"1 through 10","median_amount":145.55,"10th_percentile":145.55,"90th_percentile":145.55,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":24.28,"10th_percentile":24.28,"90th_percentile":24.28,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"45","median_amount":39.7,"10th_percentile":31.76,"90th_percentile":64.51,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"43","median_amount":142.48,"10th_percentile":142.48,"90th_percentile":1201.69,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":42.66,"10th_percentile":24.28,"90th_percentile":144.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":32.4,"10th_percentile":32.4,"90th_percentile":32.4,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 3 Minor Procedures","code_information":[{"code":"5733","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":25.66,"10th_percentile":24.28,"90th_percentile":39.22,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"21","median_amount":60.08,"10th_percentile":47.59,"90th_percentile":144.21,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"24","median_amount":683.68,"10th_percentile":120.08,"90th_percentile":1516.8,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"94","median_amount":111.25,"10th_percentile":69.6,"90th_percentile":1113.6,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":11.21,"10th_percentile":11.21,"90th_percentile":22.43,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"1 through 10","median_amount":1281.0,"10th_percentile":1281.0,"90th_percentile":1281.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"1 through 10","median_amount":1632.0,"10th_percentile":129.2,"90th_percentile":1632.0},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":113.52,"10th_percentile":113.52,"90th_percentile":113.52,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":59.49,"10th_percentile":59.49,"90th_percentile":60.08,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"21","median_amount":117.72,"10th_percentile":110.47,"90th_percentile":117.72,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"1 through 10","median_amount":1428.42,"10th_percentile":113.08,"90th_percentile":1428.42,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"1 through 10","median_amount":1428.42,"10th_percentile":1428.42,"90th_percentile":1428.42,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"33","median_amount":61.31,"10th_percentile":60.08,"90th_percentile":120.16,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":68.21,"10th_percentile":24.28,"90th_percentile":71.1,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":252.76,"10th_percentile":48.07,"90th_percentile":355.56,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"1 through 10","median_amount":166.87,"10th_percentile":166.87,"90th_percentile":166.87},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":25.49,"10th_percentile":11.29,"90th_percentile":26.94,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"212","median_amount":60.88,"10th_percentile":56.9,"90th_percentile":240.35,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"14","median_amount":1355.52,"10th_percentile":107.31,"90th_percentile":1355.52,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"1 through 10","median_amount":1363.2,"10th_percentile":1118.56,"90th_percentile":1363.2,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":24.28,"10th_percentile":24.28,"90th_percentile":24.28,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"1 through 10","median_amount":205.5,"10th_percentile":205.5,"90th_percentile":1440.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"110","median_amount":60.19,"10th_percentile":11.09,"90th_percentile":128.56,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"124","median_amount":1078.27,"10th_percentile":103.82,"90th_percentile":1347.84,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"23","median_amount":24.28,"10th_percentile":10.75,"90th_percentile":25.66,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":49.03,"10th_percentile":45.77,"90th_percentile":550.91,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"1 through 10","median_amount":246.6,"10th_percentile":246.6,"90th_percentile":246.6,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"1 through 10","median_amount":1392.0,"10th_percentile":1392.0,"90th_percentile":1392.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."}]}]},{"description":"Level 4 Minor Procedures","code_information":[{"code":"5734","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"17","median_amount":45.11,"10th_percentile":24.28,"90th_percentile":162.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"48","median_amount":124.53,"10th_percentile":91.18,"90th_percentile":131.18,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"24","median_amount":556.16,"10th_percentile":204.16,"90th_percentile":767.88,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"56","median_amount":428.04,"10th_percentile":163.33,"90th_percentile":612.48,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"1 through 10","median_amount":504.02,"10th_percentile":504.02,"90th_percentile":504.02,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"18","median_amount":47.37,"10th_percentile":26.94,"90th_percentile":71.52,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":485.22,"10th_percentile":485.22,"90th_percentile":485.22,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"1 through 10","median_amount":854.0,"10th_percentile":854.0,"90th_percentile":854.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":485.22,"10th_percentile":485.22,"90th_percentile":485.22,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"1 through 10","median_amount":627.3,"10th_percentile":627.3,"90th_percentile":3798.24},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":124.23,"10th_percentile":124.23,"90th_percentile":124.23,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"20","median_amount":255.44,"10th_percentile":239.74,"90th_percentile":255.44,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"1 through 10","median_amount":635.35,"10th_percentile":549.05,"90th_percentile":1431.62,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"1 through 10","median_amount":549.05,"10th_percentile":549.05,"90th_percentile":691.22,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"38","median_amount":126.13,"10th_percentile":91.18,"90th_percentile":165.03,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":45.11,"10th_percentile":24.28,"90th_percentile":68.11,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":104.3,"10th_percentile":104.3,"90th_percentile":104.3,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"1 through 10","median_amount":649.11,"10th_percentile":649.11,"90th_percentile":742.98},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":47.37,"10th_percentile":25.49,"90th_percentile":47.68,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"220","median_amount":130.38,"10th_percentile":109.36,"90th_percentile":142.14,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"17","median_amount":521.03,"10th_percentile":521.03,"90th_percentile":2085.52,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"1 through 10","median_amount":606.34,"10th_percentile":558.42,"90th_percentile":606.34,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":24.28,"10th_percentile":24.28,"90th_percentile":24.28,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"1 through 10","median_amount":570.4,"10th_percentile":281.6,"90th_percentile":640.5,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"139","median_amount":126.34,"10th_percentile":97.39,"90th_percentile":133.04,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"108","median_amount":512.91,"10th_percentile":89.69,"90th_percentile":593.53,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"18","median_amount":45.11,"10th_percentile":24.28,"90th_percentile":48.38,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"14","median_amount":106.39,"10th_percentile":106.39,"90th_percentile":132.99,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"1 through 10","median_amount":1418.25,"10th_percentile":1314.45,"90th_percentile":4355.96,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"1 through 10","median_amount":25.66,"10th_percentile":25.66,"90th_percentile":25.66,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."}]}]},{"description":"Level 5 Minor Procedures","code_information":[{"code":"5735","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"1 through 10","median_amount":261.0,"10th_percentile":261.0,"90th_percentile":261.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"1 through 10","median_amount":334.79,"10th_percentile":334.79,"90th_percentile":334.79,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 1 Electronic Analysis of Devices","code_information":[{"code":"5741","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":14.84,"10th_percentile":14.84,"90th_percentile":16.81,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"206","median_amount":37.72,"10th_percentile":30.17,"90th_percentile":37.72,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"40","median_amount":174.59,"10th_percentile":128.18,"90th_percentile":183.28,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"72","median_amount":128.18,"10th_percentile":105.56,"90th_percentile":134.56,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"1 through 10","median_amount":35.22,"10th_percentile":35.22,"90th_percentile":35.22,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"15","median_amount":15.58,"10th_percentile":15.58,"90th_percentile":15.78,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"1 through 10","median_amount":174.0,"10th_percentile":174.0,"90th_percentile":174.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":17.33,"10th_percentile":15.03,"90th_percentile":17.66,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"1 through 10","median_amount":187.85,"10th_percentile":154.7,"90th_percentile":221.0},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":15.03,"10th_percentile":15.03,"90th_percentile":15.03,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"21","median_amount":37.72,"10th_percentile":35.62,"90th_percentile":38.22,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"87","median_amount":73.9,"10th_percentile":69.36,"90th_percentile":74.29,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"15","median_amount":164.41,"10th_percentile":135.41,"90th_percentile":348.17,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"1 through 10","median_amount":158.13,"10th_percentile":158.13,"90th_percentile":158.13,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"256","median_amount":37.8,"10th_percentile":33.01,"90th_percentile":38.49,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"16","median_amount":14.84,"10th_percentile":14.84,"90th_percentile":15.03,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":37.87,"10th_percentile":37.87,"90th_percentile":37.87,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":30.17,"10th_percentile":29.34,"90th_percentile":37.72,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"1 through 10","median_amount":144.2,"10th_percentile":144.2,"90th_percentile":192.27},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"12","median_amount":15.58,"10th_percentile":15.58,"90th_percentile":15.78,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1412","median_amount":37.72,"10th_percentile":35.22,"90th_percentile":38.12,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"26","median_amount":156.03,"10th_percentile":128.49,"90th_percentile":157.57,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"14","median_amount":156.91,"10th_percentile":122.83,"90th_percentile":156.91,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":16.81,"10th_percentile":16.81,"90th_percentile":16.81,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"12","median_amount":165.75,"10th_percentile":136.5,"90th_percentile":165.75,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"709","median_amount":37.73,"10th_percentile":29.34,"90th_percentile":38.49,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"223","median_amount":153.6,"10th_percentile":122.88,"90th_percentile":158.24,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":14.84,"10th_percentile":14.84,"90th_percentile":16.81,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":37.42,"10th_percentile":37.42,"90th_percentile":37.42,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"34","median_amount":30.78,"10th_percentile":29.93,"90th_percentile":38.47,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"1 through 10","median_amount":160.23,"10th_percentile":159.56,"90th_percentile":329.23,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."}]}]},{"description":"Cardiac Rehabilitation","code_information":[{"code":"5771","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":64.84,"10th_percentile":64.84,"90th_percentile":64.84,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"24","median_amount":287.62,"10th_percentile":127.35,"90th_percentile":891.45,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"13","median_amount":656.49,"10th_percentile":216.0,"90th_percentile":2900.88,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"25","median_amount":648.0,"10th_percentile":216.0,"90th_percentile":1728.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":243.8,"10th_percentile":146.28,"90th_percentile":341.32,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":645.55,"10th_percentile":645.55,"90th_percentile":645.55,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":1504.8,"10th_percentile":755.31,"90th_percentile":1510.62,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"1 through 10","median_amount":1836.12,"10th_percentile":659.16,"90th_percentile":2966.22,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"1 through 10","median_amount":2852.82,"10th_percentile":2852.82,"90th_percentile":2852.82,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"19","median_amount":518.7,"10th_percentile":127.65,"90th_percentile":1222.56,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"1 through 10","median_amount":2697.87,"10th_percentile":2697.87,"90th_percentile":2697.87},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":438.84,"10th_percentile":438.84,"90th_percentile":438.84,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"238","median_amount":638.25,"10th_percentile":127.65,"90th_percentile":1318.5,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"21","median_amount":938.28,"10th_percentile":302.17,"90th_percentile":1876.56,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"1 through 10","median_amount":2830.77,"10th_percentile":2830.77,"90th_percentile":3774.36,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"126","median_amount":509.44,"10th_percentile":127.36,"90th_percentile":1278.8,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"96","median_amount":1231.56,"10th_percentile":300.46,"90th_percentile":3694.62,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":778.08,"10th_percentile":778.08,"90th_percentile":778.08,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Resuscitation and Cardioversion","code_information":[{"code":"5781","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"18","median_amount":667.89,"10th_percentile":624.02,"90th_percentile":1505.53,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"1 through 10","median_amount":5056.54,"10th_percentile":2045.02,"90th_percentile":7357.88,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"1 through 10","median_amount":2684.22,"10th_percentile":2131.73,"90th_percentile":3928.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"1 through 10","median_amount":6392.42,"10th_percentile":6392.42,"90th_percentile":6392.42},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":618.42,"10th_percentile":618.42,"90th_percentile":618.42,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":1303.52,"10th_percentile":1296.77,"90th_percentile":2383.32,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"1 through 10","median_amount":6140.38,"10th_percentile":6140.38,"90th_percentile":6140.38,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"1 through 10","median_amount":5491.61,"10th_percentile":5491.61,"90th_percentile":5491.61,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"15","median_amount":663.59,"10th_percentile":546.26,"90th_percentile":1413.18,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"1 through 10","median_amount":2456.69,"10th_percentile":2456.69,"90th_percentile":2456.69},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"115","median_amount":667.89,"10th_percentile":529.51,"90th_percentile":1222.48,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"1 through 10","median_amount":5410.59,"10th_percentile":5410.59,"90th_percentile":5410.59,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"1 through 10","median_amount":5439.99,"10th_percentile":5439.99,"90th_percentile":5439.99,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":683.13,"10th_percentile":683.13,"90th_percentile":683.13,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"41","median_amount":668.9,"10th_percentile":365.0,"90th_percentile":1225.7,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"16","median_amount":3755.67,"10th_percentile":1909.51,"90th_percentile":5276.19,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":378.55,"10th_percentile":331.85,"90th_percentile":414.34,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Pulmonary Treatment","code_information":[{"code":"5791","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":216.8,"10th_percentile":216.8,"90th_percentile":292.23,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"1 through 10","median_amount":1099.09,"10th_percentile":1099.09,"90th_percentile":1756.17,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"1 through 10","median_amount":2349.99,"10th_percentile":1467.0,"90th_percentile":2350.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":227.64,"10th_percentile":227.64,"90th_percentile":227.64,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":216.8,"10th_percentile":216.8,"90th_percentile":216.8,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":216.8,"10th_percentile":216.8,"90th_percentile":216.8,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":986.55,"10th_percentile":986.55,"90th_percentile":986.55,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"1 through 10","median_amount":250.0,"10th_percentile":250.0,"90th_percentile":250.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":240.42,"10th_percentile":126.77,"90th_percentile":248.04,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"1 through 10","median_amount":1139.4,"10th_percentile":1139.4,"90th_percentile":1139.4},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":84.83,"10th_percentile":69.0,"90th_percentile":138.44,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"14","median_amount":206.12,"10th_percentile":205.72,"90th_percentile":544.43,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"1 through 10","median_amount":1393.25,"10th_percentile":1393.25,"90th_percentile":1393.25,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":540.59,"10th_percentile":540.59,"90th_percentile":540.59,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"1 through 10","median_amount":6613.22,"10th_percentile":6613.22,"90th_percentile":6613.22,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":165.03,"10th_percentile":165.03,"90th_percentile":165.03,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"19","median_amount":1077.25,"10th_percentile":328.35,"90th_percentile":2201.59,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":127.4,"10th_percentile":74.17,"90th_percentile":302.14,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 1 Health and Behavior Services","code_information":[{"code":"5821","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":7358.1,"10th_percentile":7358.1,"90th_percentile":7358.1,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":2601.34,"10th_percentile":2601.34,"90th_percentile":2601.34,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 2 Health and Behavior Services","code_information":[{"code":"5822","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":97.88,"10th_percentile":97.88,"90th_percentile":97.88,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":217.44,"10th_percentile":217.44,"90th_percentile":355.34,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"1 through 10","median_amount":931.0,"10th_percentile":352.0,"90th_percentile":2463.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"21","median_amount":644.0,"10th_percentile":390.0,"90th_percentile":1027.88,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"1 through 10","median_amount":539.0,"10th_percentile":539.0,"90th_percentile":539.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":312.63,"10th_percentile":269.78,"90th_percentile":400.29,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":293.64,"10th_percentile":293.64,"90th_percentile":416.84,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"1 through 10","median_amount":671.81,"10th_percentile":671.81,"90th_percentile":671.81,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":87.04,"10th_percentile":87.04,"90th_percentile":87.04,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":434.9,"10th_percentile":434.9,"90th_percentile":434.9,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":372.76,"10th_percentile":286.89,"90th_percentile":502.77,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"1 through 10","median_amount":491.39,"10th_percentile":491.39,"90th_percentile":545.75,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":263.44,"10th_percentile":263.44,"90th_percentile":489.82,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"1 through 10","median_amount":61.16,"10th_percentile":61.16,"90th_percentile":61.16,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":28.0,"10th_percentile":28.0,"90th_percentile":28.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":800.97,"10th_percentile":800.97,"90th_percentile":800.97,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 3 Health and Behavior Services","code_information":[{"code":"5823","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"104","median_amount":64.21,"10th_percentile":60.42,"90th_percentile":181.26,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"117","median_amount":163.31,"10th_percentile":123.31,"90th_percentile":489.93,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"255","median_amount":289.0,"10th_percentile":125.6,"90th_percentile":573.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"724","median_amount":220.0,"10th_percentile":139.0,"90th_percentile":483.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"15","median_amount":191.0,"10th_percentile":157.0,"90th_percentile":696.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":120.84,"10th_percentile":60.42,"90th_percentile":181.26,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"273","median_amount":64.21,"10th_percentile":60.42,"90th_percentile":181.26,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"31","median_amount":158.53,"10th_percentile":120.35,"90th_percentile":385.95,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"1 through 10","median_amount":166.83,"10th_percentile":166.83,"90th_percentile":427.45,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"21","median_amount":130.21,"10th_percentile":93.48,"90th_percentile":209.65,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"41","median_amount":170.85,"10th_percentile":103.19,"90th_percentile":324.7},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"43","median_amount":120.84,"10th_percentile":64.21,"90th_percentile":201.41,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"17","median_amount":155.07,"10th_percentile":136.22,"90th_percentile":310.14,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"127","median_amount":161.44,"10th_percentile":116.8,"90th_percentile":331.81,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"57","median_amount":130.94,"10th_percentile":103.41,"90th_percentile":284.2,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"113","median_amount":188.0,"10th_percentile":71.77,"90th_percentile":419.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"65","median_amount":120.84,"10th_percentile":60.42,"90th_percentile":241.68,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":494.57,"10th_percentile":147.54,"90th_percentile":649.64,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":181.26,"10th_percentile":120.84,"90th_percentile":196.89,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":124.05,"10th_percentile":124.05,"90th_percentile":124.05,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"51","median_amount":349.74,"10th_percentile":158.4,"90th_percentile":699.48},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":64.21,"10th_percentile":64.21,"90th_percentile":151.18,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"440","median_amount":162.51,"10th_percentile":136.22,"90th_percentile":418.89,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"340","median_amount":197.68,"10th_percentile":102.37,"90th_percentile":354.37,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"104","median_amount":167.56,"10th_percentile":111.47,"90th_percentile":382.69,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"76","median_amount":120.84,"10th_percentile":60.42,"90th_percentile":279.6,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"1 through 10","median_amount":268.5,"10th_percentile":268.5,"90th_percentile":268.5},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"40","median_amount":143.25,"10th_percentile":83.4,"90th_percentile":311.86,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":126.58,"10th_percentile":29.36,"90th_percentile":158.23,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"1 through 10","median_amount":222.0,"10th_percentile":220.5,"90th_percentile":580.8,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"1 through 10","median_amount":143.25,"10th_percentile":57.33,"90th_percentile":249.75,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":116.85,"10th_percentile":116.85,"90th_percentile":348.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"14","median_amount":113.43,"10th_percentile":75.67,"90th_percentile":120.6,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"115","median_amount":272.44,"10th_percentile":153.86,"90th_percentile":433.7,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"1 through 10","median_amount":276.3,"10th_percentile":276.3,"90th_percentile":378.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"1 through 10","median_amount":213.71,"10th_percentile":113.35,"90th_percentile":438.97,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."}]}]},{"description":"Covid-19 Vaccine Administration","code_information":[{"code":"9398","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"1 through 10","median_amount":434.01,"10th_percentile":434.01,"90th_percentile":434.01,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Inj, labetalol hcl, 5mg","code_information":[{"code":"9400","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"1 through 10","median_amount":4.58,"10th_percentile":4.58,"90th_percentile":4.58,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Platelet pheres leukoreduced","code_information":[{"code":"9501","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":953.45,"10th_percentile":953.45,"90th_percentile":953.45,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":3153.06,"10th_percentile":3153.06,"90th_percentile":3153.06,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"RBC leukocytes reduced","code_information":[{"code":"9512","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":3756.4,"10th_percentile":3756.4,"90th_percentile":3756.4,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"RBC leukoreduced irradiated","code_information":[{"code":"9522","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":952.19,"10th_percentile":952.19,"90th_percentile":952.19,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Plate pheres leukoredu irrad","code_information":[{"code":"9530","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"20","median_amount":1128.02,"10th_percentile":1063.16,"90th_percentile":1436.84,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"14","median_amount":1128.42,"10th_percentile":1075.43,"90th_percentile":1393.42,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":2296.26,"10th_percentile":2296.26,"90th_percentile":2296.26,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"1 through 10","median_amount":1202.45,"10th_percentile":1186.7,"90th_percentile":2030.16,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Non-OPPS Clinic Services","code_information":[{"code":"N700","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"157","median_amount":61.85,"10th_percentile":53.56,"90th_percentile":90.32,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"328","median_amount":128.56,"10th_percentile":102.84,"90th_percentile":130.35,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"218","median_amount":164.09,"10th_percentile":88.0,"90th_percentile":255.17,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"542","median_amount":76.0,"10th_percentile":69.89,"90th_percentile":123.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"1 through 10","median_amount":76.0,"10th_percentile":76.0,"90th_percentile":123.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"43","median_amount":61.36,"10th_percentile":51.28,"90th_percentile":73.58,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"90","median_amount":69.79,"10th_percentile":61.36,"90th_percentile":116.37,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"1 through 10","median_amount":231.12,"10th_percentile":231.12,"90th_percentile":231.12,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"11","median_amount":102.09,"10th_percentile":93.79,"90th_percentile":224.93,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"1 through 10","median_amount":102.09,"10th_percentile":102.09,"90th_percentile":102.09,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"19","median_amount":64.95,"10th_percentile":64.43,"90th_percentile":73.86,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"21","median_amount":159.8,"10th_percentile":80.7,"90th_percentile":274.55},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"23","median_amount":67.11,"10th_percentile":65.81,"90th_percentile":90.61,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"52","median_amount":130.35,"10th_percentile":120.54,"90th_percentile":130.35,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"66","median_amount":255.38,"10th_percentile":239.69,"90th_percentile":256.71,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"90","median_amount":139.87,"10th_percentile":91.5,"90th_percentile":240.3,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"32","median_amount":91.5,"10th_percentile":74.4,"90th_percentile":240.3,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"372","median_amount":130.35,"10th_percentile":113.0,"90th_percentile":130.35,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"48","median_amount":69.79,"10th_percentile":61.36,"90th_percentile":88.34,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":121.19,"10th_percentile":102.84,"90th_percentile":128.56,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":112.9,"10th_percentile":112.9,"90th_percentile":112.9,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"33","median_amount":229.68,"10th_percentile":98.31,"90th_percentile":281.01},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"1 through 10","median_amount":100.0,"10th_percentile":100.0,"90th_percentile":159.61},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"34","median_amount":67.18,"10th_percentile":53.56,"90th_percentile":87.66,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1946","median_amount":130.35,"10th_percentile":120.54,"90th_percentile":130.35,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"263","median_amount":152.5,"10th_percentile":71.84,"90th_percentile":212.47,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"102","median_amount":187.44,"10th_percentile":80.23,"90th_percentile":229.33,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"50","median_amount":69.79,"10th_percentile":61.36,"90th_percentile":116.37,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"33","median_amount":203.25,"10th_percentile":84.75,"90th_percentile":242.25,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"988","median_amount":130.35,"10th_percentile":104.28,"90th_percentile":130.35,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"689","median_amount":188.35,"10th_percentile":130.66,"90th_percentile":224.49,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"14","median_amount":84.75,"10th_percentile":72.32,"90th_percentile":92.25,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"76","median_amount":65.53,"10th_percentile":53.56,"90th_percentile":103.25,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"13","median_amount":68.46,"10th_percentile":39.36,"90th_percentile":108.27,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":128.56,"10th_percentile":128.56,"90th_percentile":128.56,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"152","median_amount":120.54,"10th_percentile":110.74,"90th_percentile":132.96,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"23","median_amount":268.2,"10th_percentile":237.6,"90th_percentile":290.7,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"11","median_amount":195.66,"10th_percentile":153.12,"90th_percentile":233.21,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."}]}]},{"description":"Clinical Diagnostic Lab Services","code_information":[{"code":"N800","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"54","median_amount":92.13,"10th_percentile":53.56,"90th_percentile":212.64,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"331","median_amount":130.35,"10th_percentile":104.28,"90th_percentile":260.7,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"101","median_amount":311.26,"10th_percentile":91.64,"90th_percentile":920.89,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"308","median_amount":91.64,"10th_percentile":20.42,"90th_percentile":266.15,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"1 through 10","median_amount":20.42,"10th_percentile":20.42,"90th_percentile":20.42,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"27","median_amount":61.81,"10th_percentile":59.49,"90th_percentile":137.9,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":71.27,"10th_percentile":71.27,"90th_percentile":71.27,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"1 through 10","median_amount":413.0,"10th_percentile":413.0,"90th_percentile":413.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"16","median_amount":172.09,"10th_percentile":158.73,"90th_percentile":322.8,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"1 through 10","median_amount":388.04,"10th_percentile":388.04,"90th_percentile":388.04,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":81.0,"10th_percentile":10.53,"90th_percentile":121.37,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"22","median_amount":122.4,"10th_percentile":33.91,"90th_percentile":339.15},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":125.11,"10th_percentile":76.85,"90th_percentile":245.18,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"48","median_amount":153.44,"10th_percentile":128.56,"90th_percentile":481.05,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"32","median_amount":255.38,"10th_percentile":239.69,"90th_percentile":256.71,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"40","median_amount":318.41,"10th_percentile":182.28,"90th_percentile":650.98,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"1 through 10","median_amount":318.41,"10th_percentile":201.47,"90th_percentile":1381.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"544","median_amount":130.35,"10th_percentile":121.71,"90th_percentile":260.7,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":87.5,"10th_percentile":10.03,"90th_percentile":395.85,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"12","median_amount":104.28,"10th_percentile":102.84,"90th_percentile":208.56,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":9.71,"10th_percentile":9.71,"90th_percentile":9.71,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"28","median_amount":213.15,"10th_percentile":70.0,"90th_percentile":621.0},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"1 through 10","median_amount":1.49,"10th_percentile":1.49,"90th_percentile":1.49},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"26","median_amount":76.14,"10th_percentile":10.53,"90th_percentile":137.11,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"2280","median_amount":130.35,"10th_percentile":128.56,"90th_percentile":260.7,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"124","median_amount":302.17,"10th_percentile":153.95,"90th_percentile":964.4,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"67","median_amount":303.88,"10th_percentile":163.3,"90th_percentile":741.24,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":57.99,"10th_percentile":57.99,"90th_percentile":115.98,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"30","median_amount":188.5,"10th_percentile":109.81,"90th_percentile":439.24,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"1331","median_amount":130.35,"10th_percentile":109.63,"90th_percentile":292.08,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"543","median_amount":9.71,"10th_percentile":4.29,"90th_percentile":94.02,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"17","median_amount":32.6,"10th_percentile":17.14,"90th_percentile":103.26,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"97","median_amount":80.15,"10th_percentile":27.5,"90th_percentile":175.88,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"31","median_amount":18.43,"10th_percentile":16.52,"90th_percentile":127.35,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":128.56,"10th_percentile":128.56,"90th_percentile":128.56,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"67","median_amount":132.96,"10th_percentile":124.14,"90th_percentile":496.56,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"1 through 10","median_amount":311.4,"10th_percentile":311.4,"90th_percentile":311.4,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"1 through 10","median_amount":176.89,"10th_percentile":32.92,"90th_percentile":176.89,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."}]}]},{"description":"Therapy Services","code_information":[{"code":"N801","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"1 through 10","median_amount":307.5,"10th_percentile":307.5,"90th_percentile":1968.75,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"264","median_amount":156.8,"10th_percentile":62.66,"90th_percentile":396.24,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"539","median_amount":140.95,"10th_percentile":66.44,"90th_percentile":380.68,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"557","median_amount":770.0,"10th_percentile":249.0,"90th_percentile":1950.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"1231","median_amount":596.0,"10th_percentile":224.8,"90th_percentile":1788.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"1 through 10","median_amount":316.0,"10th_percentile":316.0,"90th_percentile":316.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"231","median_amount":173.48,"10th_percentile":65.79,"90th_percentile":395.4,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":65.79,"10th_percentile":65.79,"90th_percentile":65.79,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"1 through 10","median_amount":432.43,"10th_percentile":432.43,"90th_percentile":432.43,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"29","median_amount":461.0,"10th_percentile":264.0,"90th_percentile":1496.08,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"43","median_amount":118.32,"10th_percentile":65.79,"90th_percentile":283.98,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"115","median_amount":671.5,"10th_percentile":224.4,"90th_percentile":2105.45},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"115","median_amount":155.78,"10th_percentile":59.16,"90th_percentile":390.33,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"63","median_amount":104.92,"10th_percentile":48.2,"90th_percentile":256.32,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":182.65,"10th_percentile":140.31,"90th_percentile":269.26,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"296","median_amount":604.83,"10th_percentile":182.0,"90th_percentile":1728.93,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"43","median_amount":530.93,"10th_percentile":182.0,"90th_percentile":1928.37,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"403","median_amount":137.15,"10th_percentile":54.03,"90th_percentile":352.81,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"102","median_amount":145.1,"10th_percentile":56.91,"90th_percentile":325.55,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":145.69,"10th_percentile":64.55,"90th_percentile":210.78,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":185.49,"10th_percentile":185.49,"90th_percentile":185.49,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"11","median_amount":82.13,"10th_percentile":41.06,"90th_percentile":191.39,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"80","median_amount":617.8,"10th_percentile":185.4,"90th_percentile":1579.92},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"1 through 10","median_amount":267.2,"10th_percentile":267.2,"90th_percentile":380.97},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"200","median_amount":137.5,"10th_percentile":65.79,"90th_percentile":357.14,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"2996","median_amount":142.02,"10th_percentile":57.12,"90th_percentile":402.05,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"524","median_amount":683.22,"10th_percentile":263.0,"90th_percentile":1708.05,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"217","median_amount":759.44,"10th_percentile":366.88,"90th_percentile":2278.32,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"55","median_amount":105.4,"10th_percentile":51.87,"90th_percentile":266.78,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"1 through 10","median_amount":1522.5,"10th_percentile":890.25,"90th_percentile":2021.25},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"79","median_amount":782.78,"10th_percentile":258.2,"90th_percentile":2067.75,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"1836","median_amount":148.84,"10th_percentile":63.83,"90th_percentile":416.35,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"3073","median_amount":574.0,"10th_percentile":229.6,"90th_percentile":1704.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"1 through 10","median_amount":284.0,"10th_percentile":284.0,"90th_percentile":284.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"655","median_amount":139.34,"10th_percentile":59.16,"90th_percentile":317.45,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":62.66,"10th_percentile":62.66,"90th_percentile":62.66,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":102.67,"10th_percentile":60.42,"90th_percentile":259.05,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"215","median_amount":117.38,"10th_percentile":54.83,"90th_percentile":286.19,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"733","median_amount":926.64,"10th_percentile":308.16,"90th_percentile":2153.92,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"14","median_amount":1328.02,"10th_percentile":362.6,"90th_percentile":1813.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."}]}]},{"description":"Mammography Services","code_information":[{"code":"N804","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"22","median_amount":29.06,"10th_percentile":29.06,"90th_percentile":29.73,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"222","median_amount":105.67,"10th_percentile":105.67,"90th_percentile":108.75,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"310","median_amount":303.65,"10th_percentile":225.3,"90th_percentile":317.65,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"822","median_amount":225.3,"10th_percentile":225.3,"90th_percentile":237.3,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"1 through 10","median_amount":303.65,"10th_percentile":303.65,"90th_percentile":303.65,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"39","median_amount":30.51,"10th_percentile":30.51,"90th_percentile":31.22,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"1 through 10","median_amount":356.9,"10th_percentile":356.9,"90th_percentile":356.9,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"18","median_amount":356.9,"10th_percentile":338.98,"90th_percentile":356.9,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"1 through 10","median_amount":338.98,"10th_percentile":338.98,"90th_percentile":338.98,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":30.52,"10th_percentile":30.52,"90th_percentile":30.52,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"68","median_amount":365.5,"10th_percentile":365.5,"90th_percentile":365.5},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":29.06,"10th_percentile":29.06,"90th_percentile":29.73,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"20","median_amount":151.14,"10th_percentile":151.14,"90th_percentile":154.23,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":207.04,"10th_percentile":107.83,"90th_percentile":208.11,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"190","median_amount":319.91,"10th_percentile":319.91,"90th_percentile":319.91,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"36","median_amount":319.91,"10th_percentile":307.68,"90th_percentile":319.91,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"240","median_amount":105.67,"10th_percentile":105.67,"90th_percentile":108.75,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":29.06,"10th_percentile":29.06,"90th_percentile":29.73,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"1 through 10","median_amount":182.17,"10th_percentile":182.17,"90th_percentile":182.17},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"54","median_amount":374.1,"10th_percentile":374.1,"90th_percentile":374.1},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"1 through 10","median_amount":430.0,"10th_percentile":430.0,"90th_percentile":430.0},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"53","median_amount":30.51,"10th_percentile":30.51,"90th_percentile":31.22,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1846","median_amount":105.67,"10th_percentile":105.67,"90th_percentile":108.75,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"295","median_amount":244.01,"10th_percentile":236.9,"90th_percentile":244.01,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"93","median_amount":262.19,"10th_percentile":253.33,"90th_percentile":262.19,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":29.06,"10th_percentile":29.06,"90th_percentile":29.06,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"48","median_amount":322.5,"10th_percentile":322.5,"90th_percentile":344.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"855","median_amount":105.68,"10th_percentile":105.67,"90th_percentile":108.76,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"1791","median_amount":178.0,"10th_percentile":176.0,"90th_percentile":178.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"106","median_amount":29.06,"10th_percentile":29.06,"90th_percentile":29.73,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":105.68,"10th_percentile":105.68,"90th_percentile":105.68,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":108.76,"10th_percentile":108.76,"90th_percentile":108.76,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"53","median_amount":107.79,"10th_percentile":107.79,"90th_percentile":110.92,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"14","median_amount":250.64,"10th_percentile":242.16,"90th_percentile":250.64,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."}]}]},{"description":"Durable Medical Equipment","code_information":[{"code":"N805","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"1 through 10","median_amount":100.0,"10th_percentile":100.0,"90th_percentile":100.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"1 through 10","median_amount":526.44,"10th_percentile":526.44,"90th_percentile":526.44,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":468.54,"10th_percentile":468.54,"90th_percentile":468.54,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":100.0,"10th_percentile":100.0,"90th_percentile":100.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"1 through 10","median_amount":499.57,"10th_percentile":499.57,"90th_percentile":499.57,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"1 through 10","median_amount":530.7,"10th_percentile":530.7,"90th_percentile":530.7,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"1 through 10","median_amount":491.78,"10th_percentile":393.42,"90th_percentile":506.64,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"1 through 10","median_amount":636.84,"10th_percentile":636.84,"90th_percentile":636.84,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Medicine","code_information":[{"code":"N809","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"1 through 10","median_amount":102.79,"10th_percentile":102.79,"90th_percentile":102.79,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"105","median_amount":4.87,"10th_percentile":4.87,"90th_percentile":11.7,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"84","median_amount":30.39,"10th_percentile":29.36,"90th_percentile":60.78,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"54","median_amount":52.14,"10th_percentile":41.71,"90th_percentile":94.8,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"220","median_amount":38.28,"10th_percentile":34.8,"90th_percentile":104.28,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"1 through 10","median_amount":52.14,"10th_percentile":52.14,"90th_percentile":52.14,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":5.11,"10th_percentile":5.11,"90th_percentile":5.11,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"129","median_amount":5.11,"10th_percentile":5.11,"90th_percentile":10.22,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"1 through 10","median_amount":94.45,"10th_percentile":54.78,"90th_percentile":99.6,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":5.85,"10th_percentile":5.12,"90th_percentile":83.52,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"12","median_amount":102.0,"10th_percentile":56.1,"90th_percentile":112.2},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"21","median_amount":8.78,"10th_percentile":5.85,"90th_percentile":11.7,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"18","median_amount":30.39,"10th_percentile":28.07,"90th_percentile":30.39,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"29","median_amount":49.1,"10th_percentile":44.64,"90th_percentile":89.27,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"11","median_amount":89.28,"10th_percentile":47.23,"90th_percentile":89.28,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"37","median_amount":31.01,"10th_percentile":24.31,"90th_percentile":62.02,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"28","median_amount":4.87,"10th_percentile":4.87,"90th_percentile":11.7,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":29.36,"10th_percentile":29.36,"90th_percentile":29.36,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":4.87,"10th_percentile":4.87,"90th_percentile":9.74,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"13","median_amount":48.63,"10th_percentile":24.31,"90th_percentile":62.02,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"1 through 10","median_amount":104.4,"10th_percentile":104.4,"90th_percentile":104.4},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"12","median_amount":6.14,"10th_percentile":5.11,"90th_percentile":6.14,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"192","median_amount":48.62,"10th_percentile":29.36,"90th_percentile":132.98,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"91","median_amount":46.6,"10th_percentile":42.36,"90th_percentile":85.56,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"40","median_amount":42.6,"10th_percentile":42.6,"90th_percentile":93.72,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"24","median_amount":5.85,"10th_percentile":4.87,"90th_percentile":110.89,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"1 through 10","median_amount":47.23,"10th_percentile":47.23,"90th_percentile":47.23},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"11","median_amount":72.0,"10th_percentile":49.5,"90th_percentile":90.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"33","median_amount":60.78,"10th_percentile":30.39,"90th_percentile":179.72,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"25","median_amount":241.4,"10th_percentile":45.87,"90th_percentile":574.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":22.69,"10th_percentile":22.69,"90th_percentile":22.69,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":22.69,"10th_percentile":22.69,"90th_percentile":45.38,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"61","median_amount":31.0,"10th_percentile":24.79,"90th_percentile":99.2,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"1 through 10","median_amount":54.0,"10th_percentile":54.0,"90th_percentile":279.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"1 through 10","median_amount":47.65,"10th_percentile":47.65,"90th_percentile":47.65,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."}]}]},{"description":"Non-covered Services","code_information":[{"code":"N900","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":29.73,"10th_percentile":29.73,"90th_percentile":29.73,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":115.49,"10th_percentile":95.56,"90th_percentile":125.1,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"23","median_amount":303.65,"10th_percentile":225.3,"90th_percentile":317.65,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"47","median_amount":225.3,"10th_percentile":225.3,"90th_percentile":334.66,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"1 through 10","median_amount":338.3,"10th_percentile":256.76,"90th_percentile":338.3},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"13","median_amount":183.48,"10th_percentile":125.1,"90th_percentile":184.43,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"13","median_amount":186.0,"10th_percentile":186.0,"90th_percentile":186.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"1 through 10","median_amount":186.0,"10th_percentile":186.0,"90th_percentile":186.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"17","median_amount":93.84,"10th_percentile":74.92,"90th_percentile":122.6,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":63.51,"10th_percentile":63.51,"90th_percentile":63.51,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"1 through 10","median_amount":662.07,"10th_percentile":662.07,"90th_percentile":662.07},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":30.51,"10th_percentile":14.23,"90th_percentile":31.22,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"106","median_amount":100.29,"10th_percentile":93.65,"90th_percentile":123.2,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"1 through 10","median_amount":244.01,"10th_percentile":183.81,"90th_percentile":244.01,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"1 through 10","median_amount":262.19,"10th_percentile":262.19,"90th_percentile":262.19,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":29.73,"10th_percentile":29.73,"90th_percentile":29.73,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"1 through 10","median_amount":318.4,"10th_percentile":318.4,"90th_percentile":318.4,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"54","median_amount":99.71,"10th_percentile":93.65,"90th_percentile":122.61,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"87","median_amount":178.0,"10th_percentile":176.0,"90th_percentile":178.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"14","median_amount":29.06,"10th_percentile":13.55,"90th_percentile":29.73,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":101.69,"10th_percentile":95.52,"90th_percentile":125.04,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Packaged Services","code_information":[{"code":"N902","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"16","median_amount":60.42,"10th_percentile":53.7,"90th_percentile":60.42,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"15","median_amount":129.36,"10th_percentile":91.15,"90th_percentile":131.15,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"22","median_amount":212.8,"10th_percentile":110.01,"90th_percentile":280.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"24","median_amount":220.0,"10th_percentile":220.0,"90th_percentile":233.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"1 through 10","median_amount":220.0,"10th_percentile":220.0,"90th_percentile":698.46,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"20","median_amount":60.42,"10th_percentile":53.7,"90th_percentile":120.84,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"1 through 10","median_amount":232.4,"10th_percentile":232.4,"90th_percentile":232.4,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"1 through 10","median_amount":177.65,"10th_percentile":177.65,"90th_percentile":177.65},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"1 through 10","median_amount":200.12,"10th_percentile":200.12,"90th_percentile":233.6,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"1 through 10","median_amount":176.02,"10th_percentile":176.02,"90th_percentile":176.02,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"19","median_amount":130.35,"10th_percentile":42.15,"90th_percentile":192.42,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":24.31,"10th_percentile":24.31,"90th_percentile":24.31,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"107","median_amount":130.35,"10th_percentile":121.71,"90th_percentile":130.35,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"15","median_amount":187.8,"10th_percentile":174.92,"90th_percentile":221.69,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"1 through 10","median_amount":205.19,"10th_percentile":205.19,"90th_percentile":205.19,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"1 through 10","median_amount":2092.7,"10th_percentile":2092.7,"90th_percentile":2092.7,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":130.65,"10th_percentile":130.65,"90th_percentile":260.7,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"1 through 10","median_amount":1.83,"10th_percentile":1.83,"90th_percentile":1.83,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"1 through 10","median_amount":323.25,"10th_percentile":323.25,"90th_percentile":323.25,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":86.25,"10th_percentile":86.25,"90th_percentile":86.25,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":225.96,"10th_percentile":225.96,"90th_percentile":429.88,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Not Recognized by OPPS","code_information":[{"code":"N905","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 40.90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Other Outpatient Implant ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":707.48,"10th_percentile":707.48,"90th_percentile":707.48,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"1 through 10","median_amount":2060.99,"10th_percentile":2060.99,"90th_percentile":2060.99,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Hypertensive Encephalopathy With Mcc","code_information":[{"code":"077","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Hypertensive Encephalopathy With Cc","code_information":[{"code":"078","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":4895.18,"10th_percentile":4895.18,"90th_percentile":4895.18,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":282.88,"10th_percentile":282.88,"90th_percentile":282.88,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Hypertensive Encephalopathy Without Cc/Mcc","code_information":[{"code":"079","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cardiac Pacemaker Revision Or Device Replacement With Mcc","code_information":[{"code":"210","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cardiac Pacemaker Revision Or Device Replacement Without Mcc","code_information":[{"code":"211","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Deep Vein Thrombophlebitis With Cc/Mcc","code_information":[{"code":"294","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Deep Vein Thrombophlebitis Without Cc/Mcc","code_information":[{"code":"295","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Circulatory System O.R. Procedures With Mcc","code_information":[{"code":"361","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Circulatory System O.R. Procedures Without Mcc","code_information":[{"code":"362","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Knee Procedures With Principal Diagnosis Of Infection","code_information":[{"code":"400","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Hip Or Knee Procedures With Principal Diagnosis Of Periprosthetic Joint Infection With Mcc Or Insert","code_information":[{"code":"403","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Hip Or Knee Procedures With Principal Diagnosis Of Periprosthetic Joint Infection Without Mcc","code_information":[{"code":"404","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Revision Of Hip Or Knee Prosthesis","code_information":[{"code":"449","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Combined Anterior And Posterior Spinal Fusion With Mcc","code_information":[{"code":"453","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Combined Anterior And Posterior Spinal Fusion With Cc","code_information":[{"code":"454","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Spinal Fusion Except Cervical With Mcc","code_information":[{"code":"459","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Spinal Fusion Except Cervical Without Mcc","code_information":[{"code":"460","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Arthroscopy","code_information":[{"code":"509","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Extensive Or Complex Spinal Fusion Procedures Except Cervical With Mcc","code_information":[{"code":"523","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Extensive Or Complex Spinal Fusion Procedures Except Cervical With Cc","code_information":[{"code":"524","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Extensive Or Complex Spinal Fusion Procedures Except Cervical Without Cc/Mcc","code_information":[{"code":"525","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Uterine And Adnexa Procedures For Malignancy With Mcc","code_information":[{"code":"731","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Uterine And Adnexa Procedures For Malignancy With Cc","code_information":[{"code":"732","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Uterine And Adnexa Procedures For Malignancy Without Cc/Mcc","code_information":[{"code":"733","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Principal Diagnosis Invalid As Discharge Diagnosis","code_information":[{"code":"998","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Ungroupable","code_information":[{"code":"999","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 23.35]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment System","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":300.0,"10th_percentile":300.0,"90th_percentile":300.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Rem mlt day uroflow setup","code_information":[{"code":"0811T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":98.76,"maximum":254.15,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":131.69,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":254.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":98.76,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":134.32,"additional_payer_notes":"APC"}]}]},{"description":"Rem mntr impl ivc snr set-up","code_information":[{"code":"0982T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":98.76,"maximum":254.15,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":131.69,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":254.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":98.76,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":134.32,"additional_payer_notes":"APC"}]}]},{"description":"Rem mntr s-scl eeg sys setup","code_information":[{"code":"1008T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":98.76,"maximum":254.15,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":131.69,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":254.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":98.76,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":134.32,"additional_payer_notes":"APC"}]}]},{"description":"Eye exam new patient","code_information":[{"code":"92002","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":98.76,"maximum":254.15,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":131.69,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":254.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":98.76,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":134.32,"additional_payer_notes":"APC"}]}]},{"description":"Eye exam new patient","code_information":[{"code":"92004","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":98.76,"maximum":254.15,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":131.69,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":254.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":98.76,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":134.32,"additional_payer_notes":"APC"}]}]},{"description":"Eye exam establish patient","code_information":[{"code":"92012","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":98.76,"maximum":254.15,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":131.69,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":254.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":98.76,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":134.32,"additional_payer_notes":"APC"}]}]},{"description":"Eye exam&tx estab pt 1/>vst","code_information":[{"code":"92014","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":98.76,"maximum":254.15,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":131.69,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":254.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":98.76,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":134.32,"additional_payer_notes":"APC"}]}]},{"description":"Glucose monitoring cont","code_information":[{"code":"95250","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":98.76,"maximum":254.15,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":131.69,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":254.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":98.76,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":134.32,"additional_payer_notes":"APC"}]}]},{"description":"Rem ther mntr 1st setup&edu","code_information":[{"code":"98975","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":98.76,"maximum":254.15,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":131.69,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":254.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":98.76,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":134.32,"additional_payer_notes":"APC"}]}]},{"description":"Rem mntr physiol param setup","code_information":[{"code":"99453","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":98.76,"maximum":254.15,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":131.69,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":254.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":98.76,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":134.32,"additional_payer_notes":"APC"}]}]},{"description":"Init nb em per day hosp","code_information":[{"code":"99460","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":98.76,"maximum":254.15,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":131.69,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":254.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":98.76,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":134.32,"additional_payer_notes":"APC"}]}]},{"description":"Same day nb discharge","code_information":[{"code":"99463","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":98.76,"maximum":254.15,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":131.69,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":254.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":98.76,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":134.32,"additional_payer_notes":"APC"}]}]},{"description":"Trans care mgmt 14 day disch","code_information":[{"code":"99495","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":98.76,"maximum":254.15,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":131.69,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":254.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":98.76,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":134.32,"additional_payer_notes":"APC"}]}]},{"description":"Trans care mgmt 7 day disch","code_information":[{"code":"99496","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":98.76,"maximum":254.15,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":131.69,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":254.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":98.76,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":134.32,"additional_payer_notes":"APC"}]}]},{"description":"Periodic oral evaluation","code_information":[{"code":"D0120","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":98.76,"maximum":254.15,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":131.69,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":254.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":98.76,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":134.32,"additional_payer_notes":"APC"}]}]},{"description":"Limit oral eval problm focus","code_information":[{"code":"D0140","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":98.76,"maximum":254.15,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":131.69,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":254.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":98.76,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":134.32,"additional_payer_notes":"APC"}]}]},{"description":"Comprehensve oral evaluation","code_information":[{"code":"D0150","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":98.76,"maximum":254.15,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":131.69,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":254.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":98.76,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":134.32,"additional_payer_notes":"APC"}]}]},{"description":"Extensv oral eval prob focus","code_information":[{"code":"D0160","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":98.76,"maximum":254.15,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":131.69,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":254.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":98.76,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":134.32,"additional_payer_notes":"APC"}]}]},{"description":"Re-eval,est pt,problem focus","code_information":[{"code":"D0170","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":98.76,"maximum":254.15,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":131.69,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":254.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":98.76,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":134.32,"additional_payer_notes":"APC"}]}]},{"description":"Re-eval post-op visit","code_information":[{"code":"D0171","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":98.76,"maximum":254.15,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":131.69,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":254.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":98.76,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":134.32,"additional_payer_notes":"APC"}]}]},{"description":"Comp periodontal evaluation","code_information":[{"code":"D0180","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":98.76,"maximum":254.15,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":131.69,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":254.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":98.76,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":134.32,"additional_payer_notes":"APC"}]}]},{"description":"Assessment of a patient","code_information":[{"code":"D0191","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":98.76,"maximum":254.15,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":131.69,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":254.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":98.76,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":134.32,"additional_payer_notes":"APC"}]}]},{"description":"Dental prophylaxis adult","code_information":[{"code":"D1110","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":98.76,"maximum":254.15,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":131.69,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":254.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":98.76,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":134.32,"additional_payer_notes":"APC"}]}]},{"description":"Gingival irrigation per quad","code_information":[{"code":"D4921","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":98.76,"maximum":254.15,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":131.69,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":254.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":98.76,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":134.32,"additional_payer_notes":"APC"}]}]},{"description":"Initial foot exam pt lops","code_information":[{"code":"G0245","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":98.76,"maximum":254.15,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":131.69,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":254.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":98.76,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":134.32,"additional_payer_notes":"APC"}]}]},{"description":"Followup eval of foot pt lop","code_information":[{"code":"G0246","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":98.76,"maximum":254.15,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":131.69,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":254.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":98.76,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":134.32,"additional_payer_notes":"APC"}]}]},{"description":"Demonstrate use home inr mon","code_information":[{"code":"G0248","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":98.76,"maximum":254.15,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":131.69,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":254.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":98.76,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":134.32,"additional_payer_notes":"APC"}]}]},{"description":"Provide INR test mater/equip","code_information":[{"code":"G0249","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":98.76,"maximum":254.15,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":131.69,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":254.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":98.76,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":134.32,"additional_payer_notes":"APC"}]}]},{"description":"Initial preventive exam","code_information":[{"code":"G0402","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":98.76,"maximum":254.15,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":131.69,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":254.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":98.76,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":134.32,"additional_payer_notes":"APC"}]}]},{"description":"Hospital outpt clinic visit","code_information":[{"code":"G0463","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":98.76,"maximum":254.15,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":131.69,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":254.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":98.76,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":134.32,"additional_payer_notes":"APC"}]}]},{"description":"Supply of digital device","code_information":[{"code":"G0552","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":98.76,"maximum":254.15,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":131.69,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":254.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":98.76,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":134.32,"additional_payer_notes":"APC"}]}]},{"description":"Monthly tx for dmht 20mins","code_information":[{"code":"G0553","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":98.76,"maximum":254.15,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":131.69,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":254.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":98.76,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":134.32,"additional_payer_notes":"APC"}]}]},{"description":"Emergency dept visit","code_information":[{"code":"99281","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":62.55,"maximum":160.97,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":83.41,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":160.97,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":62.55,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":85.07,"additional_payer_notes":"APC"}]}]},{"description":"Emergency dept visit","code_information":[{"code":"99282","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":113.9,"maximum":293.11,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":151.87,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":293.11,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":113.9,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":154.91,"additional_payer_notes":"APC"}]}]},{"description":"Emergency dept visit","code_information":[{"code":"99283","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":202.5,"maximum":521.11,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":270.0,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":521.11,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":202.5,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":275.4,"additional_payer_notes":"APC"}]}]},{"description":"Dialysis one evaluation","code_information":[{"code":"90945","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":309.54,"maximum":796.55,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":412.72,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":796.55,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":309.54,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":420.97,"additional_payer_notes":"APC"}]}]},{"description":"Emergency dept visit","code_information":[{"code":"99284","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":309.54,"maximum":796.55,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":412.72,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":796.55,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":309.54,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":420.97,"additional_payer_notes":"APC"}]}]},{"description":"Opps service,sched team conf","code_information":[{"code":"G0175","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":309.54,"maximum":796.55,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":412.72,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":796.55,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":309.54,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":420.97,"additional_payer_notes":"APC"}]}]},{"description":"Emergency dept visit","code_information":[{"code":"99285","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":441.78,"maximum":1136.86,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":589.05,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1136.86,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":441.78,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":600.83,"additional_payer_notes":"APC"}]}]},{"description":"Direct refer hospital observ","code_information":[{"code":"G0379","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":441.78,"maximum":1136.86,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":589.05,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1136.86,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":441.78,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":600.83,"additional_payer_notes":"APC"}]}]},{"description":"Critical care first hour","code_information":[{"code":"99291","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":612.77,"maximum":1576.87,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":817.03,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1576.87,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":612.77,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":833.37,"additional_payer_notes":"APC"}]}]},{"description":"Trauma Respons w/hosp criti","code_information":[{"code":"G0390","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":988.8,"maximum":2544.5,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1318.39,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2544.5,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":988.8,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1344.76,"additional_payer_notes":"APC"}]}]},{"description":"Coms ther 1st appl<=50 sq cm","code_information":[{"code":"0906T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":148.84,"maximum":383.01,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":198.45,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":383.01,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":148.84,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":202.42,"additional_payer_notes":"APC"}]}]},{"description":"Laser tx skin < 250 sq cm","code_information":[{"code":"96920","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":148.84,"maximum":383.01,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":198.45,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":383.01,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":148.84,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":202.42,"additional_payer_notes":"APC"}]}]},{"description":"Laser tx skin 250-500 sq cm","code_information":[{"code":"96921","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":148.84,"maximum":383.01,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":198.45,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":383.01,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":148.84,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":202.42,"additional_payer_notes":"APC"}]}]},{"description":"Dermatological procedure","code_information":[{"code":"96999","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":148.84,"maximum":383.01,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":198.45,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":383.01,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":148.84,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":202.42,"additional_payer_notes":"APC"}]}]},{"description":"Wound(s) care non-selective","code_information":[{"code":"97602","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":148.84,"maximum":383.01,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":198.45,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":383.01,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":148.84,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":202.42,"additional_payer_notes":"APC"}]}]},{"description":"Neg press wound tx <=50 cm","code_information":[{"code":"97605","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":148.84,"maximum":383.01,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":198.45,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":383.01,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":148.84,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":202.42,"additional_payer_notes":"APC"}]}]},{"description":"Low frequency non-thermal us","code_information":[{"code":"97610","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":148.84,"maximum":383.01,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":198.45,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":383.01,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":148.84,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":202.42,"additional_payer_notes":"APC"}]}]},{"description":"Routine footcare pt w lops","code_information":[{"code":"G0247","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":148.84,"maximum":383.01,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":198.45,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":383.01,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":148.84,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":202.42,"additional_payer_notes":"APC"}]}]},{"description":"Photochemotherapy uv-a or b","code_information":[{"code":"96913","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":301.57,"maximum":776.03,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":402.09,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":776.03,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":301.57,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":410.13,"additional_payer_notes":"APC"}]}]},{"description":"Laser tx skin >500 sq cm","code_information":[{"code":"96922","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":301.57,"maximum":776.03,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":402.09,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":776.03,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":301.57,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":410.13,"additional_payer_notes":"APC"}]}]},{"description":"Neg press wound tx >50 cm","code_information":[{"code":"97606","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":301.57,"maximum":776.03,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":402.09,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":776.03,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":301.57,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":410.13,"additional_payer_notes":"APC"}]}]},{"description":"Neg press wnd tx <=50 sq cm","code_information":[{"code":"97607","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":301.57,"maximum":776.03,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":402.09,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":776.03,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":301.57,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":410.13,"additional_payer_notes":"APC"}]}]},{"description":"Neg press wound tx >50 cm","code_information":[{"code":"97608","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":301.57,"maximum":776.03,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":402.09,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":776.03,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":301.57,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":410.13,"additional_payer_notes":"APC"}]}]},{"description":"Autolog prp diab wound ulcer","code_information":[{"code":"0465?","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1530.61,"maximum":3938.76,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2040.81,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3938.76,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1530.61,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2081.63,"additional_payer_notes":"APC"}]}]},{"description":"Autologous PRP for ulcers","code_information":[{"code":"G0460","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1530.61,"maximum":3938.76,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2040.81,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3938.76,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1530.61,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2081.63,"additional_payer_notes":"APC"}]}]},{"description":"Adrc ther prtl rc tear","code_information":[{"code":"0717T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2628.85,"maximum":6764.9,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3505.13,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6764.9,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2628.85,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3575.23,"additional_payer_notes":"APC"}]}]},{"description":"Adrc ther prtl rc tear njx","code_information":[{"code":"0718T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2628.85,"maximum":6764.9,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3505.13,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6764.9,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2628.85,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3575.23,"additional_payer_notes":"APC"}]}]},{"description":"Abltj 1/+thyr ndul 1lobe prq","code_information":[{"code":"60660","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1225.21,"maximum":3152.87,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1633.61,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3152.87,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1225.21,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1666.28,"additional_payer_notes":"APC"}]}]},{"description":"Lymphovenous bypass per xtr","code_information":[{"code":"1019T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4925.89,"maximum":12675.95,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6567.85,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":12675.95,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4925.89,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6699.21,"additional_payer_notes":"APC"}]}]},{"description":"Njx b1 sub mtrl hw fixj aug","code_information":[{"code":"0869T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2427.27,"maximum":6246.19,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3236.37,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6246.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2427.27,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3301.09,"additional_payer_notes":"APC"}]}]},{"description":"Osteot femur imed lngth dev","code_information":[{"code":"27458","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":13851.98,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Osteot tibia imed lngth dev","code_information":[{"code":"27713","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":13851.98,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Dcmprn prq rmv lig flv 1lmbr","code_information":[{"code":"62330","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5382.89,"maximum":13851.98,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7177.19,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13851.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5382.89,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.73,"additional_payer_notes":"APC"}]}]},{"description":"Xenograft impltj artclr surf","code_information":[{"code":"0737T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":9524.15,"maximum":24508.8,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12698.86,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":24508.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9524.15,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12952.84,"additional_payer_notes":"APC"}]}]},{"description":"Arthrp 1st crp/mtcrpl prostc","code_information":[{"code":"1003T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":9524.15,"maximum":24508.8,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12698.86,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":24508.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9524.15,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12952.84,"additional_payer_notes":"APC"}]}]},{"description":"Vrt bdy tethering ant","code_information":[{"code":"0656T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":13007.15,"maximum":33471.73,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17342.86,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":33471.73,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13007.15,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17689.72,"additional_payer_notes":"APC"}]}]},{"description":"Vrt bdy tethering ant 8+ seg","code_information":[{"code":"0657T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":13007.15,"maximum":33471.73,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17342.86,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":33471.73,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13007.15,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17689.72,"additional_payer_notes":"APC"}]}]},{"description":"Nasopharyngoscopy","code_information":[{"code":"92511","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":148.07,"maximum":381.05,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":197.43,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":381.05,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":148.07,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":201.38,"additional_payer_notes":"APC"}]}]},{"description":"Unspecified periodontal proc","code_information":[{"code":"D4999","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":175.7,"maximum":452.14,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":234.27,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":452.14,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":175.7,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":238.96,"additional_payer_notes":"APC"}]}]},{"description":"Closd rductn splint alveolus","code_information":[{"code":"D7670","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2459.51,"maximum":6329.15,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3279.35,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6329.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2459.51,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3344.94,"additional_payer_notes":"APC"}]}]},{"description":"Alveolus clsd reduc stblz te","code_information":[{"code":"D7771","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2459.51,"maximum":6329.15,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3279.35,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6329.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2459.51,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3344.94,"additional_payer_notes":"APC"}]}]},{"description":"Facility svs dental rehab","code_information":[{"code":"G0330","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2459.51,"maximum":6329.15,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3279.35,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6329.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2459.51,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3344.94,"additional_payer_notes":"APC"}]}]},{"description":"Active thrc irrigation spx","code_information":[{"code":"1021T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":465.35,"maximum":1197.51,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":620.47,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1197.51,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":465.35,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":632.88,"additional_payer_notes":"APC"}]}]},{"description":"Tcat rmv 2chmbr ldls pm cmpl","code_information":[{"code":"0798T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2342.32,"maximum":6027.57,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3123.09,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6027.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2342.32,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3185.56,"additional_payer_notes":"APC"}]}]},{"description":"Tcat rmvl 2chmbr ldls pm ra","code_information":[{"code":"0799T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2342.32,"maximum":6027.57,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3123.09,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6027.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2342.32,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3185.56,"additional_payer_notes":"APC"}]}]},{"description":"Revsc evasc ivt angio sf 1st","code_information":[{"code":"37254","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4222.18,"maximum":10865.09,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5629.58,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":10865.09,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4222.18,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5742.17,"additional_payer_notes":"APC"}]}]},{"description":"Revsc evasc ivt angio cplx 1","code_information":[{"code":"37256","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4222.18,"maximum":10865.09,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5629.58,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":10865.09,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4222.18,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5742.17,"additional_payer_notes":"APC"}]}]},{"description":"Revsc evasc fpvt angio sf 1","code_information":[{"code":"37263","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4222.18,"maximum":10865.09,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5629.58,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":10865.09,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4222.18,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5742.17,"additional_payer_notes":"APC"}]}]},{"description":"Revsc evsc fpvt angio cplx 1","code_information":[{"code":"37265","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4222.18,"maximum":10865.09,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5629.58,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":10865.09,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4222.18,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5742.17,"additional_payer_notes":"APC"}]}]},{"description":"Revsc evasc ivt stent sf 1st","code_information":[{"code":"37258","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8563.85,"maximum":22037.64,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11418.47,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":22037.64,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8563.85,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11646.84,"additional_payer_notes":"APC"}]}]},{"description":"Revsc evasc ivt st cplx 1st","code_information":[{"code":"37260","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8563.85,"maximum":22037.64,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11418.47,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":22037.64,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8563.85,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11646.84,"additional_payer_notes":"APC"}]}]},{"description":"Revsc evsc fpvt stent sf 1st","code_information":[{"code":"37267","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8563.85,"maximum":22037.64,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11418.47,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":22037.64,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8563.85,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11646.84,"additional_payer_notes":"APC"}]}]},{"description":"Revsc evasc fpvt st cplx 1st","code_information":[{"code":"37269","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8563.85,"maximum":22037.64,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11418.47,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":22037.64,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8563.85,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11646.84,"additional_payer_notes":"APC"}]}]},{"description":"Revsc evsc tpvt angio sf 1st","code_information":[{"code":"37280","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8563.85,"maximum":22037.64,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11418.47,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":22037.64,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8563.85,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11646.84,"additional_payer_notes":"APC"}]}]},{"description":"Rvsc evsc tpvt angio cplx 1","code_information":[{"code":"37282","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8563.85,"maximum":22037.64,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11418.47,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":22037.64,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8563.85,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11646.84,"additional_payer_notes":"APC"}]}]},{"description":"Revsc evasc imvt angio sf 1","code_information":[{"code":"37296","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8563.85,"maximum":22037.64,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11418.47,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":22037.64,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8563.85,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11646.84,"additional_payer_notes":"APC"}]}]},{"description":"Revsc evsc imvt angio cplx 1","code_information":[{"code":"37298","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8563.85,"maximum":22037.64,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11418.47,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":22037.64,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8563.85,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11646.84,"additional_payer_notes":"APC"}]}]},{"description":"Prq trl rvs ch occ ant&rtrgr","code_information":[{"code":"92945","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8563.85,"maximum":22037.64,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11418.47,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":22037.64,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8563.85,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11646.84,"additional_payer_notes":"APC"}]}]},{"description":"Sim ang w/prs cath rad emb","code_information":[{"code":"C8004","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8563.85,"maximum":22037.64,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11418.47,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":22037.64,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8563.85,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11646.84,"additional_payer_notes":"APC"}]}]},{"description":"Revsc evsc fpvt athrc sf 1st","code_information":[{"code":"37271","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":13599.0,"maximum":34994.75,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18131.99,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":34994.75,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13599.0,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18494.63,"additional_payer_notes":"APC"}]}]},{"description":"Revsc evsc fpvt athrc cplx 1","code_information":[{"code":"37273","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":13599.0,"maximum":34994.75,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18131.99,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":34994.75,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13599.0,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18494.63,"additional_payer_notes":"APC"}]}]},{"description":"Rvsc evsc fpvt st athrc sf 1","code_information":[{"code":"37275","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":13599.0,"maximum":34994.75,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18131.99,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":34994.75,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13599.0,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18494.63,"additional_payer_notes":"APC"}]}]},{"description":"Rvsc evsc fpvt st athr cpx 1","code_information":[{"code":"37277","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":13599.0,"maximum":34994.75,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18131.99,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":34994.75,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13599.0,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18494.63,"additional_payer_notes":"APC"}]}]},{"description":"Revsc evasc tpvt st sf 1st","code_information":[{"code":"37284","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":13599.0,"maximum":34994.75,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18131.99,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":34994.75,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13599.0,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18494.63,"additional_payer_notes":"APC"}]}]},{"description":"Revsc evasc tpvt st cplx 1st","code_information":[{"code":"37286","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":13599.0,"maximum":34994.75,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18131.99,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":34994.75,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13599.0,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18494.63,"additional_payer_notes":"APC"}]}]},{"description":"Revsc evsc tpvt athrc sf 1st","code_information":[{"code":"37288","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":13599.0,"maximum":34994.75,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18131.99,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":34994.75,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13599.0,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18494.63,"additional_payer_notes":"APC"}]}]},{"description":"Revsc evsc tpvt athrc cplx 1","code_information":[{"code":"37290","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":13599.0,"maximum":34994.75,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18131.99,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":34994.75,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13599.0,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18494.63,"additional_payer_notes":"APC"}]}]},{"description":"Rvsc evsc tpvt st athrc sf 1","code_information":[{"code":"37292","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":13599.0,"maximum":34994.75,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18131.99,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":34994.75,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13599.0,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18494.63,"additional_payer_notes":"APC"}]}]},{"description":"Rvsc evsc tpvt st athr cpx 1","code_information":[{"code":"37294","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":13599.0,"maximum":34994.75,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18131.99,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":34994.75,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13599.0,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18494.63,"additional_payer_notes":"APC"}]}]},{"description":"Prq tcat plmt ntrac st 2+les","code_information":[{"code":"92930","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":13599.0,"maximum":34994.75,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18131.99,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":34994.75,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13599.0,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18494.63,"additional_payer_notes":"APC"}]}]},{"description":"Tcat ins 2chmbr ldls pm cmpl","code_information":[{"code":"0795T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":14288.94,"maximum":36770.21,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19051.92,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":36770.21,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14288.94,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19432.96,"additional_payer_notes":"APC"}]}]},{"description":"Tcat ins 2chmbr ldls pm ra","code_information":[{"code":"0796T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":14288.94,"maximum":36770.21,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19051.92,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":36770.21,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14288.94,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19432.96,"additional_payer_notes":"APC"}]}]},{"description":"Tcat rmv&rpl 2chmbr ldls pm","code_information":[{"code":"0801T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":14288.94,"maximum":36770.21,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19051.92,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":36770.21,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14288.94,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19432.96,"additional_payer_notes":"APC"}]}]},{"description":"Tcat rmv&rpl2chmb ldls pm ra","code_information":[{"code":"0802T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":14288.94,"maximum":36770.21,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19051.92,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":36770.21,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14288.94,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19432.96,"additional_payer_notes":"APC"}]}]},{"description":"Upr gi bld detcj snr capsule","code_information":[{"code":"0977T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":672.83,"maximum":1731.42,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":897.11,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1731.42,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":672.83,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":915.05,"additional_payer_notes":"APC"}]}]},{"description":"Perq elec nrv field stimj cn","code_information":[{"code":"64567","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":672.83,"maximum":1731.42,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":897.11,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1731.42,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":672.83,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":915.05,"additional_payer_notes":"APC"}]}]},{"description":"Gi trc img intral colon i&r","code_information":[{"code":"91113","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":689.87,"maximum":1775.27,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":919.83,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1775.27,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":689.87,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":938.23,"additional_payer_notes":"APC"}]}]},{"description":"Fecal microbiota prep instil","code_information":[{"code":"G0455","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":689.87,"maximum":1775.27,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":919.83,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1775.27,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":689.87,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":938.23,"additional_payer_notes":"APC"}]}]},{"description":"Esphgsc flx 1st tndsc dilat","code_information":[{"code":"0884T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4503.59,"maximum":11589.23,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6004.78,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11589.23,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4503.59,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6124.88,"additional_payer_notes":"APC"}]}]},{"description":"Colsc flx 1st tndsc dilat","code_information":[{"code":"0885T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4503.59,"maximum":11589.23,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6004.78,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11589.23,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4503.59,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6124.88,"additional_payer_notes":"APC"}]}]},{"description":"Sgmdsc flx 1st tndsc dilat","code_information":[{"code":"0886T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4503.59,"maximum":11589.23,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6004.78,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11589.23,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4503.59,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6124.88,"additional_payer_notes":"APC"}]}]},{"description":"Rplcmt ndwllg bldr&prtl cath","code_information":[{"code":"0872T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2656.06,"maximum":6834.92,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3541.41,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6834.92,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2656.06,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3612.24,"additional_payer_notes":"APC"}]}]},{"description":"Revj subq prtl asct pmp sys","code_information":[{"code":"0873T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2656.06,"maximum":6834.92,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3541.41,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6834.92,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2656.06,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3612.24,"additional_payer_notes":"APC"}]}]},{"description":"Rmvl pertl ascites pmp sys","code_information":[{"code":"0874T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2656.06,"maximum":6834.92,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3541.41,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6834.92,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2656.06,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3612.24,"additional_payer_notes":"APC"}]}]},{"description":"Inst pleu-perit shnt w pump","code_information":[{"code":"C8006","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4802.49,"maximum":12358.4,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6403.32,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":12358.4,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4802.49,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6531.38,"additional_payer_notes":"APC"}]}]},{"description":"Laps repos lead isdss 1st ld","code_information":[{"code":"0677T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7885.55,"maximum":20292.15,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10514.07,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":20292.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7885.55,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10724.35,"additional_payer_notes":"APC"}]}]},{"description":"Laps rmvl lead isdss","code_information":[{"code":"0679T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7885.55,"maximum":20292.15,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10514.07,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":20292.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7885.55,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10724.35,"additional_payer_notes":"APC"}]}]},{"description":"Gstr rstcv px trnsorl esg","code_information":[{"code":"43889","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7885.55,"maximum":20292.15,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10514.07,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":20292.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7885.55,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10724.35,"additional_payer_notes":"APC"}]}]},{"description":"Abltj ire liver 1+ tum perq","code_information":[{"code":"47384","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7885.55,"maximum":20292.15,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10514.07,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":20292.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7885.55,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10724.35,"additional_payer_notes":"APC"}]}]},{"description":"Lap srg prst8ct lymph nod bx","code_information":[{"code":"55868","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7885.55,"maximum":20292.15,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10514.07,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":20292.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7885.55,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10724.35,"additional_payer_notes":"APC"}]}]},{"description":"Lap srg prst8ct bi pl lmphad","code_information":[{"code":"55869","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7885.55,"maximum":20292.15,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10514.07,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":20292.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7885.55,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10724.35,"additional_payer_notes":"APC"}]}]},{"description":"Abltj ire prst8 1+ tum perq","code_information":[{"code":"55877","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7885.55,"maximum":20292.15,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10514.07,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":20292.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7885.55,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10724.35,"additional_payer_notes":"APC"}]}]},{"description":"Endo defect closure GI tract","code_information":[{"code":"C9901","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7885.55,"maximum":20292.15,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10514.07,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":20292.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7885.55,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10724.35,"additional_payer_notes":"APC"}]}]},{"description":"Bx prst8 trct us guided","code_information":[{"code":"55707","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2614.94,"maximum":6729.12,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3486.59,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6729.12,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2614.94,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3556.32,"additional_payer_notes":"APC"}]}]},{"description":"Bx prst8 trct us w/mri fus 1","code_information":[{"code":"55708","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2614.94,"maximum":6729.12,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3486.59,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6729.12,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2614.94,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3556.32,"additional_payer_notes":"APC"}]}]},{"description":"Bx prst8 tprnl us guided","code_information":[{"code":"55709","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2614.94,"maximum":6729.12,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3486.59,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6729.12,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2614.94,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3556.32,"additional_payer_notes":"APC"}]}]},{"description":"Bx prst8 tprn us w/mri fus 1","code_information":[{"code":"55710","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2614.94,"maximum":6729.12,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3486.59,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6729.12,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2614.94,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3556.32,"additional_payer_notes":"APC"}]}]},{"description":"Bx prst8 trct mri-us 1st","code_information":[{"code":"55711","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2614.94,"maximum":6729.12,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3486.59,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6729.12,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2614.94,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3556.32,"additional_payer_notes":"APC"}]}]},{"description":"Bx prst8 tprnl mri-us 1st","code_information":[{"code":"55712","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2614.94,"maximum":6729.12,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3486.59,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6729.12,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2614.94,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3556.32,"additional_payer_notes":"APC"}]}]},{"description":"Tpla b9 prst8 hyprplsa>=50ml","code_information":[{"code":"0867T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3977.55,"maximum":10235.57,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5303.4,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":10235.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3977.55,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5409.47,"additional_payer_notes":"APC"}]}]},{"description":"Bx prst8 in-bore ct/mri bx 1","code_information":[{"code":"55713","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3977.55,"maximum":10235.57,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5303.4,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":10235.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3977.55,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5409.47,"additional_payer_notes":"APC"}]}]},{"description":"Bx prst8 in-bore ct/mri 1","code_information":[{"code":"55714","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3977.55,"maximum":10235.57,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5303.4,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":10235.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3977.55,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5409.47,"additional_payer_notes":"APC"}]}]},{"description":"Cysto, litho, w suct sheath","code_information":[{"code":"C8014","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3977.55,"maximum":10235.57,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5303.4,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":10235.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3977.55,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5409.47,"additional_payer_notes":"APC"}]}]},{"description":"Cysto lo-nrg lithtrp&mcrsphr","code_information":[{"code":"0991T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7022.52,"maximum":18071.3,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9363.37,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":18071.3,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7022.52,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9550.63,"additional_payer_notes":"APC"}]}]},{"description":"Cysto 1st trurl prst8 comis","code_information":[{"code":"52443","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7022.52,"maximum":18071.3,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9363.37,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":18071.3,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7022.52,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9550.63,"additional_payer_notes":"APC"}]}]},{"description":"Trurl rbtc wtrjt rescj prst8","code_information":[{"code":"52597","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7022.52,"maximum":18071.3,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9363.37,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":18071.3,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7022.52,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9550.63,"additional_payer_notes":"APC"}]}]},{"description":"Anogenital exam child w imag","code_information":[{"code":"99170","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":149.98,"maximum":385.94,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":199.97,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":385.94,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":149.98,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":203.97,"additional_payer_notes":"APC"}]}]},{"description":"Dcmprn median nrv carpl tunl","code_information":[{"code":"64728","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1448.59,"maximum":3727.72,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1931.46,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3727.72,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1448.59,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1970.09,"additional_payer_notes":"APC"}]}]},{"description":"Rlcj pulse gen only isdss","code_information":[{"code":"0681T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2593.52,"maximum":6674.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3458.03,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6674.0,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2593.52,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3527.19,"additional_payer_notes":"APC"}]}]},{"description":"Removal pulse gen only isdss","code_information":[{"code":"0682T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2593.52,"maximum":6674.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3458.03,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6674.0,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2593.52,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3527.19,"additional_payer_notes":"APC"}]}]},{"description":"Revj/rmvl ins ptn subq&subf","code_information":[{"code":"0989T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2593.52,"maximum":6674.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3458.03,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6674.0,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2593.52,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3527.19,"additional_payer_notes":"APC"}]}]},{"description":"Revj/rplcmt bat mod sys lead","code_information":[{"code":"64655","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2593.52,"maximum":6674.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3458.03,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6674.0,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2593.52,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3527.19,"additional_payer_notes":"APC"}]}]},{"description":"Rmvl bat modul sys lead only","code_information":[{"code":"64658","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2593.52,"maximum":6674.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3458.03,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6674.0,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2593.52,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3527.19,"additional_payer_notes":"APC"}]}]},{"description":"Rmvl bat modulj sys pg only","code_information":[{"code":"64659","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2593.52,"maximum":6674.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3458.03,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6674.0,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2593.52,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3527.19,"additional_payer_notes":"APC"}]}]},{"description":"Insj/rplcmt pg only isdss","code_information":[{"code":"0680T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":14391.63,"maximum":37034.45,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19188.83,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":37034.45,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14391.63,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19572.61,"additional_payer_notes":"APC"}]}]},{"description":"Laps insj nw/rpcmt prm isdss","code_information":[{"code":"0674T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":22891.23,"maximum":58906.76,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":30521.64,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":58906.76,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22891.23,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":31132.07,"additional_payer_notes":"APC"}]}]},{"description":"Revj/rplcmt bat mod sys pg","code_information":[{"code":"64656","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":22891.23,"maximum":58906.76,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":30521.64,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":58906.76,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22891.23,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":31132.07,"additional_payer_notes":"APC"}]}]},{"description":"Opn mplnt hpgls ns ary ps gn","code_information":[{"code":"C8007","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":22891.23,"maximum":58906.76,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":30521.64,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":58906.76,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22891.23,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":31132.07,"additional_payer_notes":"APC"}]}]},{"description":"Opn mplnt hpgls ns ary rec","code_information":[{"code":"C8011","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":22891.23,"maximum":58906.76,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":30521.64,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":58906.76,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22891.23,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":31132.07,"additional_payer_notes":"APC"}]}]},{"description":"Trabeculostomy interno laser","code_information":[{"code":"0621T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3066.31,"maximum":7890.63,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4088.41,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7890.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3066.31,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4170.17,"additional_payer_notes":"APC"}]}]},{"description":"Implt ant sgm io nbio rx sys","code_information":[{"code":"0660T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3066.31,"maximum":7890.63,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4088.41,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7890.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3066.31,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4170.17,"additional_payer_notes":"APC"}]}]},{"description":"Rmvl&Rimpltj ant sgm implt","code_information":[{"code":"0661T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3066.31,"maximum":7890.63,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4088.41,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7890.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3066.31,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4170.17,"additional_payer_notes":"APC"}]}]},{"description":"Mtrz ab ntrno trph scl/tr mw","code_information":[{"code":"1012T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3066.31,"maximum":7890.63,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4088.41,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7890.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3066.31,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4170.17,"additional_payer_notes":"APC"}]}]},{"description":"Quan us tis charac w/o dx us","code_information":[{"code":"0689T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":64.56,"maximum":166.13,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":86.08,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":166.13,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":64.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":87.8,"additional_payer_notes":"APC"}]}]},{"description":"Echo examination procedure","code_information":[{"code":"76999","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":64.56,"maximum":166.13,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":86.08,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":166.13,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":64.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":87.8,"additional_payer_notes":"APC"}]}]},{"description":"Intraoral periapical first","code_information":[{"code":"D0220","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":64.56,"maximum":166.13,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":86.08,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":166.13,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":64.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":87.8,"additional_payer_notes":"APC"}]}]},{"description":"Intraoral occlusal film","code_information":[{"code":"D0240","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":64.56,"maximum":166.13,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":86.08,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":166.13,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":64.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":87.8,"additional_payer_notes":"APC"}]}]},{"description":"Extraoral 2d project image","code_information":[{"code":"D0250","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":64.56,"maximum":166.13,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":86.08,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":166.13,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":64.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":87.8,"additional_payer_notes":"APC"}]}]},{"description":"Extraoral posterior image","code_information":[{"code":"D0251","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":64.56,"maximum":166.13,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":86.08,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":166.13,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":64.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":87.8,"additional_payer_notes":"APC"}]}]},{"description":"Dental bitewing single image","code_information":[{"code":"D0270","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":64.56,"maximum":166.13,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":86.08,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":166.13,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":64.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":87.8,"additional_payer_notes":"APC"}]}]},{"description":"Dental bitewings two images","code_information":[{"code":"D0272","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":64.56,"maximum":166.13,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":86.08,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":166.13,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":64.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":87.8,"additional_payer_notes":"APC"}]}]},{"description":"Other tmj images by report","code_information":[{"code":"D0321","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":64.56,"maximum":166.13,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":86.08,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":166.13,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":64.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":87.8,"additional_payer_notes":"APC"}]}]},{"description":"2d cephalometric image","code_information":[{"code":"D0340","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":64.56,"maximum":166.13,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":86.08,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":166.13,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":64.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":87.8,"additional_payer_notes":"APC"}]}]},{"description":"Oral/facial photo images","code_information":[{"code":"D0350","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":64.56,"maximum":166.13,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":86.08,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":166.13,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":64.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":87.8,"additional_payer_notes":"APC"}]}]},{"description":"Sialoendoscopy capt & interp","code_information":[{"code":"D0371","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":64.56,"maximum":166.13,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":86.08,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":166.13,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":64.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":87.8,"additional_payer_notes":"APC"}]}]},{"description":"Trtmnt simulation 3d image","code_information":[{"code":"D0393","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":64.56,"maximum":166.13,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":86.08,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":166.13,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":64.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":87.8,"additional_payer_notes":"APC"}]}]},{"description":"Digital sub 2 or more images","code_information":[{"code":"D0394","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":64.56,"maximum":166.13,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":86.08,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":166.13,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":64.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":87.8,"additional_payer_notes":"APC"}]}]},{"description":"Fusion 2 or more 3d images","code_information":[{"code":"D0395","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":64.56,"maximum":166.13,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":86.08,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":166.13,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":64.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":87.8,"additional_payer_notes":"APC"}]}]},{"description":"Fracture of lower extremity M >=61.50","code_information":[{"code":"D0701","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":64.56,"maximum":166.13,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":86.08,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":166.13,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":64.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":87.8,"additional_payer_notes":"APC"}]}]},{"description":"Fracture of lower extremity M >=52.50 and M <61.50","code_information":[{"code":"D0702","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":64.56,"maximum":166.13,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":86.08,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":166.13,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":64.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":87.8,"additional_payer_notes":"APC"}]}]},{"description":"Fracture of lower extremity M >=41.50 and M <52.50","code_information":[{"code":"D0703","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":64.56,"maximum":166.13,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":86.08,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":166.13,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":64.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":87.8,"additional_payer_notes":"APC"}]}]},{"description":"Extra oral post radio image","code_information":[{"code":"D0705","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":64.56,"maximum":166.13,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":86.08,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":166.13,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":64.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":87.8,"additional_payer_notes":"APC"}]}]},{"description":"Intraoral occlus radio image","code_information":[{"code":"D0706","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":64.56,"maximum":166.13,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":86.08,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":166.13,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":64.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":87.8,"additional_payer_notes":"APC"}]}]},{"description":"Intraoral periap radio image","code_information":[{"code":"D0707","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":64.56,"maximum":166.13,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":86.08,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":166.13,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":64.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":87.8,"additional_payer_notes":"APC"}]}]},{"description":"Intraoral bite radio image","code_information":[{"code":"D0708","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":64.56,"maximum":166.13,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":86.08,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":166.13,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":64.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":87.8,"additional_payer_notes":"APC"}]}]},{"description":"Intraoral cmplt radio images","code_information":[{"code":"D0709","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":64.56,"maximum":166.13,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":86.08,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":166.13,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":64.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":87.8,"additional_payer_notes":"APC"}]}]},{"description":"Software meas of cardiac vol","code_information":[{"code":"G0183","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":64.56,"maximum":166.13,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":86.08,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":166.13,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":64.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":87.8,"additional_payer_notes":"APC"}]}]},{"description":"Ortho impl mvmt alys pair ct","code_information":[{"code":"0946T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":77.56,"maximum":199.58,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":103.41,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":199.58,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":77.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":105.48,"additional_payer_notes":"APC"}]}]},{"description":"Extracranial uni/ltd study","code_information":[{"code":"93882","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":77.56,"maximum":199.58,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":103.41,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":199.58,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":77.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":105.48,"additional_payer_notes":"APC"}]}]},{"description":"Intracranial limited study","code_information":[{"code":"93888","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":77.56,"maximum":199.58,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":103.41,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":199.58,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":77.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":105.48,"additional_payer_notes":"APC"}]}]},{"description":"Tcd emboli detect w/o inj","code_information":[{"code":"93892","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":77.56,"maximum":199.58,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":103.41,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":199.58,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":77.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":105.48,"additional_payer_notes":"APC"}]}]},{"description":"Tcd emboli detect w/inj","code_information":[{"code":"93893","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":77.56,"maximum":199.58,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":103.41,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":199.58,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":77.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":105.48,"additional_payer_notes":"APC"}]}]},{"description":"Lower extremity study","code_information":[{"code":"93926","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":77.56,"maximum":199.58,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":103.41,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":199.58,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":77.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":105.48,"additional_payer_notes":"APC"}]}]},{"description":"Upper extremity study","code_information":[{"code":"93931","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":77.56,"maximum":199.58,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":103.41,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":199.58,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":77.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":105.48,"additional_payer_notes":"APC"}]}]},{"description":"Extremity study","code_information":[{"code":"93971","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":77.56,"maximum":199.58,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":103.41,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":199.58,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":77.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":105.48,"additional_payer_notes":"APC"}]}]},{"description":"Vascular study","code_information":[{"code":"93976","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":77.56,"maximum":199.58,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":103.41,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":199.58,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":77.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":105.48,"additional_payer_notes":"APC"}]}]},{"description":"Vascular study","code_information":[{"code":"93979","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":77.56,"maximum":199.58,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":103.41,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":199.58,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":77.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":105.48,"additional_payer_notes":"APC"}]}]},{"description":"Penile vascular study","code_information":[{"code":"93980","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":77.56,"maximum":199.58,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":103.41,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":199.58,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":77.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":105.48,"additional_payer_notes":"APC"}]}]},{"description":"Penile vascular study","code_information":[{"code":"93981","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":77.56,"maximum":199.58,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":103.41,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":199.58,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":77.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":105.48,"additional_payer_notes":"APC"}]}]},{"description":"Dup-scan hemo compl uni std","code_information":[{"code":"93986","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":77.56,"maximum":199.58,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":103.41,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":199.58,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":77.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":105.48,"additional_payer_notes":"APC"}]}]},{"description":"Doppler flow testing","code_information":[{"code":"93990","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":77.56,"maximum":199.58,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":103.41,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":199.58,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":77.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":105.48,"additional_payer_notes":"APC"}]}]},{"description":"Dental tomographic survey","code_information":[{"code":"D0322","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":77.56,"maximum":199.58,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":103.41,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":199.58,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":77.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":105.48,"additional_payer_notes":"APC"}]}]},{"description":"Cone beam ct capt & interp","code_information":[{"code":"D0364","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":77.56,"maximum":199.58,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":103.41,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":199.58,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":77.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":105.48,"additional_payer_notes":"APC"}]}]},{"description":"Cone beam ct interprete man","code_information":[{"code":"D0365","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":77.56,"maximum":199.58,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":103.41,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":199.58,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":77.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":105.48,"additional_payer_notes":"APC"}]}]},{"description":"Cone beam ct interprete max","code_information":[{"code":"D0366","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":77.56,"maximum":199.58,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":103.41,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":199.58,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":77.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":105.48,"additional_payer_notes":"APC"}]}]},{"description":"Cone beam ct interp both jaw","code_information":[{"code":"D0367","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":77.56,"maximum":199.58,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":103.41,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":199.58,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":77.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":105.48,"additional_payer_notes":"APC"}]}]},{"description":"Cone beam ct interprete TMJ","code_information":[{"code":"D0368","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":77.56,"maximum":199.58,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":103.41,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":199.58,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":77.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":105.48,"additional_payer_notes":"APC"}]}]},{"description":"Max MRI capture & interprete","code_information":[{"code":"D0369","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":77.56,"maximum":199.58,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":103.41,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":199.58,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":77.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":105.48,"additional_payer_notes":"APC"}]}]},{"description":"Max ultrasound capt & interp","code_information":[{"code":"D0370","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":77.56,"maximum":199.58,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":103.41,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":199.58,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":77.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":105.48,"additional_payer_notes":"APC"}]}]},{"description":"Cone beam ct capture limited","code_information":[{"code":"D0380","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":77.56,"maximum":199.58,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":103.41,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":199.58,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":77.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":105.48,"additional_payer_notes":"APC"}]}]},{"description":"Cone beam ct capt mandible","code_information":[{"code":"D0381","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":77.56,"maximum":199.58,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":103.41,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":199.58,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":77.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":105.48,"additional_payer_notes":"APC"}]}]},{"description":"Cone beam ct capt maxilla","code_information":[{"code":"D0382","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":77.56,"maximum":199.58,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":103.41,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":199.58,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":77.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":105.48,"additional_payer_notes":"APC"}]}]},{"description":"Cone beam ct both jaws","code_information":[{"code":"D0383","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":77.56,"maximum":199.58,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":103.41,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":199.58,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":77.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":105.48,"additional_payer_notes":"APC"}]}]},{"description":"Cone beam ct capture TMJ","code_information":[{"code":"D0384","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":77.56,"maximum":199.58,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":103.41,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":199.58,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":77.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":105.48,"additional_payer_notes":"APC"}]}]},{"description":"Max MRI image capture","code_information":[{"code":"D0385","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":77.56,"maximum":199.58,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":103.41,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":199.58,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":77.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":105.48,"additional_payer_notes":"APC"}]}]},{"description":"Max ultrasound image capture","code_information":[{"code":"D0386","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":77.56,"maximum":199.58,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":103.41,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":199.58,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":77.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":105.48,"additional_payer_notes":"APC"}]}]},{"description":"B1 str & fx rsk assessment","code_information":[{"code":"0556T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":177.0,"maximum":455.49,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":236.0,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":455.49,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":177.0,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":240.72,"additional_payer_notes":"APC"}]}]},{"description":"Quan mri alys brn w/o dx mri","code_information":[{"code":"0865T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":177.0,"maximum":455.49,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":236.0,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":455.49,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":177.0,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":240.72,"additional_payer_notes":"APC"}]}]},{"description":"3d cntr simula trgt lvr les","code_information":[{"code":"0944T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":177.0,"maximum":455.49,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":236.0,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":455.49,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":177.0,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":240.72,"additional_payer_notes":"APC"}]}]},{"description":"N-invas assmt car rsk w/o ct","code_information":[{"code":"0992T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":177.0,"maximum":455.49,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":236.0,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":455.49,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":177.0,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":240.72,"additional_payer_notes":"APC"}]}]},{"description":"N-invas assmt car rsk w/ct","code_information":[{"code":"0993T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":177.0,"maximum":455.49,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":236.0,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":455.49,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":177.0,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":240.72,"additional_payer_notes":"APC"}]}]},{"description":"Tte w/o doppler complete","code_information":[{"code":"93307","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":177.0,"maximum":455.49,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":236.0,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":455.49,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":177.0,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":240.72,"additional_payer_notes":"APC"}]}]},{"description":"Tte f-up or lmtd","code_information":[{"code":"93308","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":177.0,"maximum":455.49,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":236.0,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":455.49,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":177.0,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":240.72,"additional_payer_notes":"APC"}]}]},{"description":"Extracranial bilat study","code_information":[{"code":"93880","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":177.0,"maximum":455.49,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":236.0,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":455.49,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":177.0,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":240.72,"additional_payer_notes":"APC"}]}]},{"description":"Intracranial complete study","code_information":[{"code":"93886","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":177.0,"maximum":455.49,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":236.0,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":455.49,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":177.0,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":240.72,"additional_payer_notes":"APC"}]}]},{"description":"Lower extremity study","code_information":[{"code":"93925","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":177.0,"maximum":455.49,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":236.0,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":455.49,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":177.0,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":240.72,"additional_payer_notes":"APC"}]}]},{"description":"Upper extremity study","code_information":[{"code":"93930","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":177.0,"maximum":455.49,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":236.0,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":455.49,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":177.0,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":240.72,"additional_payer_notes":"APC"}]}]},{"description":"Extremity study","code_information":[{"code":"93970","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":177.0,"maximum":455.49,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":236.0,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":455.49,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":177.0,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":240.72,"additional_payer_notes":"APC"}]}]},{"description":"Vascular study","code_information":[{"code":"93975","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":177.0,"maximum":455.49,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":236.0,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":455.49,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":177.0,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":240.72,"additional_payer_notes":"APC"}]}]},{"description":"Vascular study","code_information":[{"code":"93978","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":177.0,"maximum":455.49,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":236.0,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":455.49,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":177.0,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":240.72,"additional_payer_notes":"APC"}]}]},{"description":"Dup-scan hemo compl bi std","code_information":[{"code":"93985","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":177.0,"maximum":455.49,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":236.0,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":455.49,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":177.0,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":240.72,"additional_payer_notes":"APC"}]}]},{"description":"Mra w/o cont, abd","code_information":[{"code":"C8901","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":177.0,"maximum":455.49,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":236.0,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":455.49,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":177.0,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":240.72,"additional_payer_notes":"APC"}]}]},{"description":"MRA w/o cont, chest","code_information":[{"code":"C8910","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":177.0,"maximum":455.49,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":236.0,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":455.49,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":177.0,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":240.72,"additional_payer_notes":"APC"}]}]},{"description":"Mra w/o cont, lwr ext","code_information":[{"code":"C8913","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":177.0,"maximum":455.49,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":236.0,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":455.49,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":177.0,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":240.72,"additional_payer_notes":"APC"}]}]},{"description":"MRA w/o cont, pelvis","code_information":[{"code":"C8919","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":177.0,"maximum":455.49,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":236.0,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":455.49,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":177.0,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":240.72,"additional_payer_notes":"APC"}]}]},{"description":"MRA, w/o dye, spinal canal","code_information":[{"code":"C8932","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":177.0,"maximum":455.49,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":236.0,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":455.49,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":177.0,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":240.72,"additional_payer_notes":"APC"}]}]},{"description":"MRA, w/o dye, upper extr","code_information":[{"code":"C8935","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":177.0,"maximum":455.49,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":236.0,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":455.49,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":177.0,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":240.72,"additional_payer_notes":"APC"}]}]},{"description":"Intraor complete film series","code_information":[{"code":"D0210","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":177.0,"maximum":455.49,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":236.0,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":455.49,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":177.0,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":240.72,"additional_payer_notes":"APC"}]}]},{"description":"Bitewings - three images","code_information":[{"code":"D0273","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":177.0,"maximum":455.49,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":236.0,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":455.49,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":177.0,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":240.72,"additional_payer_notes":"APC"}]}]},{"description":"Bitewings four images","code_information":[{"code":"D0274","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":177.0,"maximum":455.49,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":236.0,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":455.49,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":177.0,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":240.72,"additional_payer_notes":"APC"}]}]},{"description":"Vert bitewings 7 to 8 images","code_information":[{"code":"D0277","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":177.0,"maximum":455.49,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":236.0,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":455.49,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":177.0,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":240.72,"additional_payer_notes":"APC"}]}]},{"description":"Dental saliography","code_information":[{"code":"D0310","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":177.0,"maximum":455.49,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":236.0,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":455.49,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":177.0,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":240.72,"additional_payer_notes":"APC"}]}]},{"description":"Dental tmj arthrogram incl i","code_information":[{"code":"D0320","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":177.0,"maximum":455.49,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":236.0,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":455.49,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":177.0,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":240.72,"additional_payer_notes":"APC"}]}]},{"description":"Panoramic image","code_information":[{"code":"D0330","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":177.0,"maximum":455.49,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":236.0,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":455.49,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":177.0,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":240.72,"additional_payer_notes":"APC"}]}]},{"description":"Echo transthoracic","code_information":[{"code":"93303","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":405.35,"maximum":1043.1,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":540.46,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1043.1,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":405.35,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":551.27,"additional_payer_notes":"APC"}]}]},{"description":"Echo transthoracic","code_information":[{"code":"93304","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":405.35,"maximum":1043.1,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":540.46,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1043.1,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":405.35,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":551.27,"additional_payer_notes":"APC"}]}]},{"description":"Tte w/doppler complete","code_information":[{"code":"93306","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":405.35,"maximum":1043.1,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":540.46,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1043.1,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":405.35,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":551.27,"additional_payer_notes":"APC"}]}]},{"description":"Echo transesophageal","code_information":[{"code":"93312","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":405.35,"maximum":1043.1,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":540.46,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1043.1,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":405.35,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":551.27,"additional_payer_notes":"APC"}]}]},{"description":"Echo transesophageal","code_information":[{"code":"93313","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":405.35,"maximum":1043.1,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":540.46,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1043.1,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":405.35,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":551.27,"additional_payer_notes":"APC"}]}]},{"description":"Echo transesophageal","code_information":[{"code":"93315","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":405.35,"maximum":1043.1,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":540.46,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1043.1,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":405.35,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":551.27,"additional_payer_notes":"APC"}]}]},{"description":"Echo transesophageal","code_information":[{"code":"93316","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":405.35,"maximum":1043.1,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":540.46,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1043.1,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":405.35,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":551.27,"additional_payer_notes":"APC"}]}]},{"description":"Echo Transesophageal Intraop","code_information":[{"code":"93318","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":405.35,"maximum":1043.1,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":540.46,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1043.1,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":405.35,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":551.27,"additional_payer_notes":"APC"}]}]},{"description":"Stress tte only","code_information":[{"code":"93350","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":405.35,"maximum":1043.1,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":540.46,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1043.1,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":405.35,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":551.27,"additional_payer_notes":"APC"}]}]},{"description":"Stress tte complete","code_information":[{"code":"93351","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":405.35,"maximum":1043.1,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":540.46,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1043.1,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":405.35,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":551.27,"additional_payer_notes":"APC"}]}]},{"description":"Cardiac MRI seg dys strain","code_information":[{"code":"C9762","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":405.35,"maximum":1043.1,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":540.46,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1043.1,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":405.35,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":551.27,"additional_payer_notes":"APC"}]}]},{"description":"Cardiac MRI seg dys stress","code_information":[{"code":"C9763","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":405.35,"maximum":1043.1,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":540.46,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1043.1,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":405.35,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":551.27,"additional_payer_notes":"APC"}]}]},{"description":"Ct cere prfu aly c+wo ct/cta","code_information":[{"code":"70473","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":130.12,"maximum":334.84,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":173.49,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":334.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":130.12,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":176.96,"additional_payer_notes":"APC"}]}]},{"description":"Mri w/cont, breast,  uni","code_information":[{"code":"C8903","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":130.12,"maximum":334.84,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":173.49,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":334.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":130.12,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":176.96,"additional_payer_notes":"APC"}]}]},{"description":"Cta h&n c+ w/noncontrast img","code_information":[{"code":"70471","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":258.81,"maximum":665.99,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":345.07,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":665.99,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":258.81,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":351.98,"additional_payer_notes":"APC"}]}]},{"description":"Mra w/cont, abd","code_information":[{"code":"C8900","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":258.81,"maximum":665.99,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":345.07,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":665.99,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":258.81,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":351.98,"additional_payer_notes":"APC"}]}]},{"description":"Mra w/o fol w/cont, abd","code_information":[{"code":"C8902","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":258.81,"maximum":665.99,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":345.07,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":665.99,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":258.81,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":351.98,"additional_payer_notes":"APC"}]}]},{"description":"Mri w/o fol w/cont, brst, un","code_information":[{"code":"C8905","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":258.81,"maximum":665.99,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":345.07,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":665.99,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":258.81,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":351.98,"additional_payer_notes":"APC"}]}]},{"description":"Mri w/cont, breast,  bi","code_information":[{"code":"C8906","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":258.81,"maximum":665.99,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":345.07,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":665.99,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":258.81,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":351.98,"additional_payer_notes":"APC"}]}]},{"description":"Mri w/o fol w/cont, breast,","code_information":[{"code":"C8908","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":258.81,"maximum":665.99,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":345.07,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":665.99,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":258.81,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":351.98,"additional_payer_notes":"APC"}]}]},{"description":"MRA w/cont, chest","code_information":[{"code":"C8909","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":258.81,"maximum":665.99,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":345.07,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":665.99,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":258.81,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":351.98,"additional_payer_notes":"APC"}]}]},{"description":"MRA w/o fol w/cont, chest","code_information":[{"code":"C8911","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":258.81,"maximum":665.99,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":345.07,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":665.99,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":258.81,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":351.98,"additional_payer_notes":"APC"}]}]},{"description":"Mra w/cont, lwr ext","code_information":[{"code":"C8912","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":258.81,"maximum":665.99,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":345.07,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":665.99,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":258.81,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":351.98,"additional_payer_notes":"APC"}]}]},{"description":"Mra w/o fol w/cont, lwr ext","code_information":[{"code":"C8914","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":258.81,"maximum":665.99,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":345.07,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":665.99,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":258.81,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":351.98,"additional_payer_notes":"APC"}]}]},{"description":"MRA w/cont, pelvis","code_information":[{"code":"C8918","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":258.81,"maximum":665.99,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":345.07,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":665.99,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":258.81,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":351.98,"additional_payer_notes":"APC"}]}]},{"description":"Mra w/o fol w/cont, pelvis","code_information":[{"code":"C8920","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":258.81,"maximum":665.99,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":345.07,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":665.99,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":258.81,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":351.98,"additional_payer_notes":"APC"}]}]},{"description":"2d tte w or w/o fol w/con,fu","code_information":[{"code":"C8924","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":258.81,"maximum":665.99,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":345.07,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":665.99,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":258.81,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":351.98,"additional_payer_notes":"APC"}]}]},{"description":"MRA, w/dye, spinal canal","code_information":[{"code":"C8931","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":258.81,"maximum":665.99,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":345.07,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":665.99,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":258.81,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":351.98,"additional_payer_notes":"APC"}]}]},{"description":"MRA, w/o&w/dye, spinal canal","code_information":[{"code":"C8933","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":258.81,"maximum":665.99,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":345.07,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":665.99,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":258.81,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":351.98,"additional_payer_notes":"APC"}]}]},{"description":"MRA, w/dye, upper extremity","code_information":[{"code":"C8934","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":258.81,"maximum":665.99,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":345.07,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":665.99,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":258.81,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":351.98,"additional_payer_notes":"APC"}]}]},{"description":"MRA, w/o&w/dye, upper extr","code_information":[{"code":"C8936","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":258.81,"maximum":665.99,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":345.07,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":665.99,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":258.81,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":351.98,"additional_payer_notes":"APC"}]}]},{"description":"Non-ophthalmic FVA","code_information":[{"code":"C9733","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":258.81,"maximum":665.99,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":345.07,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":665.99,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":258.81,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":351.98,"additional_payer_notes":"APC"}]}]},{"description":"Tte w or w/o fol w/cont, com","code_information":[{"code":"C8921","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":581.54,"maximum":1496.49,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":775.38,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1496.49,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":581.54,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":790.89,"additional_payer_notes":"APC"}]}]},{"description":"Tte w or w/o fol w/cont, f/u","code_information":[{"code":"C8922","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":581.54,"maximum":1496.49,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":775.38,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1496.49,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":581.54,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":790.89,"additional_payer_notes":"APC"}]}]},{"description":"2d tte w or w/o fol w/con,co","code_information":[{"code":"C8923","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":581.54,"maximum":1496.49,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":775.38,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1496.49,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":581.54,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":790.89,"additional_payer_notes":"APC"}]}]},{"description":"2d tee w or w/o fol w/con,in","code_information":[{"code":"C8925","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":581.54,"maximum":1496.49,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":775.38,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1496.49,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":581.54,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":790.89,"additional_payer_notes":"APC"}]}]},{"description":"Tee w or w/o fol w/cont,cong","code_information":[{"code":"C8926","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":581.54,"maximum":1496.49,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":775.38,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1496.49,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":581.54,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":790.89,"additional_payer_notes":"APC"}]}]},{"description":"TEE w or w/o fol w/cont, mon","code_information":[{"code":"C8927","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":581.54,"maximum":1496.49,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":775.38,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1496.49,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":581.54,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":790.89,"additional_payer_notes":"APC"}]}]},{"description":"Tte w or w/o fol w/con,stres","code_information":[{"code":"C8928","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":581.54,"maximum":1496.49,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":775.38,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1496.49,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":581.54,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":790.89,"additional_payer_notes":"APC"}]}]},{"description":"TTE w or wo fol wcon,Doppler","code_information":[{"code":"C8929","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":581.54,"maximum":1496.49,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":775.38,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1496.49,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":581.54,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":790.89,"additional_payer_notes":"APC"}]}]},{"description":"TTE w or w/o contr, cont ECG","code_information":[{"code":"C8930","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":581.54,"maximum":1496.49,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":775.38,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1496.49,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":581.54,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":790.89,"additional_payer_notes":"APC"}]}]},{"description":"Endocrine nuclear procedure","code_information":[{"code":"78099","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":296.56,"maximum":763.16,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":395.42,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":763.16,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":296.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":403.33,"additional_payer_notes":"APC"}]}]},{"description":"Blood/lymph nuclear exam","code_information":[{"code":"78199","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":296.56,"maximum":763.16,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":395.42,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":763.16,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":296.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":403.33,"additional_payer_notes":"APC"}]}]},{"description":"GI nuclear procedure","code_information":[{"code":"78299","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":296.56,"maximum":763.16,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":395.42,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":763.16,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":296.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":403.33,"additional_payer_notes":"APC"}]}]},{"description":"Musculoskeletal nuclear exam","code_information":[{"code":"78399","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":296.56,"maximum":763.16,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":395.42,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":763.16,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":296.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":403.33,"additional_payer_notes":"APC"}]}]},{"description":"Cardiovascular nuclear exam","code_information":[{"code":"78499","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":296.56,"maximum":763.16,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":395.42,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":763.16,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":296.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":403.33,"additional_payer_notes":"APC"}]}]},{"description":"Respiratory nuclear exam","code_information":[{"code":"78599","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":296.56,"maximum":763.16,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":395.42,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":763.16,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":296.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":403.33,"additional_payer_notes":"APC"}]}]},{"description":"Nervous system nuclear exam","code_information":[{"code":"78699","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":296.56,"maximum":763.16,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":395.42,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":763.16,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":296.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":403.33,"additional_payer_notes":"APC"}]}]},{"description":"Genitourinary nuclear exam","code_information":[{"code":"78799","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":296.56,"maximum":763.16,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":395.42,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":763.16,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":296.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":403.33,"additional_payer_notes":"APC"}]}]},{"description":"Nuclear diagnostic exam","code_information":[{"code":"78999","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":296.56,"maximum":763.16,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":395.42,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":763.16,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":296.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":403.33,"additional_payer_notes":"APC"}]}]},{"description":"PET not otherwise specified","code_information":[{"code":"G0235","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":296.56,"maximum":763.16,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":395.42,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":763.16,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":296.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":403.33,"additional_payer_notes":"APC"}]}]},{"description":"Alt elec fld dos&dlv sim mdl","code_information":[{"code":"1025T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":99.71,"maximum":256.58,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":132.94,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":256.58,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":99.71,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":135.6,"additional_payer_notes":"APC"}]}]},{"description":"Radiation therapy planning","code_information":[{"code":"77299","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":99.71,"maximum":256.58,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":132.94,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":256.58,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":99.71,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":135.6,"additional_payer_notes":"APC"}]}]},{"description":"External radiation dosimetry","code_information":[{"code":"77399","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":99.71,"maximum":256.58,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":132.94,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":256.58,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":99.71,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":135.6,"additional_payer_notes":"APC"}]}]},{"description":"Io rad tx delivery by x-ray","code_information":[{"code":"77424","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5463.81,"maximum":14060.2,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7285.08,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":14060.2,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5463.81,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7430.78,"additional_payer_notes":"APC"}]}]},{"description":"Io rad tx deliver by elctrns","code_information":[{"code":"77425","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5463.81,"maximum":14060.2,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7285.08,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":14060.2,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5463.81,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7430.78,"additional_payer_notes":"APC"}]}]},{"description":"Immunotherapy one injection","code_information":[{"code":"95115","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":34.74,"maximum":89.39,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":46.32,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":89.39,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":34.74,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":47.24,"additional_payer_notes":"APC"}]}]},{"description":"Immunotherapy injections","code_information":[{"code":"95117","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":34.74,"maximum":89.39,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":46.32,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":89.39,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":34.74,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":47.24,"additional_payer_notes":"APC"}]}]},{"description":"Antigen therapy services","code_information":[{"code":"95144","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":34.74,"maximum":89.39,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":46.32,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":89.39,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":34.74,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":47.24,"additional_payer_notes":"APC"}]}]},{"description":"Antigen therapy services","code_information":[{"code":"95145","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":34.74,"maximum":89.39,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":46.32,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":89.39,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":34.74,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":47.24,"additional_payer_notes":"APC"}]}]},{"description":"Antigen therapy services","code_information":[{"code":"95146","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":34.74,"maximum":89.39,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":46.32,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":89.39,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":34.74,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":47.24,"additional_payer_notes":"APC"}]}]},{"description":"Antigen therapy services","code_information":[{"code":"95165","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":34.74,"maximum":89.39,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":46.32,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":89.39,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":34.74,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":47.24,"additional_payer_notes":"APC"}]}]},{"description":"Antigen therapy services","code_information":[{"code":"95170","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":34.74,"maximum":89.39,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":46.32,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":89.39,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":34.74,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":47.24,"additional_payer_notes":"APC"}]}]},{"description":"Ther/proph/diag iv inf addon","code_information":[{"code":"96366","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":34.74,"maximum":89.39,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":46.32,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":89.39,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":34.74,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":47.24,"additional_payer_notes":"APC"}]}]},{"description":"Sc ther infusion addl hr","code_information":[{"code":"96370","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":34.74,"maximum":89.39,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":46.32,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":89.39,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":34.74,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":47.24,"additional_payer_notes":"APC"}]}]},{"description":"Tx/pro/dx inj new drug addon","code_information":[{"code":"96375","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":34.74,"maximum":89.39,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":46.32,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":89.39,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":34.74,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":47.24,"additional_payer_notes":"APC"}]}]},{"description":"Applicaton on-body injector","code_information":[{"code":"96377","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":34.74,"maximum":89.39,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":46.32,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":89.39,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":34.74,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":47.24,"additional_payer_notes":"APC"}]}]},{"description":"Ther/prop/diag inj/inf proc","code_information":[{"code":"96379","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":34.74,"maximum":89.39,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":46.32,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":89.39,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":34.74,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":47.24,"additional_payer_notes":"APC"}]}]},{"description":"Chemo ia infuse each addl hr","code_information":[{"code":"96423","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":34.74,"maximum":89.39,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":46.32,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":89.39,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":34.74,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":47.24,"additional_payer_notes":"APC"}]}]},{"description":"Chemotherapy unspecified","code_information":[{"code":"96549","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":34.74,"maximum":89.39,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":46.32,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":89.39,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":34.74,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":47.24,"additional_payer_notes":"APC"}]}]},{"description":"Admin influenza virus vac","code_information":[{"code":"G0008","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":34.74,"maximum":89.39,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":46.32,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":89.39,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":34.74,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":47.24,"additional_payer_notes":"APC"}]}]},{"description":"Admin pneumococcal vaccine","code_information":[{"code":"G0009","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":34.74,"maximum":89.39,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":46.32,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":89.39,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":34.74,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":47.24,"additional_payer_notes":"APC"}]}]},{"description":"Admin hepatitis b vaccine","code_information":[{"code":"G0010","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":34.74,"maximum":89.39,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":46.32,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":89.39,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":34.74,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":47.24,"additional_payer_notes":"APC"}]}]},{"description":"Immunization admin","code_information":[{"code":"90471","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":53.41,"maximum":137.45,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":71.22,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":137.45,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":53.41,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":72.64,"additional_payer_notes":"APC"}]}]},{"description":"Immune admin oral/nasal","code_information":[{"code":"90473","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":53.41,"maximum":137.45,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":71.22,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":137.45,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":53.41,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":72.64,"additional_payer_notes":"APC"}]}]},{"description":"Antigen therapy services","code_information":[{"code":"95147","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":53.41,"maximum":137.45,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":71.22,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":137.45,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":53.41,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":72.64,"additional_payer_notes":"APC"}]}]},{"description":"Antigen therapy services","code_information":[{"code":"95148","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":53.41,"maximum":137.45,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":71.22,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":137.45,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":53.41,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":72.64,"additional_payer_notes":"APC"}]}]},{"description":"Antigen therapy services","code_information":[{"code":"95149","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":53.41,"maximum":137.45,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":71.22,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":137.45,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":53.41,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":72.64,"additional_payer_notes":"APC"}]}]},{"description":"Tx/proph/dg addl seq iv inf","code_information":[{"code":"96367","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":53.41,"maximum":137.45,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":71.22,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":137.45,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":53.41,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":72.64,"additional_payer_notes":"APC"}]}]},{"description":"Sc ther infusion reset pump","code_information":[{"code":"96371","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":53.41,"maximum":137.45,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":71.22,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":137.45,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":53.41,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":72.64,"additional_payer_notes":"APC"}]}]},{"description":"Ther/proph/diag inj sc/im","code_information":[{"code":"96372","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":53.41,"maximum":137.45,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":71.22,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":137.45,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":53.41,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":72.64,"additional_payer_notes":"APC"}]}]},{"description":"Chemo anti-neopl sq/im","code_information":[{"code":"96401","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":53.41,"maximum":137.45,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":71.22,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":137.45,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":53.41,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":72.64,"additional_payer_notes":"APC"}]}]},{"description":"Chemo hormon antineopl sq/im","code_information":[{"code":"96402","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":53.41,"maximum":137.45,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":71.22,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":137.45,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":53.41,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":72.64,"additional_payer_notes":"APC"}]}]},{"description":"Chemo intralesional up to 7","code_information":[{"code":"96405","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":53.41,"maximum":137.45,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":71.22,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":137.45,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":53.41,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":72.64,"additional_payer_notes":"APC"}]}]},{"description":"Chemo iv push addl drug","code_information":[{"code":"96411","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":53.41,"maximum":137.45,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":71.22,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":137.45,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":53.41,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":72.64,"additional_payer_notes":"APC"}]}]},{"description":"Chemo iv infusion addl hr","code_information":[{"code":"96415","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":53.41,"maximum":137.45,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":71.22,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":137.45,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":53.41,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":72.64,"additional_payer_notes":"APC"}]}]},{"description":"Chemo iv infus each addl seq","code_information":[{"code":"96417","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":53.41,"maximum":137.45,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":71.22,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":137.45,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":53.41,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":72.64,"additional_payer_notes":"APC"}]}]},{"description":"Injection of hiv prep drug","code_information":[{"code":"G0012","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":53.41,"maximum":137.45,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":71.22,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":137.45,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":53.41,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":72.64,"additional_payer_notes":"APC"}]}]},{"description":"Ther/proph/diag iv inf init","code_information":[{"code":"96365","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":157.79,"maximum":406.05,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":210.39,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":406.05,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":157.79,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":214.59,"additional_payer_notes":"APC"}]}]},{"description":"Sc ther infusion up to 1 hr","code_information":[{"code":"96369","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":157.79,"maximum":406.05,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":210.39,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":406.05,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":157.79,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":214.59,"additional_payer_notes":"APC"}]}]},{"description":"Ther/proph/diag inj ia","code_information":[{"code":"96373","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":157.79,"maximum":406.05,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":210.39,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":406.05,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":157.79,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":214.59,"additional_payer_notes":"APC"}]}]},{"description":"Ther/proph/diag inj iv push","code_information":[{"code":"96374","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":157.79,"maximum":406.05,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":210.39,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":406.05,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":157.79,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":214.59,"additional_payer_notes":"APC"}]}]},{"description":"Chemo intralesional over 7","code_information":[{"code":"96406","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":157.79,"maximum":406.05,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":210.39,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":406.05,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":157.79,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":214.59,"additional_payer_notes":"APC"}]}]},{"description":"Refill/maint portable pump","code_information":[{"code":"96521","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":157.79,"maximum":406.05,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":210.39,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":406.05,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":157.79,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":214.59,"additional_payer_notes":"APC"}]}]},{"description":"Refill/maint pump/resvr syst","code_information":[{"code":"96522","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":157.79,"maximum":406.05,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":210.39,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":406.05,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":157.79,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":214.59,"additional_payer_notes":"APC"}]}]},{"description":"Prolonged iv inf, req pump","code_information":[{"code":"C8957","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":157.79,"maximum":406.05,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":210.39,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":406.05,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":157.79,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":214.59,"additional_payer_notes":"APC"}]}]},{"description":"Car-t admn autologous","code_information":[{"code":"38228","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":245.03,"maximum":630.55,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":326.71,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":630.55,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":245.03,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":333.24,"additional_payer_notes":"APC"}]}]},{"description":"Chemo iv push sngl drug","code_information":[{"code":"96409","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":245.03,"maximum":630.55,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":326.71,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":630.55,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":245.03,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":333.24,"additional_payer_notes":"APC"}]}]},{"description":"Chemo iv infusion 1 hr","code_information":[{"code":"96413","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":245.03,"maximum":630.55,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":326.71,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":630.55,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":245.03,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":333.24,"additional_payer_notes":"APC"}]}]},{"description":"Chemo prolong infuse w/pump","code_information":[{"code":"96416","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":245.03,"maximum":630.55,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":326.71,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":630.55,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":245.03,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":333.24,"additional_payer_notes":"APC"}]}]},{"description":"Chemo ia push tecnique","code_information":[{"code":"96420","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":245.03,"maximum":630.55,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":326.71,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":630.55,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":245.03,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":333.24,"additional_payer_notes":"APC"}]}]},{"description":"Chemo ia infusion up to 1 hr","code_information":[{"code":"96422","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":245.03,"maximum":630.55,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":326.71,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":630.55,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":245.03,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":333.24,"additional_payer_notes":"APC"}]}]},{"description":"Chemotherapy infusion method","code_information":[{"code":"96425","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":245.03,"maximum":630.55,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":326.71,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":630.55,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":245.03,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":333.24,"additional_payer_notes":"APC"}]}]},{"description":"Chemotherapy intracavitary","code_information":[{"code":"96440","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":245.03,"maximum":630.55,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":326.71,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":630.55,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":245.03,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":333.24,"additional_payer_notes":"APC"}]}]},{"description":"Chemotx admn prtl cavity","code_information":[{"code":"96446","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":245.03,"maximum":630.55,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":326.71,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":630.55,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":245.03,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":333.24,"additional_payer_notes":"APC"}]}]},{"description":"Chemotherapy into cns","code_information":[{"code":"96450","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":245.03,"maximum":630.55,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":326.71,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":630.55,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":245.03,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":333.24,"additional_payer_notes":"APC"}]}]},{"description":"Chemotherapy injection","code_information":[{"code":"96542","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":245.03,"maximum":630.55,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":326.71,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":630.55,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":245.03,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":333.24,"additional_payer_notes":"APC"}]}]},{"description":"Chemo extend iv infus w/pump","code_information":[{"code":"G0498","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":245.03,"maximum":630.55,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":326.71,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":630.55,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":245.03,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":333.24,"additional_payer_notes":"APC"}]}]},{"description":"Compre audiometry evaluation","code_information":[{"code":"0212T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":95.45,"maximum":245.63,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":127.27,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":245.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":95.45,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":129.82,"additional_payer_notes":"APC"}]}]},{"description":"Visual ep test for glaucoma","code_information":[{"code":"0464T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":95.45,"maximum":245.63,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":127.27,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":245.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":95.45,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":129.82,"additional_payer_notes":"APC"}]}]},{"description":"Smmg cncrnt appl imu snr","code_information":[{"code":"0778T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":95.45,"maximum":245.63,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":127.27,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":245.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":95.45,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":129.82,"additional_payer_notes":"APC"}]}]},{"description":"Tc auriculr neurostimulation","code_information":[{"code":"0783T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":95.45,"maximum":245.63,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":127.27,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":245.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":95.45,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":129.82,"additional_payer_notes":"APC"}]}]},{"description":"Rem mlt day uroflow dev sply","code_information":[{"code":"0812T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":95.45,"maximum":245.63,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":127.27,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":245.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":95.45,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":129.82,"additional_payer_notes":"APC"}]}]},{"description":"Crtj dig 3d mdl surf mesh 1","code_information":[{"code":"1030T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":95.45,"maximum":245.63,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":127.27,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":245.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":95.45,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":129.82,"additional_payer_notes":"APC"}]}]},{"description":"Crtj dig 3d mdl mesh&sim 1","code_information":[{"code":"1032T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":95.45,"maximum":245.63,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":127.27,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":245.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":95.45,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":129.82,"additional_payer_notes":"APC"}]}]},{"description":"Crt dig 3d mdl msh sim&aly 1","code_information":[{"code":"1034T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":95.45,"maximum":245.63,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":127.27,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":245.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":95.45,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":129.82,"additional_payer_notes":"APC"}]}]},{"description":"Multifocal erg w/i&r","code_information":[{"code":"92274","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":95.45,"maximum":245.63,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":127.27,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":245.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":95.45,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":129.82,"additional_payer_notes":"APC"}]}]},{"description":"Vemp test i&r cervical","code_information":[{"code":"92517","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":95.45,"maximum":245.63,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":127.27,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":245.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":95.45,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":129.82,"additional_payer_notes":"APC"}]}]},{"description":"Vemp test i&r ocular","code_information":[{"code":"92518","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":95.45,"maximum":245.63,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":127.27,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":245.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":95.45,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":129.82,"additional_payer_notes":"APC"}]}]},{"description":"Caloric vstblr test w/rec","code_information":[{"code":"92537","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":95.45,"maximum":245.63,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":127.27,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":245.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":95.45,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":129.82,"additional_payer_notes":"APC"}]}]},{"description":"Optokinetic nystagmus test","code_information":[{"code":"92544","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":95.45,"maximum":245.63,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":127.27,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":245.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":95.45,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":129.82,"additional_payer_notes":"APC"}]}]},{"description":"Sinusoidal rotational test","code_information":[{"code":"92546","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":95.45,"maximum":245.63,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":127.27,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":245.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":95.45,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":129.82,"additional_payer_notes":"APC"}]}]},{"description":"Audiometry air & bone","code_information":[{"code":"92553","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":95.45,"maximum":245.63,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":127.27,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":245.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":95.45,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":129.82,"additional_payer_notes":"APC"}]}]},{"description":"Comprehensive hearing test","code_information":[{"code":"92557","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":95.45,"maximum":245.63,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":127.27,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":245.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":95.45,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":129.82,"additional_payer_notes":"APC"}]}]},{"description":"Acoustic immitance testing","code_information":[{"code":"92570","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":95.45,"maximum":245.63,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":127.27,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":245.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":95.45,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":129.82,"additional_payer_notes":"APC"}]}]},{"description":"Staggered spondaic word test","code_information":[{"code":"92572","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":95.45,"maximum":245.63,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":127.27,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":245.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":95.45,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":129.82,"additional_payer_notes":"APC"}]}]},{"description":"Conditioning play audiometry","code_information":[{"code":"92582","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":95.45,"maximum":245.63,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":127.27,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":245.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":95.45,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":129.82,"additional_payer_notes":"APC"}]}]},{"description":"Electrocochleography","code_information":[{"code":"92584","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":95.45,"maximum":245.63,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":127.27,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":245.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":95.45,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":129.82,"additional_payer_notes":"APC"}]}]},{"description":"Cochlear implt f/up exam <7","code_information":[{"code":"92601","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":95.45,"maximum":245.63,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":127.27,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":245.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":95.45,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":129.82,"additional_payer_notes":"APC"}]}]},{"description":"Reprogram cochlear implt 7/>","code_information":[{"code":"92602","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":95.45,"maximum":245.63,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":127.27,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":245.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":95.45,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":129.82,"additional_payer_notes":"APC"}]}]},{"description":"Cochlear implt f/up exam 7/>","code_information":[{"code":"92603","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":95.45,"maximum":245.63,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":127.27,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":245.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":95.45,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":129.82,"additional_payer_notes":"APC"}]}]},{"description":"Reprogram cochlear implt 7/>","code_information":[{"code":"92604","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":95.45,"maximum":245.63,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":127.27,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":245.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":95.45,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":129.82,"additional_payer_notes":"APC"}]}]},{"description":"Auditory function 60 min","code_information":[{"code":"92620","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":95.45,"maximum":245.63,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":127.27,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":245.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":95.45,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":129.82,"additional_payer_notes":"APC"}]}]},{"description":"Dx aly aud oi snd prcsr 1st","code_information":[{"code":"92622","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":95.45,"maximum":245.63,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":127.27,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":245.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":95.45,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":129.82,"additional_payer_notes":"APC"}]}]},{"description":"Tinnitus assessment","code_information":[{"code":"92625","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":95.45,"maximum":245.63,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":127.27,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":245.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":95.45,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":129.82,"additional_payer_notes":"APC"}]}]},{"description":"Eval aud rehab status","code_information":[{"code":"92626","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":95.45,"maximum":245.63,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":127.27,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":245.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":95.45,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":129.82,"additional_payer_notes":"APC"}]}]},{"description":"Aud brainstem implt programg","code_information":[{"code":"92640","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":95.45,"maximum":245.63,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":127.27,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":245.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":95.45,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":129.82,"additional_payer_notes":"APC"}]}]},{"description":"Microvolt t-wave assess","code_information":[{"code":"93025","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":95.45,"maximum":245.63,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":127.27,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":245.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":95.45,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":129.82,"additional_payer_notes":"APC"}]}]},{"description":"Interrog crtd sins bat ip wo","code_information":[{"code":"93145","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":95.45,"maximum":245.63,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":127.27,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":245.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":95.45,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":129.82,"additional_payer_notes":"APC"}]}]},{"description":"Interrog crtd sins bat ip w/","code_information":[{"code":"93146","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":95.45,"maximum":245.63,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":127.27,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":245.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":95.45,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":129.82,"additional_payer_notes":"APC"}]}]},{"description":"Bis xtracell fluid analysis","code_information":[{"code":"93702","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":95.45,"maximum":245.63,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":127.27,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":245.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":95.45,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":129.82,"additional_payer_notes":"APC"}]}]},{"description":"Temperature gradient studies","code_information":[{"code":"93740","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":95.45,"maximum":245.63,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":127.27,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":245.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":95.45,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":129.82,"additional_payer_notes":"APC"}]}]},{"description":"Spirometry up to 2 yrs old","code_information":[{"code":"94011","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":95.45,"maximum":245.63,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":127.27,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":245.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":95.45,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":129.82,"additional_payer_notes":"APC"}]}]},{"description":"Vital capacity test","code_information":[{"code":"94150","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":95.45,"maximum":245.63,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":127.27,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":245.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":95.45,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":129.82,"additional_payer_notes":"APC"}]}]},{"description":"Hypoxia response curve","code_information":[{"code":"94450","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":95.45,"maximum":245.63,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":127.27,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":245.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":95.45,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":129.82,"additional_payer_notes":"APC"}]}]},{"description":"Exhaled air analysis o2","code_information":[{"code":"94680","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":95.45,"maximum":245.63,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":127.27,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":245.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":95.45,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":129.82,"additional_payer_notes":"APC"}]}]},{"description":"Pulm funct test oscillometry","code_information":[{"code":"94728","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":95.45,"maximum":245.63,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":127.27,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":245.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":95.45,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":129.82,"additional_payer_notes":"APC"}]}]},{"description":"Measure blood oxygen level","code_information":[{"code":"94762","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":95.45,"maximum":245.63,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":127.27,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":245.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":95.45,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":129.82,"additional_payer_notes":"APC"}]}]},{"description":"Ped home apnea rec hk-up","code_information":[{"code":"94775","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":95.45,"maximum":245.63,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":127.27,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":245.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":95.45,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":129.82,"additional_payer_notes":"APC"}]}]},{"description":"Ped home apnea rec downld","code_information":[{"code":"94776","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":95.45,"maximum":245.63,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":127.27,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":245.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":95.45,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":129.82,"additional_payer_notes":"APC"}]}]},{"description":"Pulmonary service/procedure","code_information":[{"code":"94799","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":95.45,"maximum":245.63,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":127.27,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":245.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":95.45,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":129.82,"additional_payer_notes":"APC"}]}]},{"description":"Muscle test 3 limbs","code_information":[{"code":"95863","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":95.45,"maximum":245.63,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":127.27,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":245.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":95.45,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":129.82,"additional_payer_notes":"APC"}]}]},{"description":"Muscle test 4 limbs","code_information":[{"code":"95864","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":95.45,"maximum":245.63,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":127.27,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":245.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":95.45,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":129.82,"additional_payer_notes":"APC"}]}]},{"description":"Muscle test hemidiaphragm","code_information":[{"code":"95866","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":95.45,"maximum":245.63,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":127.27,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":245.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":95.45,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":129.82,"additional_payer_notes":"APC"}]}]},{"description":"Limb exercise test","code_information":[{"code":"95875","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":95.45,"maximum":245.63,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":127.27,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":245.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":95.45,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":129.82,"additional_payer_notes":"APC"}]}]},{"description":"Autonomic nrv parasym inervj","code_information":[{"code":"95921","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":95.45,"maximum":245.63,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":127.27,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":245.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":95.45,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":129.82,"additional_payer_notes":"APC"}]}]},{"description":"Neuromuscular junction test","code_information":[{"code":"95937","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":95.45,"maximum":245.63,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":127.27,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":245.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":95.45,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":129.82,"additional_payer_notes":"APC"}]}]},{"description":"Neurological procedure","code_information":[{"code":"95999","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":95.45,"maximum":245.63,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":127.27,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":245.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":95.45,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":129.82,"additional_payer_notes":"APC"}]}]},{"description":"Devel tst phys/qhp 1st hr","code_information":[{"code":"96112","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":95.45,"maximum":245.63,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":127.27,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":245.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":95.45,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":129.82,"additional_payer_notes":"APC"}]}]},{"description":"3d anat seg imaging preop","code_information":[{"code":"C8001","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":95.45,"maximum":245.63,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":127.27,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":245.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":95.45,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":129.82,"additional_payer_notes":"APC"}]}]},{"description":"3d bn img algor drvd fr mri","code_information":[{"code":"G0566","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":95.45,"maximum":245.63,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":127.27,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":245.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":95.45,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":129.82,"additional_payer_notes":"APC"}]}]},{"description":"Pattern erg w/i&r","code_information":[{"code":"0509T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":160.18,"maximum":412.19,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":213.57,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":412.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":160.18,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":217.84,"additional_payer_notes":"APC"}]}]},{"description":"N-nvs artl plaq alys quan","code_information":[{"code":"0712T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":160.18,"maximum":412.19,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":213.57,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":412.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":160.18,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":217.84,"additional_payer_notes":"APC"}]}]},{"description":"Tc mag stimj pn 1st tx 1nrv","code_information":[{"code":"0766T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":160.18,"maximum":412.19,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":213.57,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":412.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":160.18,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":217.84,"additional_payer_notes":"APC"}]}]},{"description":"Tcranial magn stim tx plan","code_information":[{"code":"90867","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":160.18,"maximum":412.19,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":213.57,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":412.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":160.18,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":217.84,"additional_payer_notes":"APC"}]}]},{"description":"Tcranial magn stim tx deli","code_information":[{"code":"90868","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":160.18,"maximum":412.19,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":213.57,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":412.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":160.18,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":217.84,"additional_payer_notes":"APC"}]}]},{"description":"Tcran magn stim redetemine","code_information":[{"code":"90869","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":160.18,"maximum":412.19,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":213.57,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":412.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":160.18,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":217.84,"additional_payer_notes":"APC"}]}]},{"description":"Rct snsatn tone&cmplianc std","code_information":[{"code":"91124","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":160.18,"maximum":412.19,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":213.57,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":412.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":160.18,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":217.84,"additional_payer_notes":"APC"}]}]},{"description":"Cptrz oph img pst sg rta oct","code_information":[{"code":"92137","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":160.18,"maximum":412.19,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":213.57,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":412.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":160.18,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":217.84,"additional_payer_notes":"APC"}]}]},{"description":"Fluorescein angrph uni/bi","code_information":[{"code":"92235","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":160.18,"maximum":412.19,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":213.57,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":412.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":160.18,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":217.84,"additional_payer_notes":"APC"}]}]},{"description":"Icg angiography uni/bi","code_information":[{"code":"92240","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":160.18,"maximum":412.19,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":213.57,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":412.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":160.18,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":217.84,"additional_payer_notes":"APC"}]}]},{"description":"Fluorescein icg angiography","code_information":[{"code":"92242","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":160.18,"maximum":412.19,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":213.57,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":412.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":160.18,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":217.84,"additional_payer_notes":"APC"}]}]},{"description":"Full field erg w/i&r","code_information":[{"code":"92273","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":160.18,"maximum":412.19,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":213.57,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":412.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":160.18,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":217.84,"additional_payer_notes":"APC"}]}]},{"description":"Nasal function studies","code_information":[{"code":"92512","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":160.18,"maximum":412.19,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":213.57,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":412.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":160.18,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":217.84,"additional_payer_notes":"APC"}]}]},{"description":"Facial nerve function test","code_information":[{"code":"92516","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":160.18,"maximum":412.19,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":213.57,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":412.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":160.18,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":217.84,"additional_payer_notes":"APC"}]}]},{"description":"Vemp tst i&r cervical&ocular","code_information":[{"code":"92519","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":160.18,"maximum":412.19,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":213.57,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":412.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":160.18,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":217.84,"additional_payer_notes":"APC"}]}]},{"description":"Caloric vstblr test w/rec","code_information":[{"code":"92538","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":160.18,"maximum":412.19,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":213.57,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":412.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":160.18,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":217.84,"additional_payer_notes":"APC"}]}]},{"description":"Basic vestibular evaluation","code_information":[{"code":"92540","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":160.18,"maximum":412.19,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":213.57,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":412.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":160.18,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":217.84,"additional_payer_notes":"APC"}]}]},{"description":"Oscillating tracking test","code_information":[{"code":"92545","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":160.18,"maximum":412.19,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":213.57,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":412.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":160.18,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":217.84,"additional_payer_notes":"APC"}]}]},{"description":"Tympanometry & reflex thresh","code_information":[{"code":"92550","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":160.18,"maximum":412.19,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":213.57,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":412.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":160.18,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":217.84,"additional_payer_notes":"APC"}]}]},{"description":"Loudness balance test","code_information":[{"code":"92562","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":160.18,"maximum":412.19,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":213.57,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":412.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":160.18,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":217.84,"additional_payer_notes":"APC"}]}]},{"description":"Visual audiometry (vra)","code_information":[{"code":"92579","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":160.18,"maximum":412.19,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":213.57,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":412.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":160.18,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":217.84,"additional_payer_notes":"APC"}]}]},{"description":"Evoked auditory test limited","code_information":[{"code":"92587","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":160.18,"maximum":412.19,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":213.57,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":412.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":160.18,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":217.84,"additional_payer_notes":"APC"}]}]},{"description":"Aep hearing status deter i&r","code_information":[{"code":"92651","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":160.18,"maximum":412.19,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":213.57,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":412.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":160.18,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":217.84,"additional_payer_notes":"APC"}]}]},{"description":"Aep thrshld est mlt freq i&r","code_information":[{"code":"92652","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":160.18,"maximum":412.19,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":213.57,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":412.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":160.18,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":217.84,"additional_payer_notes":"APC"}]}]},{"description":"Aep neurodiagnostic i&r","code_information":[{"code":"92653","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":160.18,"maximum":412.19,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":213.57,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":412.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":160.18,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":217.84,"additional_payer_notes":"APC"}]}]},{"description":"Cardiovascular stress test","code_information":[{"code":"93017","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":160.18,"maximum":412.19,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":213.57,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":412.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":160.18,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":217.84,"additional_payer_notes":"APC"}]}]},{"description":"Upr/lxtr art stdy 3+ lvls","code_information":[{"code":"93923","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":160.18,"maximum":412.19,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":213.57,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":412.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":160.18,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":217.84,"additional_payer_notes":"APC"}]}]},{"description":"Lwr xtr vasc stdy bilat","code_information":[{"code":"93924","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":160.18,"maximum":412.19,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":213.57,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":412.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":160.18,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":217.84,"additional_payer_notes":"APC"}]}]},{"description":"Breathing capacity test","code_information":[{"code":"94010","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":160.18,"maximum":412.19,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":213.57,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":412.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":160.18,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":217.84,"additional_payer_notes":"APC"}]}]},{"description":"Spirmtry w/brnchdil inf-2 yr","code_information":[{"code":"94012","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":160.18,"maximum":412.19,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":213.57,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":412.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":160.18,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":217.84,"additional_payer_notes":"APC"}]}]},{"description":"Patient recorded spirometry","code_information":[{"code":"94015","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":160.18,"maximum":412.19,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":213.57,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":412.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":160.18,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":217.84,"additional_payer_notes":"APC"}]}]},{"description":"Respiratory flow volume loop","code_information":[{"code":"94375","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":160.18,"maximum":412.19,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":213.57,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":412.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":160.18,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":217.84,"additional_payer_notes":"APC"}]}]},{"description":"Pulm function test by gas","code_information":[{"code":"94727","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":160.18,"maximum":412.19,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":213.57,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":412.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":160.18,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":217.84,"additional_payer_notes":"APC"}]}]},{"description":"Eeg cont rec w/vid eeg tech","code_information":[{"code":"95700","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":160.18,"maximum":412.19,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":213.57,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":412.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":160.18,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":217.84,"additional_payer_notes":"APC"}]}]},{"description":"Eeg w/o vid 2-12 hr unmntr","code_information":[{"code":"95705","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":160.18,"maximum":412.19,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":213.57,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":412.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":160.18,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":217.84,"additional_payer_notes":"APC"}]}]},{"description":"Eeg wo vid 2-12hr intmt mntr","code_information":[{"code":"95706","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":160.18,"maximum":412.19,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":213.57,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":412.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":160.18,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":217.84,"additional_payer_notes":"APC"}]}]},{"description":"Eeg w/o vid 2-12hr cont mntr","code_information":[{"code":"95707","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":160.18,"maximum":412.19,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":213.57,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":412.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":160.18,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":217.84,"additional_payer_notes":"APC"}]}]},{"description":"Veeg 2-12 hr unmonitored","code_information":[{"code":"95711","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":160.18,"maximum":412.19,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":213.57,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":412.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":160.18,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":217.84,"additional_payer_notes":"APC"}]}]},{"description":"Slp stdy unattended","code_information":[{"code":"95800","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":160.18,"maximum":412.19,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":213.57,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":412.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":160.18,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":217.84,"additional_payer_notes":"APC"}]}]},{"description":"Sleep study unatt&resp efft","code_information":[{"code":"95806","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":160.18,"maximum":412.19,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":213.57,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":412.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":160.18,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":217.84,"additional_payer_notes":"APC"}]}]},{"description":"Eeg 41-60 minutes","code_information":[{"code":"95812","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":160.18,"maximum":412.19,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":213.57,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":412.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":160.18,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":217.84,"additional_payer_notes":"APC"}]}]},{"description":"Eeg over 1 hour","code_information":[{"code":"95813","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":160.18,"maximum":412.19,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":213.57,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":412.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":160.18,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":217.84,"additional_payer_notes":"APC"}]}]},{"description":"Eeg awake and drowsy","code_information":[{"code":"95816","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":160.18,"maximum":412.19,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":213.57,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":412.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":160.18,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":217.84,"additional_payer_notes":"APC"}]}]},{"description":"Eeg awake and asleep","code_information":[{"code":"95819","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":160.18,"maximum":412.19,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":213.57,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":412.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":160.18,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":217.84,"additional_payer_notes":"APC"}]}]},{"description":"Eeg coma or sleep only","code_information":[{"code":"95822","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":160.18,"maximum":412.19,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":213.57,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":412.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":160.18,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":217.84,"additional_payer_notes":"APC"}]}]},{"description":"Cholinesterase challenge","code_information":[{"code":"95857","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":160.18,"maximum":412.19,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":213.57,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":412.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":160.18,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":217.84,"additional_payer_notes":"APC"}]}]},{"description":"Muscle test cran nerv unilat","code_information":[{"code":"95867","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":160.18,"maximum":412.19,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":213.57,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":412.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":160.18,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":217.84,"additional_payer_notes":"APC"}]}]},{"description":"Muscle test cran nerve bilat","code_information":[{"code":"95868","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":160.18,"maximum":412.19,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":213.57,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":412.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":160.18,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":217.84,"additional_payer_notes":"APC"}]}]},{"description":"Muscle test thor paraspinal","code_information":[{"code":"95869","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":160.18,"maximum":412.19,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":213.57,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":412.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":160.18,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":217.84,"additional_payer_notes":"APC"}]}]},{"description":"Muscle test one fiber","code_information":[{"code":"95872","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":160.18,"maximum":412.19,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":213.57,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":412.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":160.18,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":217.84,"additional_payer_notes":"APC"}]}]},{"description":"Nvr cndj tst 1-2 studies","code_information":[{"code":"95907","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":160.18,"maximum":412.19,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":213.57,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":412.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":160.18,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":217.84,"additional_payer_notes":"APC"}]}]},{"description":"Nrv cndj tst 3-4 studies","code_information":[{"code":"95908","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":160.18,"maximum":412.19,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":213.57,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":412.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":160.18,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":217.84,"additional_payer_notes":"APC"}]}]},{"description":"Nrv cndj tst 5-6 studies","code_information":[{"code":"95909","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":160.18,"maximum":412.19,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":213.57,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":412.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":160.18,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":217.84,"additional_payer_notes":"APC"}]}]},{"description":"Ans parasymp & symp w/tilt","code_information":[{"code":"95924","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":160.18,"maximum":412.19,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":213.57,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":412.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":160.18,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":217.84,"additional_payer_notes":"APC"}]}]},{"description":"Somatosensory testing","code_information":[{"code":"95925","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":160.18,"maximum":412.19,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":213.57,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":412.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":160.18,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":217.84,"additional_payer_notes":"APC"}]}]},{"description":"Somatosensory testing","code_information":[{"code":"95926","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":160.18,"maximum":412.19,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":213.57,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":412.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":160.18,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":217.84,"additional_payer_notes":"APC"}]}]},{"description":"Somatosensory testing","code_information":[{"code":"95927","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":160.18,"maximum":412.19,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":213.57,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":412.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":160.18,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":217.84,"additional_payer_notes":"APC"}]}]},{"description":"Visual evoked potential test","code_information":[{"code":"95930","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":160.18,"maximum":412.19,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":213.57,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":412.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":160.18,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":217.84,"additional_payer_notes":"APC"}]}]},{"description":"Dynamic surface emg","code_information":[{"code":"96002","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":160.18,"maximum":412.19,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":213.57,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":412.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":160.18,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":217.84,"additional_payer_notes":"APC"}]}]},{"description":"Neurobehavioral status exam","code_information":[{"code":"96116","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":160.18,"maximum":412.19,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":213.57,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":412.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":160.18,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":217.84,"additional_payer_notes":"APC"}]}]},{"description":"Psycl tst eval phys/qhp 1st","code_information":[{"code":"96130","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":160.18,"maximum":412.19,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":213.57,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":412.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":160.18,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":217.84,"additional_payer_notes":"APC"}]}]},{"description":"Pre-op service LVRS 10-15dos","code_information":[{"code":"G0303","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":160.18,"maximum":412.19,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":213.57,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":412.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":160.18,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":217.84,"additional_payer_notes":"APC"}]}]},{"description":"Home sleep test/type 2 porta","code_information":[{"code":"G0398","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":160.18,"maximum":412.19,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":213.57,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":412.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":160.18,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":217.84,"additional_payer_notes":"APC"}]}]},{"description":"Home sleep test/type 3 porta","code_information":[{"code":"G0399","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":160.18,"maximum":412.19,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":213.57,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":412.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":160.18,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":217.84,"additional_payer_notes":"APC"}]}]},{"description":"Home sleep test/type 4 porta","code_information":[{"code":"G0400","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":160.18,"maximum":412.19,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":213.57,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":412.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":160.18,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":217.84,"additional_payer_notes":"APC"}]}]},{"description":"Myocardial imaging mcg","code_information":[{"code":"0541T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":276.82,"maximum":712.35,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":369.09,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":712.35,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":276.82,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":376.48,"additional_payer_notes":"APC"}]}]},{"description":"Gi myoelectrical actv study","code_information":[{"code":"0779T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":276.82,"maximum":712.35,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":369.09,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":712.35,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":276.82,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":376.48,"additional_payer_notes":"APC"}]}]},{"description":"Ext trnscranl mag stimj meas","code_information":[{"code":"0858T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":276.82,"maximum":712.35,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":369.09,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":712.35,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":276.82,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":376.48,"additional_payer_notes":"APC"}]}]},{"description":"Hi-res gastric ep mapping","code_information":[{"code":"0868T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":276.82,"maximum":712.35,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":369.09,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":712.35,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":276.82,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":376.48,"additional_payer_notes":"APC"}]}]},{"description":"Anrct mano rct snsatn&balo","code_information":[{"code":"91125","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":276.82,"maximum":712.35,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":369.09,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":712.35,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":276.82,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":376.48,"additional_payer_notes":"APC"}]}]},{"description":"Eye exam with photos","code_information":[{"code":"92230","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":276.82,"maximum":712.35,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":369.09,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":712.35,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":276.82,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":376.48,"additional_payer_notes":"APC"}]}]},{"description":"Stenger test speech","code_information":[{"code":"92577","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":276.82,"maximum":712.35,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":369.09,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":712.35,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":276.82,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":376.48,"additional_payer_notes":"APC"}]}]},{"description":"Evoked auditory tst complete","code_information":[{"code":"92588","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":276.82,"maximum":712.35,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":369.09,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":712.35,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":276.82,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":376.48,"additional_payer_notes":"APC"}]}]},{"description":"Remote 30 day ecg tech supp","code_information":[{"code":"93229","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":276.82,"maximum":712.35,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":369.09,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":712.35,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":276.82,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":376.48,"additional_payer_notes":"APC"}]}]},{"description":"Meas lung vol thru 2 yrs","code_information":[{"code":"94013","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":276.82,"maximum":712.35,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":369.09,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":712.35,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":276.82,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":376.48,"additional_payer_notes":"APC"}]}]},{"description":"Evaluation of wheezing","code_information":[{"code":"94060","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":276.82,"maximum":712.35,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":369.09,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":712.35,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":276.82,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":376.48,"additional_payer_notes":"APC"}]}]},{"description":"Evaluation of wheezing","code_information":[{"code":"94070","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":276.82,"maximum":712.35,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":369.09,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":712.35,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":276.82,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":376.48,"additional_payer_notes":"APC"}]}]},{"description":"Pulm stress test/complex","code_information":[{"code":"94621","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":276.82,"maximum":712.35,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":369.09,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":712.35,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":276.82,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":376.48,"additional_payer_notes":"APC"}]}]},{"description":"Exhaled air analysis o2/co2","code_information":[{"code":"94681","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":276.82,"maximum":712.35,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":369.09,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":712.35,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":276.82,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":376.48,"additional_payer_notes":"APC"}]}]},{"description":"Pulm funct tst plethysmograp","code_information":[{"code":"94726","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":276.82,"maximum":712.35,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":369.09,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":712.35,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":276.82,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":376.48,"additional_payer_notes":"APC"}]}]},{"description":"Breath recording infant","code_information":[{"code":"94772","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":276.82,"maximum":712.35,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":369.09,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":712.35,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":276.82,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":376.48,"additional_payer_notes":"APC"}]}]},{"description":"Bronchial allergy tests","code_information":[{"code":"95070","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":276.82,"maximum":712.35,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":369.09,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":712.35,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":276.82,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":376.48,"additional_payer_notes":"APC"}]}]},{"description":"Ingest challenge ini 120 min","code_information":[{"code":"95076","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":276.82,"maximum":712.35,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":369.09,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":712.35,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":276.82,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":376.48,"additional_payer_notes":"APC"}]}]},{"description":"Eeg wo vid ea 12-26hr unmntr","code_information":[{"code":"95708","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":276.82,"maximum":712.35,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":369.09,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":712.35,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":276.82,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":376.48,"additional_payer_notes":"APC"}]}]},{"description":"Eeg w/o vid ea 12-26hr intmt","code_information":[{"code":"95709","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":276.82,"maximum":712.35,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":369.09,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":712.35,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":276.82,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":376.48,"additional_payer_notes":"APC"}]}]},{"description":"Eeg w/o vid ea 12-26hr cont","code_information":[{"code":"95710","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":276.82,"maximum":712.35,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":369.09,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":712.35,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":276.82,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":376.48,"additional_payer_notes":"APC"}]}]},{"description":"Veeg 2-12 hr intmt mntr","code_information":[{"code":"95712","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":276.82,"maximum":712.35,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":369.09,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":712.35,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":276.82,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":376.48,"additional_payer_notes":"APC"}]}]},{"description":"Veeg 2-12 hr cont mntr","code_information":[{"code":"95713","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":276.82,"maximum":712.35,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":369.09,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":712.35,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":276.82,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":376.48,"additional_payer_notes":"APC"}]}]},{"description":"Veeg ea 12-26 hr unmntr","code_information":[{"code":"95714","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":276.82,"maximum":712.35,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":369.09,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":712.35,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":276.82,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":376.48,"additional_payer_notes":"APC"}]}]},{"description":"Veeg ea 12-26hr intmt mntr","code_information":[{"code":"95715","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":276.82,"maximum":712.35,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":369.09,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":712.35,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":276.82,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":376.48,"additional_payer_notes":"APC"}]}]},{"description":"Sleep study attended","code_information":[{"code":"95807","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":276.82,"maximum":712.35,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":369.09,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":712.35,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":276.82,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":376.48,"additional_payer_notes":"APC"}]}]},{"description":"Eeg cerebral death only","code_information":[{"code":"95824","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":276.82,"maximum":712.35,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":369.09,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":712.35,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":276.82,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":376.48,"additional_payer_notes":"APC"}]}]},{"description":"Nrv cndj test 7-8 studies","code_information":[{"code":"95910","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":276.82,"maximum":712.35,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":369.09,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":712.35,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":276.82,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":376.48,"additional_payer_notes":"APC"}]}]},{"description":"Nrv cndj test 9-10 studies","code_information":[{"code":"95911","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":276.82,"maximum":712.35,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":369.09,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":712.35,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":276.82,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":376.48,"additional_payer_notes":"APC"}]}]},{"description":"Nrv cndj test 11-12 studies","code_information":[{"code":"95912","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":276.82,"maximum":712.35,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":369.09,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":712.35,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":276.82,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":376.48,"additional_payer_notes":"APC"}]}]},{"description":"Nrv cndj test 13/> studies","code_information":[{"code":"95913","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":276.82,"maximum":712.35,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":369.09,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":712.35,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":276.82,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":376.48,"additional_payer_notes":"APC"}]}]},{"description":"C motor evoked lwr limbs","code_information":[{"code":"95929","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":276.82,"maximum":712.35,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":369.09,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":712.35,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":276.82,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":376.48,"additional_payer_notes":"APC"}]}]},{"description":"EEG monitoring/giving drugs","code_information":[{"code":"95954","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":276.82,"maximum":712.35,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":369.09,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":712.35,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":276.82,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":376.48,"additional_payer_notes":"APC"}]}]},{"description":"Motion analysis video/3d","code_information":[{"code":"96000","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":276.82,"maximum":712.35,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":369.09,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":712.35,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":276.82,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":376.48,"additional_payer_notes":"APC"}]}]},{"description":"Nrpsyc tst eval phys/qhp 1st","code_information":[{"code":"96132","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":276.82,"maximum":712.35,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":369.09,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":712.35,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":276.82,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":376.48,"additional_payer_notes":"APC"}]}]},{"description":"Pre-op service LVRS complete","code_information":[{"code":"G0302","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":276.82,"maximum":712.35,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":369.09,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":712.35,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":276.82,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":376.48,"additional_payer_notes":"APC"}]}]},{"description":"Pre-op service LVRS 1-9 dos","code_information":[{"code":"G0304","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":276.82,"maximum":712.35,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":369.09,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":712.35,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":276.82,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":376.48,"additional_payer_notes":"APC"}]}]},{"description":"Post op service LVRS min 6","code_information":[{"code":"G0305","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":276.82,"maximum":712.35,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":369.09,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":712.35,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":276.82,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":376.48,"additional_payer_notes":"APC"}]}]},{"description":"Blinded conv. Tx MDD clin tr","code_information":[{"code":"G2000","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":276.82,"maximum":712.35,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":369.09,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":712.35,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":276.82,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":376.48,"additional_payer_notes":"APC"}]}]},{"description":"N-invas augmnt arrhyt alys","code_information":[{"code":"0897T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":637.04,"maximum":1639.32,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":849.39,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1639.32,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":637.04,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":866.38,"additional_payer_notes":"APC"}]}]},{"description":"N-invas prst8 cancer est map","code_information":[{"code":"0898T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":637.04,"maximum":1639.32,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":849.39,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1639.32,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":637.04,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":866.38,"additional_payer_notes":"APC"}]}]},{"description":"Electroconvulsive therapy","code_information":[{"code":"90870","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":637.04,"maximum":1639.32,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":849.39,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1639.32,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":637.04,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":866.38,"additional_payer_notes":"APC"}]}]},{"description":"Percut allergy skin tests","code_information":[{"code":"95004","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":637.04,"maximum":1639.32,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":849.39,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1639.32,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":637.04,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":866.38,"additional_payer_notes":"APC"}]}]},{"description":"Allergy patch tests","code_information":[{"code":"95044","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":637.04,"maximum":1639.32,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":849.39,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1639.32,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":637.04,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":866.38,"additional_payer_notes":"APC"}]}]},{"description":"Veeg ea 12-26hr cont mntr","code_information":[{"code":"95716","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":637.04,"maximum":1639.32,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":849.39,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1639.32,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":637.04,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":866.38,"additional_payer_notes":"APC"}]}]},{"description":"Polysom <6 yrs 4/> paramtrs","code_information":[{"code":"95782","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":637.04,"maximum":1639.32,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":849.39,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1639.32,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":637.04,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":866.38,"additional_payer_notes":"APC"}]}]},{"description":"Polysom <6 yrs cpap/bilvl","code_information":[{"code":"95783","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":637.04,"maximum":1639.32,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":849.39,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1639.32,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":637.04,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":866.38,"additional_payer_notes":"APC"}]}]},{"description":"Multiple sleep latency test","code_information":[{"code":"95805","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":637.04,"maximum":1639.32,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":849.39,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1639.32,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":637.04,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":866.38,"additional_payer_notes":"APC"}]}]},{"description":"Polysom any age 1-3> param","code_information":[{"code":"95808","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":637.04,"maximum":1639.32,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":849.39,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1639.32,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":637.04,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":866.38,"additional_payer_notes":"APC"}]}]},{"description":"Polysom 6/> yrs 4/> param","code_information":[{"code":"95810","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":637.04,"maximum":1639.32,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":849.39,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1639.32,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":637.04,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":866.38,"additional_payer_notes":"APC"}]}]},{"description":"Polysom 6/>yrs cpap 4/> parm","code_information":[{"code":"95811","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":637.04,"maximum":1639.32,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":849.39,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1639.32,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":637.04,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":866.38,"additional_payer_notes":"APC"}]}]},{"description":"C motor evoked uppr limbs","code_information":[{"code":"95928","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":637.04,"maximum":1639.32,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":849.39,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1639.32,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":637.04,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":866.38,"additional_payer_notes":"APC"}]}]},{"description":"Somatosensory testing","code_information":[{"code":"95938","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":637.04,"maximum":1639.32,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":849.39,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1639.32,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":637.04,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":866.38,"additional_payer_notes":"APC"}]}]},{"description":"C motor evoked upr&lwr limbs","code_information":[{"code":"95939","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":637.04,"maximum":1639.32,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":849.39,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1639.32,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":637.04,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":866.38,"additional_payer_notes":"APC"}]}]},{"description":"EEG monitoring/function test","code_information":[{"code":"95958","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":637.04,"maximum":1639.32,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":849.39,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1639.32,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":637.04,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":866.38,"additional_payer_notes":"APC"}]}]},{"description":"Electrode stimulation brain","code_information":[{"code":"95961","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":637.04,"maximum":1639.32,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":849.39,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1639.32,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":637.04,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":866.38,"additional_payer_notes":"APC"}]}]},{"description":"Meg spontaneous","code_information":[{"code":"95965","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":637.04,"maximum":1639.32,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":849.39,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1639.32,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":637.04,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":866.38,"additional_payer_notes":"APC"}]}]},{"description":"Meg evoked single","code_information":[{"code":"95966","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":637.04,"maximum":1639.32,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":849.39,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1639.32,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":637.04,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":866.38,"additional_payer_notes":"APC"}]}]},{"description":"Motion test w/ft press meas","code_information":[{"code":"96001","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":637.04,"maximum":1639.32,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":849.39,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1639.32,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":637.04,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":866.38,"additional_payer_notes":"APC"}]}]},{"description":"Pre-plan 3d model w/ccta","code_information":[{"code":"C9793","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":637.04,"maximum":1639.32,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":849.39,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1639.32,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":637.04,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":866.38,"additional_payer_notes":"APC"}]}]},{"description":"Replacment pt electronic sys","code_information":[{"code":"G0555","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":637.04,"maximum":1639.32,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":849.39,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1639.32,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":637.04,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":866.38,"additional_payer_notes":"APC"}]}]},{"description":"BIA whole body","code_information":[{"code":"0358T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":21.46,"maximum":55.21,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":28.61,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":55.21,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21.46,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":29.18,"additional_payer_notes":"APC"}]}]},{"description":"Interrog dev eval wcs ip","code_information":[{"code":"0521T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":21.46,"maximum":55.21,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":28.61,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":55.21,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21.46,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":29.18,"additional_payer_notes":"APC"}]}]},{"description":"Air displacmnt plethysmograp","code_information":[{"code":"1002T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":21.46,"maximum":55.21,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":28.61,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":55.21,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21.46,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":29.18,"additional_payer_notes":"APC"}]}]},{"description":"Eye service or procedure","code_information":[{"code":"92499","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":21.46,"maximum":55.21,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":28.61,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":55.21,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21.46,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":29.18,"additional_payer_notes":"APC"}]}]},{"description":"Ent procedure/service","code_information":[{"code":"92700","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":21.46,"maximum":55.21,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":28.61,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":55.21,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21.46,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":29.18,"additional_payer_notes":"APC"}]}]},{"description":"Art pressure waveform analys","code_information":[{"code":"93050","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":21.46,"maximum":55.21,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":28.61,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":55.21,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21.46,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":29.18,"additional_payer_notes":"APC"}]}]},{"description":"Ilr device interrogate","code_information":[{"code":"93291","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":21.46,"maximum":55.21,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":28.61,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":55.21,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21.46,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":29.18,"additional_payer_notes":"APC"}]}]},{"description":"Noninvas vasc dx study proc","code_information":[{"code":"93998","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":21.46,"maximum":55.21,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":28.61,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":55.21,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21.46,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":29.18,"additional_payer_notes":"APC"}]}]},{"description":"Perq & icut allg test venoms","code_information":[{"code":"95017","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":21.46,"maximum":55.21,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":28.61,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":55.21,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21.46,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":29.18,"additional_payer_notes":"APC"}]}]},{"description":"Icut allergy titrate-airborn","code_information":[{"code":"95027","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":21.46,"maximum":55.21,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":28.61,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":55.21,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21.46,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":29.18,"additional_payer_notes":"APC"}]}]},{"description":"Allergy immunology services","code_information":[{"code":"95199","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":21.46,"maximum":55.21,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":28.61,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":55.21,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21.46,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":29.18,"additional_payer_notes":"APC"}]}]},{"description":"Psycl/nrpsyc tst auto result","code_information":[{"code":"96146","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":21.46,"maximum":55.21,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":28.61,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":55.21,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21.46,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":29.18,"additional_payer_notes":"APC"}]}]},{"description":"Acupunct w/o stimul 15 min","code_information":[{"code":"97810","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":21.46,"maximum":55.21,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":28.61,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":55.21,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21.46,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":29.18,"additional_payer_notes":"APC"}]}]},{"description":"Acupunct w/stimul 15 min","code_information":[{"code":"97813","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":21.46,"maximum":55.21,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":28.61,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":55.21,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21.46,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":29.18,"additional_payer_notes":"APC"}]}]},{"description":"Self-meas bp pt educaj/train","code_information":[{"code":"99473","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":21.46,"maximum":55.21,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":28.61,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":55.21,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21.46,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":29.18,"additional_payer_notes":"APC"}]}]},{"description":"Glaucoma scrn hgh risk direc","code_information":[{"code":"G0117","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":21.46,"maximum":55.21,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":28.61,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":55.21,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21.46,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":29.18,"additional_payer_notes":"APC"}]}]},{"description":"Therapeutic procd strg endur","code_information":[{"code":"G0237","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":21.46,"maximum":55.21,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":28.61,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":55.21,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21.46,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":29.18,"additional_payer_notes":"APC"}]}]},{"description":"Oth resp proc, indiv","code_information":[{"code":"G0238","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":21.46,"maximum":55.21,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":28.61,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":55.21,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21.46,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":29.18,"additional_payer_notes":"APC"}]}]},{"description":"EKG tracing for initial prev","code_information":[{"code":"G0404","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":21.46,"maximum":55.21,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":28.61,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":55.21,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21.46,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":29.18,"additional_payer_notes":"APC"}]}]},{"description":"No pt prsnt train initial 30","code_information":[{"code":"G0541","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":21.46,"maximum":55.21,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":28.61,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":55.21,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21.46,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":29.18,"additional_payer_notes":"APC"}]}]},{"description":"Group train w/o patient","code_information":[{"code":"G0543","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":21.46,"maximum":55.21,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":28.61,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":55.21,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21.46,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":29.18,"additional_payer_notes":"APC"}]}]},{"description":"Alcohol/sub abuse assess","code_information":[{"code":"G2011","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":21.46,"maximum":55.21,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":28.61,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":55.21,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21.46,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":29.18,"additional_payer_notes":"APC"}]}]},{"description":"Touch Quant Sensory Test","code_information":[{"code":"0106T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":27.71,"maximum":71.3,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":36.94,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":71.3,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27.71,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":37.68,"additional_payer_notes":"APC"}]}]},{"description":"Vibrate Quant Sensory Test","code_information":[{"code":"0107T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":27.71,"maximum":71.3,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":36.94,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":71.3,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27.71,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":37.68,"additional_payer_notes":"APC"}]}]},{"description":"Heat Quant Sensory Test","code_information":[{"code":"0109T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":27.71,"maximum":71.3,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":36.94,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":71.3,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27.71,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":37.68,"additional_payer_notes":"APC"}]}]},{"description":"Audiometry air only","code_information":[{"code":"0208T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":27.71,"maximum":71.3,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":36.94,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":71.3,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27.71,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":37.68,"additional_payer_notes":"APC"}]}]},{"description":"Audiometry air & bone","code_information":[{"code":"0209T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":27.71,"maximum":71.3,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":36.94,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":71.3,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27.71,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":37.68,"additional_payer_notes":"APC"}]}]},{"description":"Speech audiometry threshold","code_information":[{"code":"0210T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":27.71,"maximum":71.3,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":36.94,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":71.3,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27.71,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":37.68,"additional_payer_notes":"APC"}]}]},{"description":"Speech audiom thresh & recog","code_information":[{"code":"0211T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":27.71,"maximum":71.3,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":36.94,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":71.3,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27.71,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":37.68,"additional_payer_notes":"APC"}]}]},{"description":"Vis field assmnt tech suppt","code_information":[{"code":"0379T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":27.71,"maximum":71.3,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":36.94,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":71.3,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27.71,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":37.68,"additional_payer_notes":"APC"}]}]},{"description":"Ncntc nr ifr spctrsc wnd","code_information":[{"code":"0640T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":27.71,"maximum":71.3,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":36.94,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":71.3,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27.71,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":37.68,"additional_payer_notes":"APC"}]}]},{"description":"Surf radj ther tx planning","code_information":[{"code":"77436","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":27.71,"maximum":71.3,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":36.94,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":71.3,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27.71,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":37.68,"additional_payer_notes":"APC"}]}]},{"description":"Remote retinal imaging mgmt","code_information":[{"code":"92228","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":27.71,"maximum":71.3,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":36.94,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":71.3,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27.71,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":37.68,"additional_payer_notes":"APC"}]}]},{"description":"Ophthalmoscopy/dynamometry","code_information":[{"code":"92260","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":27.71,"maximum":71.3,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":36.94,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":71.3,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27.71,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":37.68,"additional_payer_notes":"APC"}]}]},{"description":"Eye photography","code_information":[{"code":"92285","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":27.71,"maximum":71.3,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":36.94,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":71.3,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27.71,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":37.68,"additional_payer_notes":"APC"}]}]},{"description":"Rx corneoscleral cntact lens","code_information":[{"code":"92317","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":27.71,"maximum":71.3,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":36.94,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":71.3,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27.71,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":37.68,"additional_payer_notes":"APC"}]}]},{"description":"Fit spectacles single system","code_information":[{"code":"92354","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":27.71,"maximum":71.3,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":36.94,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":71.3,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27.71,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":37.68,"additional_payer_notes":"APC"}]}]},{"description":"Fit spectacles compound lens","code_information":[{"code":"92355","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":27.71,"maximum":71.3,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":36.94,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":71.3,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27.71,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":37.68,"additional_payer_notes":"APC"}]}]},{"description":"Tone decay hearing test","code_information":[{"code":"92563","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":27.71,"maximum":71.3,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":36.94,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":71.3,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27.71,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":37.68,"additional_payer_notes":"APC"}]}]},{"description":"Tympanometry","code_information":[{"code":"92567","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":27.71,"maximum":71.3,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":36.94,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":71.3,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27.71,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":37.68,"additional_payer_notes":"APC"}]}]},{"description":"Acoustic refl threshold tst","code_information":[{"code":"92568","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":27.71,"maximum":71.3,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":36.94,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":71.3,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27.71,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":37.68,"additional_payer_notes":"APC"}]}]},{"description":"Filtered speech hearing test","code_information":[{"code":"92571","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":27.71,"maximum":71.3,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":36.94,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":71.3,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27.71,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":37.68,"additional_payer_notes":"APC"}]}]},{"description":"Sensorineural acuity test","code_information":[{"code":"92575","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":27.71,"maximum":71.3,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":36.94,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":71.3,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27.71,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":37.68,"additional_payer_notes":"APC"}]}]},{"description":"Synthetic sentence test","code_information":[{"code":"92576","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":27.71,"maximum":71.3,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":36.94,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":71.3,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27.71,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":37.68,"additional_payer_notes":"APC"}]}]},{"description":"Ear protector evaluation","code_information":[{"code":"92596","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":27.71,"maximum":71.3,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":36.94,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":71.3,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27.71,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":37.68,"additional_payer_notes":"APC"}]}]},{"description":"Ext ecg>48hr<7d recording","code_information":[{"code":"93242","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":27.71,"maximum":71.3,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":36.94,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":71.3,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27.71,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":37.68,"additional_payer_notes":"APC"}]}]},{"description":"Ext ecg>7d<15d recording","code_information":[{"code":"93246","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":27.71,"maximum":71.3,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":36.94,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":71.3,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27.71,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":37.68,"additional_payer_notes":"APC"}]}]},{"description":"Car seat/bed test 60 min","code_information":[{"code":"94780","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":27.71,"maximum":71.3,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":36.94,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":71.3,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27.71,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":37.68,"additional_payer_notes":"APC"}]}]},{"description":"Exhaled Nitric Oxide Meas","code_information":[{"code":"95012","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":27.71,"maximum":71.3,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":36.94,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":71.3,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27.71,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":37.68,"additional_payer_notes":"APC"}]}]},{"description":"Perq&ic allg test drugs/biol","code_information":[{"code":"95018","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":27.71,"maximum":71.3,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":36.94,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":71.3,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27.71,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":37.68,"additional_payer_notes":"APC"}]}]},{"description":"Icut allergy test-delayed","code_information":[{"code":"95028","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":27.71,"maximum":71.3,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":36.94,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":71.3,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27.71,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":37.68,"additional_payer_notes":"APC"}]}]},{"description":"Nose allergy test","code_information":[{"code":"95065","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":27.71,"maximum":71.3,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":36.94,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":71.3,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27.71,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":37.68,"additional_payer_notes":"APC"}]}]},{"description":"Brief emotional/behav assmt","code_information":[{"code":"96127","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":27.71,"maximum":71.3,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":36.94,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":71.3,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27.71,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":37.68,"additional_payer_notes":"APC"}]}]},{"description":"Ultraviolet light therapy","code_information":[{"code":"96900","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":27.71,"maximum":71.3,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":36.94,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":71.3,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27.71,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":37.68,"additional_payer_notes":"APC"}]}]},{"description":"Appl modality 1+lllt po pain","code_information":[{"code":"97037","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":27.71,"maximum":71.3,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":36.94,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":71.3,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27.71,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":37.68,"additional_payer_notes":"APC"}]}]},{"description":"Glaucoma scrn hgh risk direc","code_information":[{"code":"G0118","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":27.71,"maximum":71.3,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":36.94,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":71.3,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27.71,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":37.68,"additional_payer_notes":"APC"}]}]},{"description":"Oth resp proc, group","code_information":[{"code":"G0239","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":27.71,"maximum":71.3,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":36.94,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":71.3,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27.71,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":37.68,"additional_payer_notes":"APC"}]}]},{"description":"Non-cov surg proc,clin trial","code_information":[{"code":"G0293","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":27.71,"maximum":71.3,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":36.94,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":71.3,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27.71,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":37.68,"additional_payer_notes":"APC"}]}]},{"description":"Non-cov proc, clinical trial","code_information":[{"code":"G0294","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":27.71,"maximum":71.3,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":36.94,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":71.3,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27.71,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":37.68,"additional_payer_notes":"APC"}]}]},{"description":"Cool Quant Sensory Test","code_information":[{"code":"0108T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":43.76,"maximum":112.62,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":58.35,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":112.62,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":43.76,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":59.52,"additional_payer_notes":"APC"}]}]},{"description":"Mac pgmt opt dns meas hfp","code_information":[{"code":"0506T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":43.76,"maximum":112.62,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":58.35,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":112.62,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":43.76,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":59.52,"additional_payer_notes":"APC"}]}]},{"description":"Near ifr 2img mibmn glnd i&r","code_information":[{"code":"0507T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":43.76,"maximum":112.62,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":58.35,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":112.62,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":43.76,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":59.52,"additional_payer_notes":"APC"}]}]},{"description":"Augmnt ai-based fcl phnt a/r","code_information":[{"code":"0731T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":43.76,"maximum":112.62,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":58.35,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":112.62,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":43.76,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":59.52,"additional_payer_notes":"APC"}]}]},{"description":"Rem auton alg nsln cal setup","code_information":[{"code":"0740T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":43.76,"maximum":112.62,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":58.35,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":112.62,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":43.76,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":59.52,"additional_payer_notes":"APC"}]}]},{"description":"Ecg alg 12 ld rdcd trcg only","code_information":[{"code":"0904T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":43.76,"maximum":112.62,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":58.35,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":112.62,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":43.76,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":59.52,"additional_payer_notes":"APC"}]}]},{"description":"Elec aly nstm sys vgs nrv wo","code_information":[{"code":"0911T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":43.76,"maximum":112.62,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":58.35,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":112.62,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":43.76,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":59.52,"additional_payer_notes":"APC"}]}]},{"description":"Raman spectroscopy 1+skn les","code_information":[{"code":"1020T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":43.76,"maximum":112.62,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":58.35,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":112.62,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":43.76,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":59.52,"additional_payer_notes":"APC"}]}]},{"description":"Corneal Topography","code_information":[{"code":"92025","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":43.76,"maximum":112.62,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":58.35,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":112.62,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":43.76,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":59.52,"additional_payer_notes":"APC"}]}]},{"description":"Special eye evaluation","code_information":[{"code":"92060","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":43.76,"maximum":112.62,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":58.35,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":112.62,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":43.76,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":59.52,"additional_payer_notes":"APC"}]}]},{"description":"Orthop traing supvj phys/qhp","code_information":[{"code":"92066","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":43.76,"maximum":112.62,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":58.35,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":112.62,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":43.76,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":59.52,"additional_payer_notes":"APC"}]}]},{"description":"Visual field examination(s)","code_information":[{"code":"92081","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":43.76,"maximum":112.62,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":58.35,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":112.62,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":43.76,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":59.52,"additional_payer_notes":"APC"}]}]},{"description":"Visual field examination(s)","code_information":[{"code":"92082","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":43.76,"maximum":112.62,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":58.35,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":112.62,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":43.76,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":59.52,"additional_payer_notes":"APC"}]}]},{"description":"Cmptr ophth dx img ant segmt","code_information":[{"code":"92132","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":43.76,"maximum":112.62,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":58.35,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":112.62,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":43.76,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":59.52,"additional_payer_notes":"APC"}]}]},{"description":"Cmptr ophth img optic nerve","code_information":[{"code":"92133","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":43.76,"maximum":112.62,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":58.35,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":112.62,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":43.76,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":59.52,"additional_payer_notes":"APC"}]}]},{"description":"Cptr ophth dx img post segmt","code_information":[{"code":"92134","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":43.76,"maximum":112.62,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":58.35,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":112.62,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":43.76,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":59.52,"additional_payer_notes":"APC"}]}]},{"description":"Corneal hysteresis deter","code_information":[{"code":"92145","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":43.76,"maximum":112.62,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":58.35,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":112.62,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":43.76,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":59.52,"additional_payer_notes":"APC"}]}]},{"description":"Opscpy extnd rta draw uni/bi","code_information":[{"code":"92201","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":43.76,"maximum":112.62,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":58.35,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":112.62,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":43.76,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":59.52,"additional_payer_notes":"APC"}]}]},{"description":"Opscpy extnd on/mac draw","code_information":[{"code":"92202","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":43.76,"maximum":112.62,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":58.35,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":112.62,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":43.76,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":59.52,"additional_payer_notes":"APC"}]}]},{"description":"Remote dx retinal imaging","code_information":[{"code":"92227","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":43.76,"maximum":112.62,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":58.35,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":112.62,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":43.76,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":59.52,"additional_payer_notes":"APC"}]}]},{"description":"Img rta detc/mntr ds poc aly","code_information":[{"code":"92229","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":43.76,"maximum":112.62,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":58.35,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":112.62,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":43.76,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":59.52,"additional_payer_notes":"APC"}]}]},{"description":"Eye muscle evaluation","code_information":[{"code":"92265","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":43.76,"maximum":112.62,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":58.35,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":112.62,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":43.76,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":59.52,"additional_payer_notes":"APC"}]}]},{"description":"Color vision examination","code_information":[{"code":"92283","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":43.76,"maximum":112.62,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":58.35,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":112.62,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":43.76,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":59.52,"additional_payer_notes":"APC"}]}]},{"description":"Replacement of contact lens","code_information":[{"code":"92326","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":43.76,"maximum":112.62,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":58.35,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":112.62,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":43.76,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":59.52,"additional_payer_notes":"APC"}]}]},{"description":"Fit aphakia spectcl monofocl","code_information":[{"code":"92352","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":43.76,"maximum":112.62,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":58.35,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":112.62,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":43.76,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":59.52,"additional_payer_notes":"APC"}]}]},{"description":"Fit aphakia spectcl multifoc","code_information":[{"code":"92353","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":43.76,"maximum":112.62,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":58.35,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":112.62,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":43.76,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":59.52,"additional_payer_notes":"APC"}]}]},{"description":"Aphakia prosth service temp","code_information":[{"code":"92358","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":43.76,"maximum":112.62,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":58.35,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":112.62,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":43.76,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":59.52,"additional_payer_notes":"APC"}]}]},{"description":"Repair & adjust spectacles","code_information":[{"code":"92371","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":43.76,"maximum":112.62,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":58.35,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":112.62,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":43.76,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":59.52,"additional_payer_notes":"APC"}]}]},{"description":"Speech threshold audiometry","code_information":[{"code":"92555","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":43.76,"maximum":112.62,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":58.35,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":112.62,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":43.76,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":59.52,"additional_payer_notes":"APC"}]}]},{"description":"Speech audiometry complete","code_information":[{"code":"92556","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":43.76,"maximum":112.62,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":58.35,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":112.62,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":43.76,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":59.52,"additional_payer_notes":"APC"}]}]},{"description":"Stenger test pure tone","code_information":[{"code":"92565","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":43.76,"maximum":112.62,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":58.35,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":112.62,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":43.76,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":59.52,"additional_payer_notes":"APC"}]}]},{"description":"Select picture audiometry","code_information":[{"code":"92583","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":43.76,"maximum":112.62,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":58.35,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":112.62,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":43.76,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":59.52,"additional_payer_notes":"APC"}]}]},{"description":"Electrocardiogram tracing","code_information":[{"code":"93005","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":43.76,"maximum":112.62,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":58.35,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":112.62,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":43.76,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":59.52,"additional_payer_notes":"APC"}]}]},{"description":"Rhythm ecg tracing","code_information":[{"code":"93041","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":43.76,"maximum":112.62,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":58.35,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":112.62,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":43.76,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":59.52,"additional_payer_notes":"APC"}]}]},{"description":"Ecg monit/reprt up to 48 hrs","code_information":[{"code":"93226","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":43.76,"maximum":112.62,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":58.35,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":112.62,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":43.76,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":59.52,"additional_payer_notes":"APC"}]}]},{"description":"ECG/signal-averaged","code_information":[{"code":"93278","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":43.76,"maximum":112.62,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":58.35,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":112.62,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":43.76,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":59.52,"additional_payer_notes":"APC"}]}]},{"description":"Peripheral Vascular Rehab","code_information":[{"code":"93668","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":43.76,"maximum":112.62,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":58.35,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":112.62,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":43.76,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":59.52,"additional_payer_notes":"APC"}]}]},{"description":"Lung function test (MBC/MVV)","code_information":[{"code":"94200","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":43.76,"maximum":112.62,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":58.35,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":112.62,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":43.76,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":59.52,"additional_payer_notes":"APC"}]}]},{"description":"Exercise tst brncspsm wo ecg","code_information":[{"code":"94619","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":43.76,"maximum":112.62,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":58.35,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":112.62,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":43.76,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":59.52,"additional_payer_notes":"APC"}]}]},{"description":"Phy/qhp op pulm rhb w/o mntr","code_information":[{"code":"94625","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":43.76,"maximum":112.62,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":58.35,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":112.62,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":43.76,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":59.52,"additional_payer_notes":"APC"}]}]},{"description":"Phy/qhp op pulm rhb w/mntr","code_information":[{"code":"94626","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":43.76,"maximum":112.62,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":58.35,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":112.62,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":43.76,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":59.52,"additional_payer_notes":"APC"}]}]},{"description":"Exhaled air analysis","code_information":[{"code":"94690","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":43.76,"maximum":112.62,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":58.35,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":112.62,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":43.76,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":59.52,"additional_payer_notes":"APC"}]}]},{"description":"Icut allergy test drug/bug","code_information":[{"code":"95024","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":43.76,"maximum":112.62,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":58.35,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":112.62,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":43.76,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":59.52,"additional_payer_notes":"APC"}]}]},{"description":"Photo patch test","code_information":[{"code":"95052","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":43.76,"maximum":112.62,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":58.35,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":112.62,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":43.76,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":59.52,"additional_payer_notes":"APC"}]}]},{"description":"Cont gluc mntr pt prov eqp","code_information":[{"code":"95249","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":43.76,"maximum":112.62,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":58.35,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":112.62,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":43.76,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":59.52,"additional_payer_notes":"APC"}]}]},{"description":"Slp stdy unatnd w/anal","code_information":[{"code":"95801","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":43.76,"maximum":112.62,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":58.35,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":112.62,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":43.76,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":59.52,"additional_payer_notes":"APC"}]}]},{"description":"Actigraphy testing","code_information":[{"code":"95803","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":43.76,"maximum":112.62,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":58.35,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":112.62,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":43.76,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":59.52,"additional_payer_notes":"APC"}]}]},{"description":"Blink reflex test","code_information":[{"code":"95933","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":43.76,"maximum":112.62,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":58.35,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":112.62,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":43.76,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":59.52,"additional_payer_notes":"APC"}]}]},{"description":"Io anal gast n-stim subsq","code_information":[{"code":"95981","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":43.76,"maximum":112.62,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":58.35,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":112.62,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":43.76,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":59.52,"additional_payer_notes":"APC"}]}]},{"description":"Irrig drug delivery device","code_information":[{"code":"96523","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":43.76,"maximum":112.62,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":58.35,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":112.62,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":43.76,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":59.52,"additional_payer_notes":"APC"}]}]},{"description":"Photochemotherapy with UV-B","code_information":[{"code":"96910","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":43.76,"maximum":112.62,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":58.35,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":112.62,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":43.76,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":59.52,"additional_payer_notes":"APC"}]}]},{"description":"Photochemotherapy with UV-A","code_information":[{"code":"96912","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":43.76,"maximum":112.62,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":58.35,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":112.62,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":43.76,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":59.52,"additional_payer_notes":"APC"}]}]},{"description":"Nos Quant Sensory Test","code_information":[{"code":"0110T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":98.7,"maximum":253.99,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":131.6,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":253.99,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":98.7,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":134.23,"additional_payer_notes":"APC"}]}]},{"description":"Ocular blood flow measure","code_information":[{"code":"0198T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":98.7,"maximum":253.99,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":131.6,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":253.99,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":98.7,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":134.23,"additional_payer_notes":"APC"}]}]},{"description":"Eye mvmt alys w/o calbrj i&r","code_information":[{"code":"0615T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":98.7,"maximum":253.99,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":131.6,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":253.99,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":98.7,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":134.23,"additional_payer_notes":"APC"}]}]},{"description":"Asstv alg ecg rsk asmt cncrt","code_information":[{"code":"0764T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":98.7,"maximum":253.99,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":131.6,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":253.99,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":98.7,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":134.23,"additional_payer_notes":"APC"}]}]},{"description":"Asstv alg ecg rsk asmt prev","code_information":[{"code":"0765T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":98.7,"maximum":253.99,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":131.6,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":253.99,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":98.7,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":134.23,"additional_payer_notes":"APC"}]}]},{"description":"Instlj fecal microbiota ssp","code_information":[{"code":"0780T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":98.7,"maximum":253.99,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":131.6,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":253.99,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":98.7,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":134.23,"additional_payer_notes":"APC"}]}]},{"description":"N-invas assmt bld oxygnation","code_information":[{"code":"0893T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":98.7,"maximum":253.99,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":131.6,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":253.99,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":98.7,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":134.23,"additional_payer_notes":"APC"}]}]},{"description":"Qtc ntrvl augmnt alg aly ecg","code_information":[{"code":"0902T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":98.7,"maximum":253.99,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":131.6,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":253.99,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":98.7,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":134.23,"additional_payer_notes":"APC"}]}]},{"description":"Asstv alg alys acous&ecg rec","code_information":[{"code":"0962T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":98.7,"maximum":253.99,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":131.6,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":253.99,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":98.7,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":134.23,"additional_payer_notes":"APC"}]}]},{"description":"Elec alys s-scl eeg wo prgrm","code_information":[{"code":"1004T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":98.7,"maximum":253.99,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":131.6,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":253.99,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":98.7,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":134.23,"additional_payer_notes":"APC"}]}]},{"description":"Cptr oph alys monoc eye mvmt","code_information":[{"code":"1010T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":98.7,"maximum":253.99,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":131.6,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":253.99,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":98.7,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":134.23,"additional_payer_notes":"APC"}]}]},{"description":"Augmnt alg alys enceph wvfrm","code_information":[{"code":"1041T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":98.7,"maximum":253.99,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":131.6,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":253.99,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":98.7,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":134.23,"additional_payer_notes":"APC"}]}]},{"description":"Special eye evaluation","code_information":[{"code":"92020","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":98.7,"maximum":253.99,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":131.6,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":253.99,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":98.7,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":134.23,"additional_payer_notes":"APC"}]}]},{"description":"Visual field examination(s)","code_information":[{"code":"92083","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":98.7,"maximum":253.99,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":131.6,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":253.99,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":98.7,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":134.23,"additional_payer_notes":"APC"}]}]},{"description":"Ophthalmic biometry","code_information":[{"code":"92136","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":98.7,"maximum":253.99,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":131.6,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":253.99,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":98.7,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":134.23,"additional_payer_notes":"APC"}]}]},{"description":"Eye exam with photos","code_information":[{"code":"92250","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":98.7,"maximum":253.99,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":131.6,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":253.99,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":98.7,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":134.23,"additional_payer_notes":"APC"}]}]},{"description":"Electro-oculography","code_information":[{"code":"92270","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":98.7,"maximum":253.99,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":131.6,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":253.99,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":98.7,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":134.23,"additional_payer_notes":"APC"}]}]},{"description":"Internal eye photography","code_information":[{"code":"92286","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":98.7,"maximum":253.99,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":131.6,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":253.99,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":98.7,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":134.23,"additional_payer_notes":"APC"}]}]},{"description":"Internal eye photography","code_information":[{"code":"92287","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":98.7,"maximum":253.99,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":131.6,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":253.99,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":98.7,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":134.23,"additional_payer_notes":"APC"}]}]},{"description":"Contact lens fitting","code_information":[{"code":"92312","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":98.7,"maximum":253.99,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":131.6,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":253.99,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":98.7,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":134.23,"additional_payer_notes":"APC"}]}]},{"description":"Contact lens fitting","code_information":[{"code":"92313","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":98.7,"maximum":253.99,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":131.6,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":253.99,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":98.7,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":134.23,"additional_payer_notes":"APC"}]}]},{"description":"Rx cntact lens aphakia 1 eye","code_information":[{"code":"92315","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":98.7,"maximum":253.99,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":131.6,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":253.99,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":98.7,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":134.23,"additional_payer_notes":"APC"}]}]},{"description":"Rx cntact lens aphakia 2 eye","code_information":[{"code":"92316","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":98.7,"maximum":253.99,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":131.6,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":253.99,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":98.7,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":134.23,"additional_payer_notes":"APC"}]}]},{"description":"Modification of contact lens","code_information":[{"code":"92325","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":98.7,"maximum":253.99,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":131.6,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":253.99,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":98.7,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":134.23,"additional_payer_notes":"APC"}]}]},{"description":"Laryngeal function studies","code_information":[{"code":"92520","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":98.7,"maximum":253.99,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":131.6,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":253.99,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":98.7,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":134.23,"additional_payer_notes":"APC"}]}]},{"description":"Spontaneous nystagmus test","code_information":[{"code":"92541","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":98.7,"maximum":253.99,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":131.6,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":253.99,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":98.7,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":134.23,"additional_payer_notes":"APC"}]}]},{"description":"Positional nystagmus test","code_information":[{"code":"92542","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":98.7,"maximum":253.99,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":131.6,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":253.99,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":98.7,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":134.23,"additional_payer_notes":"APC"}]}]},{"description":"Posturography","code_information":[{"code":"92548","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":98.7,"maximum":253.99,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":131.6,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":253.99,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":98.7,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":134.23,"additional_payer_notes":"APC"}]}]},{"description":"Cdp-sot 6 cond w/i&r mct&adt","code_information":[{"code":"92549","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":98.7,"maximum":253.99,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":131.6,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":253.99,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":98.7,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":134.23,"additional_payer_notes":"APC"}]}]},{"description":"Pure tone audiometry air","code_information":[{"code":"92552","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":98.7,"maximum":253.99,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":131.6,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":253.99,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":98.7,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":134.23,"additional_payer_notes":"APC"}]}]},{"description":"Ecg monit/reprt up to 48 hrs","code_information":[{"code":"93225","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":98.7,"maximum":253.99,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":131.6,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":253.99,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":98.7,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":134.23,"additional_payer_notes":"APC"}]}]},{"description":"Ext ecg>48hr<7d scan a/r","code_information":[{"code":"93243","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":98.7,"maximum":253.99,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":131.6,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":253.99,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":98.7,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":134.23,"additional_payer_notes":"APC"}]}]},{"description":"Ext ecg>7d<15d scan a/r","code_information":[{"code":"93247","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":98.7,"maximum":253.99,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":131.6,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":253.99,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":98.7,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":134.23,"additional_payer_notes":"APC"}]}]},{"description":"Bioimpedance cv analysis","code_information":[{"code":"93701","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":98.7,"maximum":253.99,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":131.6,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":253.99,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":98.7,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":134.23,"additional_payer_notes":"APC"}]}]},{"description":"Ambulatory BP recording","code_information":[{"code":"93786","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":98.7,"maximum":253.99,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":131.6,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":253.99,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":98.7,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":134.23,"additional_payer_notes":"APC"}]}]},{"description":"Ambulatory BP analysis","code_information":[{"code":"93788","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":98.7,"maximum":253.99,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":131.6,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":253.99,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":98.7,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":134.23,"additional_payer_notes":"APC"}]}]},{"description":"Upr/l xtremity art 2 levels","code_information":[{"code":"93922","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":98.7,"maximum":253.99,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":131.6,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":253.99,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":98.7,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":134.23,"additional_payer_notes":"APC"}]}]},{"description":"Hast w/report","code_information":[{"code":"94452","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":98.7,"maximum":253.99,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":131.6,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":253.99,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":98.7,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":134.23,"additional_payer_notes":"APC"}]}]},{"description":"Hast w/oxygen titrate","code_information":[{"code":"94453","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":98.7,"maximum":253.99,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":131.6,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":253.99,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":98.7,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":134.23,"additional_payer_notes":"APC"}]}]},{"description":"Exercise tst brncspsm","code_information":[{"code":"94617","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":98.7,"maximum":253.99,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":131.6,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":253.99,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":98.7,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":134.23,"additional_payer_notes":"APC"}]}]},{"description":"Pulmonary stress testing","code_information":[{"code":"94618","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":98.7,"maximum":253.99,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":131.6,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":253.99,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":98.7,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":134.23,"additional_payer_notes":"APC"}]}]},{"description":"Cbt 1st hour","code_information":[{"code":"94644","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":98.7,"maximum":253.99,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":131.6,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":253.99,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":98.7,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":134.23,"additional_payer_notes":"APC"}]}]},{"description":"Chest wall manipulation","code_information":[{"code":"94667","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":98.7,"maximum":253.99,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":131.6,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":253.99,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":98.7,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":134.23,"additional_payer_notes":"APC"}]}]},{"description":"Chest wall manipulation","code_information":[{"code":"94668","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":98.7,"maximum":253.99,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":131.6,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":253.99,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":98.7,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":134.23,"additional_payer_notes":"APC"}]}]},{"description":"Photosensitivity tests","code_information":[{"code":"95056","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":98.7,"maximum":253.99,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":131.6,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":253.99,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":98.7,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":134.23,"additional_payer_notes":"APC"}]}]},{"description":"Eye allergy tests","code_information":[{"code":"95060","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":98.7,"maximum":253.99,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":131.6,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":253.99,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":98.7,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":134.23,"additional_payer_notes":"APC"}]}]},{"description":"Muscle test one limb","code_information":[{"code":"95860","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":98.7,"maximum":253.99,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":131.6,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":253.99,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":98.7,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":134.23,"additional_payer_notes":"APC"}]}]},{"description":"Muscle test 2 limbs","code_information":[{"code":"95861","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":98.7,"maximum":253.99,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":131.6,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":253.99,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":98.7,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":134.23,"additional_payer_notes":"APC"}]}]},{"description":"Muscle test larynx","code_information":[{"code":"95865","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":98.7,"maximum":253.99,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":131.6,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":253.99,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":98.7,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":134.23,"additional_payer_notes":"APC"}]}]},{"description":"Muscle test nonparaspinal","code_information":[{"code":"95870","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":98.7,"maximum":253.99,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":131.6,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":253.99,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":98.7,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":134.23,"additional_payer_notes":"APC"}]}]},{"description":"Quan puplmtry phy/qhp uni/bi","code_information":[{"code":"95919","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":98.7,"maximum":253.99,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":131.6,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":253.99,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":98.7,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":134.23,"additional_payer_notes":"APC"}]}]},{"description":"Autonomic nrv adrenrg inervj","code_information":[{"code":"95922","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":98.7,"maximum":253.99,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":131.6,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":253.99,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":98.7,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":134.23,"additional_payer_notes":"APC"}]}]},{"description":"Autonomic nrv syst funj test","code_information":[{"code":"95923","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":98.7,"maximum":253.99,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":131.6,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":253.99,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":98.7,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":134.23,"additional_payer_notes":"APC"}]}]},{"description":"Analyze neurostim no prog","code_information":[{"code":"95970","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":98.7,"maximum":253.99,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":131.6,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":253.99,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":98.7,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":134.23,"additional_payer_notes":"APC"}]}]},{"description":"Psycl/nrpsyc tst phy/qhp 1st","code_information":[{"code":"96136","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":98.7,"maximum":253.99,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":131.6,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":253.99,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":98.7,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":134.23,"additional_payer_notes":"APC"}]}]},{"description":"Phlebotomy","code_information":[{"code":"99195","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":98.7,"maximum":253.99,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":131.6,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":253.99,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":98.7,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":134.23,"additional_payer_notes":"APC"}]}]},{"description":"Extrnl counterpulse, per tx","code_information":[{"code":"G0166","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":98.7,"maximum":253.99,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":131.6,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":253.99,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":98.7,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":134.23,"additional_payer_notes":"APC"}]}]},{"description":"Cryotherapy oral cavity","code_information":[{"code":"0881T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":331.39,"maximum":852.79,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":441.86,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":852.79,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":331.39,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":450.7,"additional_payer_notes":"APC"}]}]},{"description":"Dark adaptation eye exam","code_information":[{"code":"92284","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":331.39,"maximum":852.79,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":441.86,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":852.79,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":331.39,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":450.7,"additional_payer_notes":"APC"}]}]},{"description":"Contact lens fitting","code_information":[{"code":"92311","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":331.39,"maximum":852.79,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":441.86,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":852.79,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":331.39,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":450.7,"additional_payer_notes":"APC"}]}]},{"description":"Cardiac drug stress test","code_information":[{"code":"93024","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":331.39,"maximum":852.79,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":441.86,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":852.79,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":331.39,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":450.7,"additional_payer_notes":"APC"}]}]},{"description":"Patient recorded spirometry","code_information":[{"code":"94014","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":331.39,"maximum":852.79,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":441.86,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":852.79,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":331.39,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":450.7,"additional_payer_notes":"APC"}]}]},{"description":"Rapid desensitization","code_information":[{"code":"95180","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":331.39,"maximum":852.79,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":441.86,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":852.79,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":331.39,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":450.7,"additional_payer_notes":"APC"}]}]},{"description":"Motor &/ sens nrve cndj test","code_information":[{"code":"95905","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":331.39,"maximum":852.79,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":441.86,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":852.79,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":331.39,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":450.7,"additional_payer_notes":"APC"}]}]},{"description":"Psycl/nrpsyc tech 1st","code_information":[{"code":"96138","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":331.39,"maximum":852.79,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":441.86,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":852.79,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":331.39,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":450.7,"additional_payer_notes":"APC"}]}]},{"description":"Prgrmg eval cardiac modulj","code_information":[{"code":"0417T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":27.69,"maximum":71.25,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":36.92,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":71.25,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27.69,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":37.65,"additional_payer_notes":"APC"}]}]},{"description":"Interro eval cardiac modulj","code_information":[{"code":"0418T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":27.69,"maximum":71.25,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":36.92,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":71.25,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27.69,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":37.65,"additional_payer_notes":"APC"}]}]},{"description":"Prgrmg dev eval wcs ip","code_information":[{"code":"0522T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":27.69,"maximum":71.25,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":36.92,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":71.25,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27.69,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":37.65,"additional_payer_notes":"APC"}]}]},{"description":"Prgrmg dev eval iims ip","code_information":[{"code":"0528T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":27.69,"maximum":71.25,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":36.92,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":71.25,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27.69,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":37.65,"additional_payer_notes":"APC"}]}]},{"description":"Interrog dev eval iims ip","code_information":[{"code":"0529T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":27.69,"maximum":71.25,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":36.92,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":71.25,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27.69,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":37.65,"additional_payer_notes":"APC"}]}]},{"description":"Prgrmg dev eval icds ss ip","code_information":[{"code":"0575T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":27.69,"maximum":71.25,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":36.92,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":71.25,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27.69,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":37.65,"additional_payer_notes":"APC"}]}]},{"description":"Interrog dev eval icds ss ip","code_information":[{"code":"0576T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":27.69,"maximum":71.25,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":36.92,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":71.25,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27.69,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":37.65,"additional_payer_notes":"APC"}]}]},{"description":"Rem interrog dev icds tech","code_information":[{"code":"0579T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":27.69,"maximum":71.25,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":36.92,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":71.25,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27.69,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":37.65,"additional_payer_notes":"APC"}]}]},{"description":"Prgrmg dev eval scrms remote","code_information":[{"code":"0650T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":27.69,"maximum":71.25,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":36.92,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":71.25,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27.69,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":37.65,"additional_payer_notes":"APC"}]}]},{"description":"Prgrmg dev eval isdss ip","code_information":[{"code":"0683T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":27.69,"maximum":71.25,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":36.92,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":71.25,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27.69,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":37.65,"additional_payer_notes":"APC"}]}]},{"description":"Interrog dev eval isdss ip","code_information":[{"code":"0685T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":27.69,"maximum":71.25,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":36.92,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":71.25,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27.69,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":37.65,"additional_payer_notes":"APC"}]}]},{"description":"Bdy surf mapg pm/cvdfb f/up","code_information":[{"code":"0696T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":27.69,"maximum":71.25,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":36.92,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":71.25,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27.69,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":37.65,"additional_payer_notes":"APC"}]}]},{"description":"Rem auton alg nsln data coll","code_information":[{"code":"0741T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":27.69,"maximum":71.25,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":36.92,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":71.25,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27.69,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":37.65,"additional_payer_notes":"APC"}]}]},{"description":"Prgrmg evl ldls pm 2chmbr ip","code_information":[{"code":"0804T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":27.69,"maximum":71.25,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":36.92,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":71.25,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27.69,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":37.65,"additional_payer_notes":"APC"}]}]},{"description":"Prgrmg evl ldls pm 1chmbr ip","code_information":[{"code":"0826T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":27.69,"maximum":71.25,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":36.92,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":71.25,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27.69,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":37.65,"additional_payer_notes":"APC"}]}]},{"description":"Prgrm subq prtl asct pmp sys","code_information":[{"code":"0875T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":27.69,"maximum":71.25,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":36.92,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":71.25,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27.69,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":37.65,"additional_payer_notes":"APC"}]}]},{"description":"Prgrmg dev eval ccm-d ip","code_information":[{"code":"0926T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":27.69,"maximum":71.25,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":36.92,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":71.25,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27.69,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":37.65,"additional_payer_notes":"APC"}]}]},{"description":"Interrog dev eval ccm-d ip","code_information":[{"code":"0927T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":27.69,"maximum":71.25,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":36.92,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":71.25,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27.69,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":37.65,"additional_payer_notes":"APC"}]}]},{"description":"Rem interrog dev ccm-d tech","code_information":[{"code":"0929T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":27.69,"maximum":71.25,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":36.92,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":71.25,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27.69,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":37.65,"additional_payer_notes":"APC"}]}]},{"description":"Rem interrog dev ccm tech","code_information":[{"code":"0949T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":27.69,"maximum":71.25,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":36.92,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":71.25,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27.69,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":37.65,"additional_payer_notes":"APC"}]}]},{"description":"Rem mntr impl ivc snr phys","code_information":[{"code":"0983T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":27.69,"maximum":71.25,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":36.92,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":71.25,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27.69,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":37.65,"additional_payer_notes":"APC"}]}]},{"description":"Prgrmg dev eval impltbl sys","code_information":[{"code":"93260","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":27.69,"maximum":71.25,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":36.92,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":71.25,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27.69,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":37.65,"additional_payer_notes":"APC"}]}]},{"description":"Interrogate subq defib","code_information":[{"code":"93261","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":27.69,"maximum":71.25,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":36.92,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":71.25,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27.69,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":37.65,"additional_payer_notes":"APC"}]}]},{"description":"Rem mntr wrls p-art prs snr","code_information":[{"code":"93264","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":27.69,"maximum":71.25,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":36.92,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":71.25,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27.69,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":37.65,"additional_payer_notes":"APC"}]}]},{"description":"Remote 30 day ecg rev/report","code_information":[{"code":"93270","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":27.69,"maximum":71.25,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":36.92,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":71.25,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27.69,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":37.65,"additional_payer_notes":"APC"}]}]},{"description":"Pm device progr eval sngl","code_information":[{"code":"93279","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":27.69,"maximum":71.25,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":36.92,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":71.25,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27.69,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":37.65,"additional_payer_notes":"APC"}]}]},{"description":"Pm device progr eval dual","code_information":[{"code":"93280","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":27.69,"maximum":71.25,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":36.92,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":71.25,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27.69,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":37.65,"additional_payer_notes":"APC"}]}]},{"description":"Pm device progr eval multi","code_information":[{"code":"93281","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":27.69,"maximum":71.25,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":36.92,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":71.25,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27.69,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":37.65,"additional_payer_notes":"APC"}]}]},{"description":"Prgrmg eval implantable dfb","code_information":[{"code":"93282","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":27.69,"maximum":71.25,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":36.92,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":71.25,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27.69,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":37.65,"additional_payer_notes":"APC"}]}]},{"description":"Prgrmg eval implantable dfb","code_information":[{"code":"93283","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":27.69,"maximum":71.25,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":36.92,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":71.25,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27.69,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":37.65,"additional_payer_notes":"APC"}]}]},{"description":"Prgrmg eval implantable dfb","code_information":[{"code":"93284","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":27.69,"maximum":71.25,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":36.92,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":71.25,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27.69,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":37.65,"additional_payer_notes":"APC"}]}]},{"description":"Ilr device eval progr","code_information":[{"code":"93285","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":27.69,"maximum":71.25,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":36.92,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":71.25,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27.69,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":37.65,"additional_payer_notes":"APC"}]}]},{"description":"Pm device eval in person","code_information":[{"code":"93288","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":27.69,"maximum":71.25,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":36.92,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":71.25,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27.69,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":37.65,"additional_payer_notes":"APC"}]}]},{"description":"Interrog device eval heart","code_information":[{"code":"93289","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":27.69,"maximum":71.25,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":36.92,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":71.25,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27.69,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":37.65,"additional_payer_notes":"APC"}]}]},{"description":"Icm device eval","code_information":[{"code":"93290","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":27.69,"maximum":71.25,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":36.92,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":71.25,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27.69,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":37.65,"additional_payer_notes":"APC"}]}]},{"description":"Wcd device interrogate","code_information":[{"code":"93292","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":27.69,"maximum":71.25,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":36.92,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":71.25,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27.69,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":37.65,"additional_payer_notes":"APC"}]}]},{"description":"Pm phone r-strip device eval","code_information":[{"code":"93293","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":27.69,"maximum":71.25,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":36.92,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":71.25,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27.69,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":37.65,"additional_payer_notes":"APC"}]}]},{"description":"Pm/icd remote tech serv","code_information":[{"code":"93296","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":27.69,"maximum":71.25,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":36.92,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":71.25,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27.69,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":37.65,"additional_payer_notes":"APC"}]}]},{"description":"Icm device interrogat remote","code_information":[{"code":"93297","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":27.69,"maximum":71.25,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":36.92,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":71.25,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27.69,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":37.65,"additional_payer_notes":"APC"}]}]},{"description":"Ilr device interrogat remote","code_information":[{"code":"93298","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":27.69,"maximum":71.25,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":36.92,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":71.25,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27.69,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":37.65,"additional_payer_notes":"APC"}]}]},{"description":"Ecog impltd brn npgt <=30 d","code_information":[{"code":"95836","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":27.69,"maximum":71.25,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":36.92,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":71.25,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27.69,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":37.65,"additional_payer_notes":"APC"}]}]},{"description":"Alys smpl cn npgt prgrmg","code_information":[{"code":"95976","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":27.69,"maximum":71.25,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":36.92,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":71.25,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27.69,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":37.65,"additional_payer_notes":"APC"}]}]},{"description":"Io ga n-stim subsq w/reprog","code_information":[{"code":"95982","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":27.69,"maximum":71.25,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":36.92,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":71.25,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27.69,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":37.65,"additional_payer_notes":"APC"}]}]},{"description":"Rem ther mntr dev sply resp","code_information":[{"code":"98976","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":27.69,"maximum":71.25,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":36.92,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":71.25,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27.69,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":37.65,"additional_payer_notes":"APC"}]}]},{"description":"Rem ther mntr dv sply mscskl","code_information":[{"code":"98977","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":27.69,"maximum":71.25,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":36.92,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":71.25,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27.69,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":37.65,"additional_payer_notes":"APC"}]}]},{"description":"Rem ther mntr dev sply cbt","code_information":[{"code":"98978","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":27.69,"maximum":71.25,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":36.92,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":71.25,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27.69,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":37.65,"additional_payer_notes":"APC"}]}]},{"description":"Rtm dev sply resp sys 2-15 d","code_information":[{"code":"98984","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":27.69,"maximum":71.25,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":36.92,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":71.25,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27.69,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":37.65,"additional_payer_notes":"APC"}]}]},{"description":"Rtm dev sply mscsk sys 2-15d","code_information":[{"code":"98985","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":27.69,"maximum":71.25,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":36.92,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":71.25,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27.69,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":37.65,"additional_payer_notes":"APC"}]}]},{"description":"Rtm dev sply cbt 2-15 d","code_information":[{"code":"98986","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":27.69,"maximum":71.25,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":36.92,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":71.25,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27.69,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":37.65,"additional_payer_notes":"APC"}]}]},{"description":"Rem mntr physiol param 2-15","code_information":[{"code":"99445","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":27.69,"maximum":71.25,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":36.92,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":71.25,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27.69,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":37.65,"additional_payer_notes":"APC"}]}]},{"description":"Rem mntr physiol param dev","code_information":[{"code":"99454","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":27.69,"maximum":71.25,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":36.92,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":71.25,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27.69,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":37.65,"additional_payer_notes":"APC"}]}]},{"description":"Cardiac rehab","code_information":[{"code":"93797","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":95.63,"maximum":246.08,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":127.5,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":246.08,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":95.63,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":130.05,"additional_payer_notes":"APC"}]}]},{"description":"Cardiac rehab/monitor","code_information":[{"code":"93798","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":95.63,"maximum":246.08,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":127.5,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":246.08,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":95.63,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":130.05,"additional_payer_notes":"APC"}]}]},{"description":"Intens cardiac rehab w/exerc","code_information":[{"code":"G0422","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":95.63,"maximum":246.08,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":127.5,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":246.08,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":95.63,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":130.05,"additional_payer_notes":"APC"}]}]},{"description":"Intens cardiac rehab no exer","code_information":[{"code":"G0423","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":95.63,"maximum":246.08,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":127.5,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":246.08,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":95.63,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":130.05,"additional_payer_notes":"APC"}]}]},{"description":"Nb resuscitation","code_information":[{"code":"99465","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":490.31,"maximum":1261.73,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":653.75,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1261.73,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":490.31,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":666.82,"additional_payer_notes":"APC"}]}]},{"description":"Surfactant Admin Thru Tube","code_information":[{"code":"94610","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":162.44,"maximum":418.02,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":216.59,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":418.02,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":162.44,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":220.92,"additional_payer_notes":"APC"}]}]},{"description":"Airway inhalation treatment","code_information":[{"code":"94640","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":162.44,"maximum":418.02,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":216.59,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":418.02,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":162.44,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":220.92,"additional_payer_notes":"APC"}]}]},{"description":"Aerosol inhalation treatment","code_information":[{"code":"94642","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":162.44,"maximum":418.02,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":216.59,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":418.02,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":162.44,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":220.92,"additional_payer_notes":"APC"}]}]},{"description":"Pos airway pressure cpap","code_information":[{"code":"94660","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":162.44,"maximum":418.02,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":216.59,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":418.02,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":162.44,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":220.92,"additional_payer_notes":"APC"}]}]},{"description":"Evaluate pt use of inhaler","code_information":[{"code":"94664","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":162.44,"maximum":418.02,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":216.59,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":418.02,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":162.44,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":220.92,"additional_payer_notes":"APC"}]}]},{"description":"Mechanical chest wall oscill","code_information":[{"code":"94669","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":162.44,"maximum":418.02,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":216.59,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":418.02,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":162.44,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":220.92,"additional_payer_notes":"APC"}]}]},{"description":"Expose behav assessment","code_information":[{"code":"0362T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":27.8,"maximum":71.53,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":37.06,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":71.53,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27.8,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":37.8,"additional_payer_notes":"APC"}]}]},{"description":"Exposure behavior treatment","code_information":[{"code":"0373T","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":27.8,"maximum":71.53,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":37.06,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":71.53,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27.8,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":37.8,"additional_payer_notes":"APC"}]}]},{"description":"Psychiatric service/therapy","code_information":[{"code":"90899","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":27.8,"maximum":71.53,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":37.06,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":71.53,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27.8,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":37.8,"additional_payer_notes":"APC"}]}]},{"description":"Pt-focused hlth risk assmt","code_information":[{"code":"96160","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":27.8,"maximum":71.53,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":37.06,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":71.53,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27.8,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":37.8,"additional_payer_notes":"APC"}]}]},{"description":"Caregiver health risk assmt","code_information":[{"code":"96161","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":27.8,"maximum":71.53,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":37.06,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":71.53,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27.8,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":37.8,"additional_payer_notes":"APC"}]}]},{"description":"Hlth bhv ivntj grp 1st 30","code_information":[{"code":"96164","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":27.8,"maximum":71.53,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":37.06,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":71.53,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27.8,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":37.8,"additional_payer_notes":"APC"}]}]},{"description":"Hlth bhv ivntj fam 1st 30","code_information":[{"code":"96167","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":27.8,"maximum":71.53,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":37.06,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":71.53,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27.8,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":37.8,"additional_payer_notes":"APC"}]}]},{"description":"Grp adapt bhv tx by tech","code_information":[{"code":"97154","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":27.8,"maximum":71.53,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":37.06,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":71.53,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27.8,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":37.8,"additional_payer_notes":"APC"}]}]},{"description":"Fam adapt bhv tx gdn phy/qhp","code_information":[{"code":"97156","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":27.8,"maximum":71.53,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":37.06,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":71.53,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27.8,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":37.8,"additional_payer_notes":"APC"}]}]},{"description":"Mult fam adapt bhv tx gdn","code_information":[{"code":"97157","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":27.8,"maximum":71.53,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":37.06,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":71.53,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27.8,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":37.8,"additional_payer_notes":"APC"}]}]},{"description":"Grp adapt bhv tx by phy/qhp","code_information":[{"code":"97158","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":27.8,"maximum":71.53,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":37.06,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":71.53,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27.8,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":37.8,"additional_payer_notes":"APC"}]}]},{"description":"Behav chng smoking 3-10 min","code_information":[{"code":"99406","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":27.8,"maximum":71.53,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":37.06,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":71.53,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27.8,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":37.8,"additional_payer_notes":"APC"}]}]},{"description":"Behav chng smoking > 10 min","code_information":[{"code":"99407","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":27.8,"maximum":71.53,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":37.06,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":71.53,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27.8,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":37.8,"additional_payer_notes":"APC"}]}]},{"description":"Care mgmt svc bhvl hlth cond","code_information":[{"code":"99484","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":27.8,"maximum":71.53,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":37.06,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":71.53,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27.8,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":37.8,"additional_payer_notes":"APC"}]}]},{"description":"Hopd mntl hlt, 15-29 min","code_information":[{"code":"C7900","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":27.8,"maximum":71.53,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":37.06,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":71.53,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27.8,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":37.8,"additional_payer_notes":"APC"}]}]},{"description":"Hopd mntl hlt, grp","code_information":[{"code":"C7903","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":27.8,"maximum":71.53,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":37.06,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":71.53,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27.8,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":37.8,"additional_payer_notes":"APC"}]}]},{"description":"Hiv prep counsel, clin staff","code_information":[{"code":"G0013","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":27.8,"maximum":71.53,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":37.06,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":71.53,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27.8,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":37.8,"additional_payer_notes":"APC"}]}]},{"description":"Adm of soc dtr assess 5-15 m","code_information":[{"code":"G0136","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":27.8,"maximum":71.53,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":37.06,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":71.53,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27.8,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":37.8,"additional_payer_notes":"APC"}]}]},{"description":"Care manage beh svs 20mins","code_information":[{"code":"G0323","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":27.8,"maximum":71.53,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":37.06,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":71.53,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27.8,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":37.8,"additional_payer_notes":"APC"}]}]},{"description":"Alcohol/subs interv 15-30mn","code_information":[{"code":"G0396","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":27.8,"maximum":71.53,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":37.06,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":71.53,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27.8,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":37.8,"additional_payer_notes":"APC"}]}]},{"description":"Annual alcohol screen 15 min","code_information":[{"code":"G0442","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":27.8,"maximum":71.53,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":37.06,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":71.53,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27.8,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":37.8,"additional_payer_notes":"APC"}]}]},{"description":"Depression Screen annual","code_information":[{"code":"G0444","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":27.8,"maximum":71.53,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":37.06,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":71.53,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27.8,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":37.8,"additional_payer_notes":"APC"}]}]},{"description":"Intens behave ther cardio dx","code_information":[{"code":"G0446","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":27.8,"maximum":71.53,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":37.06,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":71.53,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27.8,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":37.8,"additional_payer_notes":"APC"}]}]},{"description":"Group behave couns 2-10","code_information":[{"code":"G0473","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":27.8,"maximum":71.53,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":37.06,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":71.53,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27.8,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":37.8,"additional_payer_notes":"APC"}]}]},{"description":"Risk ascvd tst once pr 12 mo","code_information":[{"code":"G0537","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":27.8,"maximum":71.53,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":37.06,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":71.53,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27.8,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":37.8,"additional_payer_notes":"APC"}]}]},{"description":"Adv prim care mgmt lvl 1","code_information":[{"code":"G0556","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":27.8,"maximum":71.53,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":37.06,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":71.53,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27.8,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":37.8,"additional_payer_notes":"APC"}]}]},{"description":"Adv prim care mgmt lvl 2","code_information":[{"code":"G0557","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":27.8,"maximum":71.53,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":37.06,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":71.53,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27.8,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":37.8,"additional_payer_notes":"APC"}]}]},{"description":"Care manage serv, pr cal mo","code_information":[{"code":"G0570","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":27.8,"maximum":71.53,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":37.06,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":71.53,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27.8,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":37.8,"additional_payer_notes":"APC"}]}]},{"description":"Group psychotherapy","code_information":[{"code":"90853","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":75.36,"maximum":193.93,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":100.48,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":193.93,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":75.36,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":102.49,"additional_payer_notes":"APC"}]}]},{"description":"Hypnotherapy","code_information":[{"code":"90880","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":75.36,"maximum":193.93,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":100.48,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":193.93,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":75.36,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":102.49,"additional_payer_notes":"APC"}]}]},{"description":"Hlth bhv assmt/reassessment","code_information":[{"code":"96156","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":75.36,"maximum":193.93,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":100.48,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":193.93,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":75.36,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":102.49,"additional_payer_notes":"APC"}]}]},{"description":"Bhv id assmt by phys/qhp","code_information":[{"code":"97151","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":75.36,"maximum":193.93,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":100.48,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":193.93,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":75.36,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":102.49,"additional_payer_notes":"APC"}]}]},{"description":"Bhv id suprt assmt by 1 tech","code_information":[{"code":"97152","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":75.36,"maximum":193.93,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":100.48,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":193.93,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":75.36,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":102.49,"additional_payer_notes":"APC"}]}]},{"description":"Adaptive behavior tx by tech","code_information":[{"code":"97153","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":75.36,"maximum":193.93,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":100.48,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":193.93,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":75.36,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":102.49,"additional_payer_notes":"APC"}]}]},{"description":"Prin care mgmt staff 1st 30","code_information":[{"code":"99426","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":75.36,"maximum":193.93,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":100.48,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":193.93,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":75.36,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":102.49,"additional_payer_notes":"APC"}]}]},{"description":"Assmt & care pln pt cog imp","code_information":[{"code":"99483","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":75.36,"maximum":193.93,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":100.48,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":193.93,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":75.36,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":102.49,"additional_payer_notes":"APC"}]}]},{"description":"Chron care mgmt srvc 20 min","code_information":[{"code":"99490","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":75.36,"maximum":193.93,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":100.48,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":193.93,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":75.36,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":102.49,"additional_payer_notes":"APC"}]}]},{"description":"1st psyc collab care mgmt","code_information":[{"code":"99492","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":75.36,"maximum":193.93,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":100.48,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":193.93,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":75.36,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":102.49,"additional_payer_notes":"APC"}]}]},{"description":"Sbsq psyc collab care mgmt","code_information":[{"code":"99493","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":75.36,"maximum":193.93,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":100.48,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":193.93,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":75.36,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":102.49,"additional_payer_notes":"APC"}]}]},{"description":"Advncd care plan 30 min","code_information":[{"code":"99497","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":75.36,"maximum":193.93,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":100.48,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":193.93,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":75.36,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":102.49,"additional_payer_notes":"APC"}]}]},{"description":"Hopd mntl hlt, 30-60 min","code_information":[{"code":"C7901","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":75.36,"maximum":193.93,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":100.48,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":193.93,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":75.36,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":102.49,"additional_payer_notes":"APC"}]}]},{"description":"Comm hlth intg svs sdoh 60mn","code_information":[{"code":"G0019","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":75.36,"maximum":193.93,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":100.48,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":193.93,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":75.36,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":102.49,"additional_payer_notes":"APC"}]}]},{"description":"Pin service 60m per month","code_information":[{"code":"G0023","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":75.36,"maximum":193.93,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":100.48,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":193.93,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":75.36,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":102.49,"additional_payer_notes":"APC"}]}]},{"description":"CA screen;pelvic/breast exam","code_information":[{"code":"G0101","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":75.36,"maximum":193.93,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":100.48,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":193.93,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":75.36,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":102.49,"additional_payer_notes":"APC"}]}]},{"description":"Nav srv peer sup 60 min pr m","code_information":[{"code":"G0140","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":75.36,"maximum":193.93,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":100.48,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":193.93,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":75.36,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":102.49,"additional_payer_notes":"APC"}]}]},{"description":"Visit to determ ldct elig","code_information":[{"code":"G0296","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":75.36,"maximum":193.93,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":100.48,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":193.93,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":75.36,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":102.49,"additional_payer_notes":"APC"}]}]},{"description":"Brief alcohol misuse counsel","code_information":[{"code":"G0443","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":75.36,"maximum":193.93,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":100.48,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":193.93,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":75.36,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":102.49,"additional_payer_notes":"APC"}]}]},{"description":"High inten beh couns STD 30m","code_information":[{"code":"G0445","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":75.36,"maximum":193.93,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":100.48,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":193.93,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":75.36,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":102.49,"additional_payer_notes":"APC"}]}]},{"description":"Behavior counsel obesity 15m","code_information":[{"code":"G0447","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":75.36,"maximum":193.93,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":100.48,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":193.93,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":75.36,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":102.49,"additional_payer_notes":"APC"}]}]},{"description":"Devlopment test interpt&rep","code_information":[{"code":"G0451","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":75.36,"maximum":193.93,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":100.48,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":193.93,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":75.36,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":102.49,"additional_payer_notes":"APC"}]}]},{"description":"Ascvd rsk mng clin stf pr mo","code_information":[{"code":"G0538","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":75.36,"maximum":193.93,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":100.48,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":193.93,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":75.36,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":102.49,"additional_payer_notes":"APC"}]}]},{"description":"Post d/c phone follow up","code_information":[{"code":"G0544","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":75.36,"maximum":193.93,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":100.48,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":193.93,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":75.36,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":102.49,"additional_payer_notes":"APC"}]}]},{"description":"Adv prim care mgmt lvl 3","code_information":[{"code":"G0558","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":75.36,"maximum":193.93,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":100.48,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":193.93,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":75.36,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":102.49,"additional_payer_notes":"APC"}]}]},{"description":"Int psych care mng, 1 cal mo","code_information":[{"code":"G0568","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":75.36,"maximum":193.93,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":100.48,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":193.93,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":75.36,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":102.49,"additional_payer_notes":"APC"}]}]},{"description":"Subs psych care mng, subs mo","code_information":[{"code":"G0569","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":75.36,"maximum":193.93,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":100.48,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":193.93,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":75.36,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":102.49,"additional_payer_notes":"APC"}]}]},{"description":"Init/sub psych care m 1st 30","code_information":[{"code":"G2214","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":75.36,"maximum":193.93,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":100.48,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":193.93,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":75.36,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":102.49,"additional_payer_notes":"APC"}]}]},{"description":"Psych diagnostic evaluation","code_information":[{"code":"90791","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":131.67,"maximum":338.84,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":175.56,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":338.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":131.67,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":179.07,"additional_payer_notes":"APC"}]}]},{"description":"Psych diag eval w/med srvcs","code_information":[{"code":"90792","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":131.67,"maximum":338.84,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":175.56,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":338.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":131.67,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":179.07,"additional_payer_notes":"APC"}]}]},{"description":"Psytx w pt 30 minutes","code_information":[{"code":"90832","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":131.67,"maximum":338.84,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":175.56,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":338.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":131.67,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":179.07,"additional_payer_notes":"APC"}]}]},{"description":"Psytx w pt 45 minutes","code_information":[{"code":"90834","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":131.67,"maximum":338.84,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":175.56,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":338.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":131.67,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":179.07,"additional_payer_notes":"APC"}]}]},{"description":"Psytx w pt 60 minutes","code_information":[{"code":"90837","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":131.67,"maximum":338.84,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":175.56,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":338.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":131.67,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":179.07,"additional_payer_notes":"APC"}]}]},{"description":"Psytx crisis initial 60 min","code_information":[{"code":"90839","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":131.67,"maximum":338.84,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":175.56,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":338.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":131.67,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":179.07,"additional_payer_notes":"APC"}]}]},{"description":"Psychoanalysis","code_information":[{"code":"90845","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":131.67,"maximum":338.84,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":175.56,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":338.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":131.67,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":179.07,"additional_payer_notes":"APC"}]}]},{"description":"Family psytx w/o pt 50 min","code_information":[{"code":"90846","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":131.67,"maximum":338.84,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":175.56,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":338.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":131.67,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":179.07,"additional_payer_notes":"APC"}]}]},{"description":"Family psytx w/pt 50 min","code_information":[{"code":"90847","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":131.67,"maximum":338.84,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":175.56,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":338.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":131.67,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":179.07,"additional_payer_notes":"APC"}]}]},{"description":"Multiple family group psytx","code_information":[{"code":"90849","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":131.67,"maximum":338.84,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":175.56,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":338.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":131.67,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":179.07,"additional_payer_notes":"APC"}]}]},{"description":"Narcosynthesis","code_information":[{"code":"90865","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":131.67,"maximum":338.84,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":175.56,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":338.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":131.67,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":179.07,"additional_payer_notes":"APC"}]}]},{"description":"Hlth bhv ivntj indiv 1st 30","code_information":[{"code":"96158","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":131.67,"maximum":338.84,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":175.56,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":338.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":131.67,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":179.07,"additional_payer_notes":"APC"}]}]},{"description":"Adapt behavior tx phys/qhp","code_information":[{"code":"97155","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":131.67,"maximum":338.84,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":175.56,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":338.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":131.67,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":179.07,"additional_payer_notes":"APC"}]}]},{"description":"Cmplx chron care w/o pt vsit","code_information":[{"code":"99487","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":131.67,"maximum":338.84,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":175.56,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":338.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":131.67,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":179.07,"additional_payer_notes":"APC"}]}]},{"description":"Alcohol/subs interv >30 min","code_information":[{"code":"G0397","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":131.67,"maximum":338.84,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":175.56,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":338.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":131.67,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":179.07,"additional_payer_notes":"APC"}]}]},{"description":"Off base opioid tx 70min","code_information":[{"code":"G2086","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":131.67,"maximum":338.84,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":175.56,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":338.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":131.67,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":179.07,"additional_payer_notes":"APC"}]}]},{"description":"Off base opioid tx, 60 m","code_information":[{"code":"G2087","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":131.67,"maximum":338.84,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":175.56,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":338.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":131.67,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":179.07,"additional_payer_notes":"APC"}]}]},{"description":"Admn sarscov2 vacc 1 dose","code_information":[{"code":"90480","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":30.15,"maximum":77.58,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":40.2,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":77.58,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":30.15,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":41.0,"additional_payer_notes":"APC"}]}]},{"description":"Platelet pheres leukoreduced","code_information":[{"code":"P9035","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":383.69,"maximum":987.37,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":511.59,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":987.37,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":383.69,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":521.82,"additional_payer_notes":"APC"}]}]},{"description":"Rbc leukocytes reduced","code_information":[{"code":"P9016","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":138.68,"maximum":356.88,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":184.91,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":356.88,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":138.68,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":188.61,"additional_payer_notes":"APC"}]}]},{"description":"RBC leukoreduced irradiated","code_information":[{"code":"P9040","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":199.06,"maximum":512.24,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":265.41,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":512.24,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":199.06,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":270.72,"additional_payer_notes":"APC"}]}]},{"description":"Plate pheres leukoredu irrad","code_information":[{"code":"P9037","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":510.46,"maximum":1313.58,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":680.61,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1313.58,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":510.46,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":694.22,"additional_payer_notes":"APC"}]}]},{"description":"Onc urthl mrna xprsn 6 snp","code_information":[{"code":"0420U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":996.24,"maximum":2563.66,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1328.32,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2563.66,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":996.24,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1354.89,"additional_payer_notes":"APC"}]}]},{"description":"Onc pan solid tum alys dna","code_information":[{"code":"0422U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1457.41,"maximum":3750.4,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1943.21,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3750.4,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1457.41,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1982.07,"additional_payer_notes":"APC"}]}]},{"description":"Genom rpd seq alys ea cmprtr","code_information":[{"code":"0425U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3070.79,"maximum":7902.17,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4094.39,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7902.17,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3070.79,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4176.28,"additional_payer_notes":"APC"}]}]},{"description":"Genome ultra-rapid seq alys","code_information":[{"code":"0426U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5686.65,"maximum":14633.65,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7582.2,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":14633.65,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5686.65,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7733.84,"additional_payer_notes":"APC"}]}]},{"description":"Onc lng plsm alys 388 prtn","code_information":[{"code":"0436U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1128.18,"maximum":2903.18,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1504.24,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2903.18,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1128.18,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1534.32,"additional_payer_notes":"APC"}]}]},{"description":"Crd chd dna alys 5 snp 3 dna","code_information":[{"code":"0439U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":640.5,"maximum":1648.22,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":854.0,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1648.22,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":640.5,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":871.08,"additional_payer_notes":"APC"}]}]},{"description":"Crd chd dna alys 10 snp 6dna","code_information":[{"code":"0440U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":640.5,"maximum":1648.22,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":854.0,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1648.22,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":640.5,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":871.08,"additional_payer_notes":"APC"}]}]},{"description":"Nfct ds bct fngl/viral semiq","code_information":[{"code":"0441U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":333.06,"maximum":857.07,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":444.08,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":857.07,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":333.06,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":452.96,"additional_payer_notes":"APC"}]}]},{"description":"Neurflmnt lt chn ultrsens ia","code_information":[{"code":"0443U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":87.17,"maximum":224.32,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":116.23,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":224.32,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":87.17,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":118.55,"additional_payer_notes":"APC"}]}]},{"description":"Onc whl bld/bucc rtpcr 24gen","code_information":[{"code":"0460U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":687.81,"maximum":1769.96,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":917.08,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1769.96,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":687.81,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":935.42,"additional_payer_notes":"APC"}]}]},{"description":"Onc rxgenom alys rtpcr 24gen","code_information":[{"code":"0461U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":687.81,"maximum":1769.96,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":917.08,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1769.96,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":687.81,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":935.42,"additional_payer_notes":"APC"}]}]},{"description":"Onc crvx mrna genxprsn 14bmk","code_information":[{"code":"0463U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":570.0,"maximum":1466.8,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":760.0,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1466.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":570.0,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":775.2,"additional_payer_notes":"APC"}]}]},{"description":"Crd cad dna gwas 564856 snp","code_information":[{"code":"0466U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":259.07,"maximum":666.68,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":345.43,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":666.68,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":259.07,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":352.34,"additional_payer_notes":"APC"}]}]},{"description":"Onc orop detcj mrd 8 dna hpv","code_information":[{"code":"0470U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":448.43,"maximum":1153.97,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":597.91,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1153.97,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":448.43,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":609.87,"additional_payer_notes":"APC"}]}]},{"description":"Ca vi psp&sp1 antb sj?gren","code_information":[{"code":"0472U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":20.92,"maximum":53.85,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27.9,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":53.85,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20.92,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":28.46,"additional_payer_notes":"APC"}]}]},{"description":"Onc nsclc dna&rna dpcr 9 gen","code_information":[{"code":"0478U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":414.74,"maximum":1067.27,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":552.99,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1067.27,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":414.74,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":564.05,"additional_payer_notes":"APC"}]}]},{"description":"Nfct ds ng gyra s91f pt mut","code_information":[{"code":"0483U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":26.32,"maximum":67.72,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":35.09,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":67.72,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26.32,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":35.79,"additional_payer_notes":"APC"}]}]},{"description":"Nfct ds mgen 23s rrna pt mut","code_information":[{"code":"0484U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":26.32,"maximum":67.72,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":35.09,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":67.72,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26.32,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":35.79,"additional_payer_notes":"APC"}]}]},{"description":"Onc sol tum cfdna&rna ngs gm","code_information":[{"code":"0485U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2737.11,"maximum":7043.5,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3649.48,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7043.5,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2737.11,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3722.47,"additional_payer_notes":"APC"}]}]},{"description":"Onc pan sol tum ngs cfctdna","code_information":[{"code":"0486U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1233.19,"maximum":3173.4,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1644.25,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3173.4,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1233.19,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1677.14,"additional_payer_notes":"APC"}]}]},{"description":"Onc clrct cfdna 8/7 genes","code_information":[{"code":"0496U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":364.4,"maximum":937.71,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":485.86,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":937.71,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":364.4,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":495.58,"additional_payer_notes":"APC"}]}]},{"description":"Onc clrct ngs mut detc 43gen","code_information":[{"code":"0498U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1008.98,"maximum":2596.45,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1345.31,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2596.45,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1008.98,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1372.22,"additional_payer_notes":"APC"}]}]},{"description":"Onc pncrtc ca alg alys 16gen","code_information":[{"code":"0510U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":355.43,"maximum":914.65,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":473.91,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":914.65,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":355.43,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":483.39,"additional_payer_notes":"APC"}]}]},{"description":"Rf iga&igm ccp antb sr-a ia","code_information":[{"code":"0521U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":38.85,"maximum":99.97,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":51.8,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":99.97,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":38.85,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":52.84,"additional_payer_notes":"APC"}]}]},{"description":"Ca vi psp&sp1 antb cl semiql","code_information":[{"code":"0522U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":195.38,"maximum":502.76,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":260.5,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":502.76,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":195.38,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":265.71,"additional_payer_notes":"APC"}]}]},{"description":"Onc soltum dna ngs snv 22gen","code_information":[{"code":"0523U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1014.07,"maximum":2609.53,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1352.09,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2609.53,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1014.07,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1379.13,"additional_payer_notes":"APC"}]}]},{"description":"Ob pe sflt-1/plgf ia srm/pls","code_information":[{"code":"0524U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":96.62,"maximum":248.62,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":128.82,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":248.62,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":96.62,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":131.4,"additional_payer_notes":"APC"}]}]},{"description":"Onc sphrd cell cul 11-rx pnl","code_information":[{"code":"0525U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2275.4,"maximum":5855.35,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3033.86,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5855.35,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2275.4,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3094.54,"additional_payer_notes":"APC"}]}]},{"description":"Hsv 1&2 vzv amp prb tq pthgn","code_information":[{"code":"0527U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":106.97,"maximum":275.28,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":142.63,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":275.28,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":106.97,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":145.48,"additional_payer_notes":"APC"}]}]},{"description":"Lrt iad 18bct/8vir&7arg rna","code_information":[{"code":"0528U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":476.13,"maximum":1225.24,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":634.84,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1225.24,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":476.13,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":647.54,"additional_payer_notes":"APC"}]}]},{"description":"Onc pan-sol tum ctdna 77 gen","code_information":[{"code":"0530U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2189.7,"maximum":5634.83,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2919.6,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5634.83,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2189.7,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2977.99,"additional_payer_notes":"APC"}]}]},{"description":"Rare ds whlgen&mitochdrl dna","code_information":[{"code":"0532U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3773.4,"maximum":9710.22,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5031.2,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":9710.22,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3773.4,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5131.82,"additional_payer_notes":"APC"}]}]},{"description":"Rx metab advrs gnotyp 16gens","code_information":[{"code":"0533U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":312.58,"maximum":804.39,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":416.78,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":804.39,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":312.58,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":425.12,"additional_payer_notes":"APC"}]}]},{"description":"Pfas lc-ms/ms plsm/srm quan","code_information":[{"code":"0535U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":46.6,"maximum":119.93,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":62.14,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":119.93,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":46.6,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":63.38,"additional_payer_notes":"APC"}]}]},{"description":"Rbcag ftl rhd pcr alys exon4","code_information":[{"code":"0536U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":144.0,"maximum":370.56,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":192.0,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":370.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":144.0,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":195.84,"additional_payer_notes":"APC"}]}]},{"description":"Onc clrct ca cfdna >2500 dmr","code_information":[{"code":"0537U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1121.25,"maximum":2885.35,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1495.0,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2885.35,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1121.25,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1524.9,"additional_payer_notes":"APC"}]}]},{"description":"Onc sol tum ngts ffpe 600gen","code_information":[{"code":"0538U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2242.16,"maximum":5769.83,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2989.55,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5769.83,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2242.16,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3049.34,"additional_payer_notes":"APC"}]}]},{"description":"Onc sol tumor cfctdna 152gen","code_information":[{"code":"0539U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2466.38,"maximum":6346.82,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3288.51,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6346.82,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2466.38,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3354.28,"additional_payer_notes":"APC"}]}]},{"description":"Trnsplj med quan dd-cfdna","code_information":[{"code":"0540U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2064.94,"maximum":5313.77,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2753.25,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5313.77,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2064.94,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2808.32,"additional_payer_notes":"APC"}]}]},{"description":"Onc sol tum ngs dna 517 gens","code_information":[{"code":"0543U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2242.16,"maximum":5769.83,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2989.55,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5769.83,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2242.16,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3049.34,"additional_payer_notes":"APC"}]}]},{"description":"Achr antb id imfluor livecll","code_information":[{"code":"0545U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":28.3,"maximum":72.82,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":37.73,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":72.82,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":28.3,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":38.48,"additional_payer_notes":"APC"}]}]},{"description":"Ldns lrp4 antb imflr livecll","code_information":[{"code":"0546U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":28.3,"maximum":72.82,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":37.73,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":72.82,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":28.3,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":38.48,"additional_payer_notes":"APC"}]}]},{"description":"Neurflmnt lt chn cleia plsm","code_information":[{"code":"0547U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":87.17,"maximum":224.32,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":116.23,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":224.32,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":87.17,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":118.55,"additional_payer_notes":"APC"}]}]},{"description":"Gfap cleia plasma","code_information":[{"code":"0548U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":87.17,"maximum":224.32,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":116.23,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":224.32,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":87.17,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":118.55,"additional_payer_notes":"APC"}]}]},{"description":"Onc urthl dna mthyltd rt pcr","code_information":[{"code":"0549U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":570.0,"maximum":1466.8,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":760.0,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1466.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":570.0,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":775.2,"additional_payer_notes":"APC"}]}]},{"description":"Repr med pga embry te strux","code_information":[{"code":"0553U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":569.29,"maximum":1464.97,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":759.05,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1464.97,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":569.29,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":774.23,"additional_payer_notes":"APC"}]}]},{"description":"Repr med pga 24chrm te bx qc","code_information":[{"code":"0554U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":569.29,"maximum":1464.97,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":759.05,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1464.97,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":569.29,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":774.23,"additional_payer_notes":"APC"}]}]},{"description":"Repr med pga embryonic te qc","code_information":[{"code":"0555U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":569.29,"maximum":1464.97,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":759.05,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1464.97,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":569.29,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":774.23,"additional_payer_notes":"APC"}]}]},{"description":"Nfct ds p-s dna&rna 12 trgts","code_information":[{"code":"0556U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":106.97,"maximum":275.28,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":142.63,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":275.28,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":106.97,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":145.48,"additional_payer_notes":"APC"}]}]},{"description":"Nfct ds bv dna mrk vag fluid","code_information":[{"code":"0557U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":197.24,"maximum":507.57,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":262.99,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":507.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":197.24,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":268.25,"additional_payer_notes":"APC"}]}]},{"description":"Onc clrct elisa bf7 ag serum","code_information":[{"code":"0558U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":15.61,"maximum":40.16,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20.81,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":40.16,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15.61,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21.23,"additional_payer_notes":"APC"}]}]},{"description":"Onc brs quan elisa bf9ag srm","code_information":[{"code":"0559U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":15.61,"maximum":40.16,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20.81,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":40.16,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15.61,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21.23,"additional_payer_notes":"APC"}]}]},{"description":"Onc mrd gsa cfdna baseline","code_information":[{"code":"0560U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2908.84,"maximum":7485.41,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3878.45,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7485.41,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2908.84,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3956.02,"additional_payer_notes":"APC"}]}]},{"description":"Onc mrd gsa cfdna subsequent","code_information":[{"code":"0561U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":595.87,"maximum":1533.37,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":794.49,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1533.37,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":595.87,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":810.38,"additional_payer_notes":"APC"}]}]},{"description":"Onc sol tum tgsa 33gens snvs","code_information":[{"code":"0562U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":448.43,"maximum":1153.97,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":597.91,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1153.97,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":448.43,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":609.87,"additional_payer_notes":"APC"}]}]},{"description":"Nfct ds pthgn-sna 11vir&4bct","code_information":[{"code":"0563U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":312.58,"maximum":804.39,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":416.78,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":804.39,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":312.58,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":425.12,"additional_payer_notes":"APC"}]}]},{"description":"Nfct ds pthgn-sna 10vir&4bct","code_information":[{"code":"0564U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":312.58,"maximum":804.39,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":416.78,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":804.39,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":312.58,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":425.12,"additional_payer_notes":"APC"}]}]},{"description":"Onc hcc ngs detc 6626epigalt","code_information":[{"code":"0565U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":870.0,"maximum":2238.8,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1160.0,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2238.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":870.0,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1183.2,"additional_payer_notes":"APC"}]}]},{"description":"Onc lng qpcr-bsd alys 13dmrs","code_information":[{"code":"0566U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":312.58,"maximum":804.39,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":416.78,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":804.39,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":312.58,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":425.12,"additional_payer_notes":"APC"}]}]},{"description":"Rare ds whl gen seq srs&lrs","code_information":[{"code":"0567U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3773.4,"maximum":9710.22,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5031.2,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":9710.22,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3773.4,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5131.82,"additional_payer_notes":"APC"}]}]},{"description":"Neurol dementia ?amyl ptau","code_information":[{"code":"0568U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":672.75,"maximum":1731.21,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":897.0,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1731.21,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":672.75,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":914.94,"additional_payer_notes":"APC"}]}]},{"description":"Neurol tbi alys gfap&uch-l1","code_information":[{"code":"0570U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":195.38,"maximum":502.76,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":260.5,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":502.76,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":195.38,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":265.71,"additional_payer_notes":"APC"}]}]},{"description":"Onc sol tum dna80&rna10g ngs","code_information":[{"code":"0571U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2189.7,"maximum":5634.83,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2919.6,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5634.83,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2189.7,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2977.99,"additional_payer_notes":"APC"}]}]},{"description":"Trnsplj med lar rtpcr 4genes","code_information":[{"code":"0575U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":285.0,"maximum":733.4,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":380.0,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":733.4,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":285.0,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":387.6,"additional_payer_notes":"APC"}]}]},{"description":"Trnsplj med lar quan ddcfdna","code_information":[{"code":"0576U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2430.0,"maximum":6253.2,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3240.0,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6253.2,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2430.0,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3304.8,"additional_payer_notes":"APC"}]}]},{"description":"Onc cutan mln rna qpcr 10gen","code_information":[{"code":"0578U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2904.75,"maximum":7474.89,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3873.0,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7474.89,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2904.75,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3950.46,"additional_payer_notes":"APC"}]}]},{"description":"Nfro dbtc ckd elisa apoa4","code_information":[{"code":"0579U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":293.06,"maximum":754.15,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":390.75,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":754.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":293.06,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":398.56,"additional_payer_notes":"APC"}]}]},{"description":"Bbrgdrferi antb detc 24rprtn","code_information":[{"code":"0580U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":12.91,"maximum":33.22,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17.21,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":33.22,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.91,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17.55,"additional_payer_notes":"APC"}]}]},{"description":"Trnspl med antb nohla 39trgt","code_information":[{"code":"0581U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":244.35,"maximum":628.79,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":325.8,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":628.79,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":244.35,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":332.32,"additional_payer_notes":"APC"}]}]},{"description":"Rare ds rpd whlgen dna vrnts","code_information":[{"code":"0582U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5686.65,"maximum":14633.65,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7582.2,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":14633.65,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5686.65,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7733.84,"additional_payer_notes":"APC"}]}]},{"description":"Rare ds rpd whlgen cmptr dna","code_information":[{"code":"0583U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2843.32,"maximum":7316.82,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3791.1,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7316.82,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2843.32,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3866.92,"additional_payer_notes":"APC"}]}]},{"description":"Neuro csf prion prtn qual","code_information":[{"code":"0584U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":405.74,"maximum":1044.11,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":540.99,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1044.11,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":405.74,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":551.81,"additional_payer_notes":"APC"}]}]},{"description":"Tgsap so neo cfdna 521 genes","code_information":[{"code":"0585U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2189.7,"maximum":5634.83,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2919.6,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5634.83,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2189.7,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2977.99,"additional_payer_notes":"APC"}]}]},{"description":"Onc mrna gen xprsn 216 genes","code_information":[{"code":"0586U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2189.7,"maximum":5634.83,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2919.6,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5634.83,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2189.7,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2977.99,"additional_payer_notes":"APC"}]}]},{"description":"Ther rx mntr 60-150rx&metabl","code_information":[{"code":"0587U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":85.82,"maximum":220.85,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":114.43,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":220.85,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":85.82,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":116.72,"additional_payer_notes":"APC"}]}]},{"description":"Nfct ds bct/vir 32genes mrna","code_information":[{"code":"0588U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":570.0,"maximum":1466.8,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":760.0,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1466.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":570.0,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":775.2,"additional_payer_notes":"APC"}]}]},{"description":"Pfas24cmpnd hi-perf lc-ms/ms","code_information":[{"code":"0589U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":149.06,"maximum":383.57,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":198.74,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":383.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":149.06,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":202.71,"additional_payer_notes":"APC"}]}]},{"description":"Onc prst8 ca 3prtns plsm srm","code_information":[{"code":"0591U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":570.0,"maximum":1466.8,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":760.0,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1466.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":570.0,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":775.2,"additional_payer_notes":"APC"}]}]},{"description":"Onc hl neo dna tgs 417 genes","code_information":[{"code":"0592U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2189.7,"maximum":5634.83,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2919.6,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5634.83,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2189.7,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2977.99,"additional_payer_notes":"APC"}]}]},{"description":"Nfct ds gu pthgn dna 46trgt","code_information":[{"code":"0593U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":476.13,"maximum":1225.24,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":634.84,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1225.24,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":476.13,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":647.54,"additional_payer_notes":"APC"}]}]},{"description":"Nfct ds tfp vctrbrn&zoonotic","code_information":[{"code":"0595U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":197.24,"maximum":507.57,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":262.99,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":507.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":197.24,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":268.25,"additional_payer_notes":"APC"}]}]},{"description":"Gi ibs igg antb 18food items","code_information":[{"code":"0598U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":225.0,"maximum":579.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":300.0,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":579.0,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":225.0,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":306.0,"additional_payer_notes":"APC"}]}]},{"description":"Onc pncrtc ca mult ia serum","code_information":[{"code":"0599U","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":672.75,"maximum":1731.21,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":897.0,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1731.21,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":672.75,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":914.94,"additional_payer_notes":"APC"}]}]},{"description":"Cytog alys chrml abnor ogm","code_information":[{"code":"81354","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":947.65,"maximum":2438.61,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1263.53,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2438.61,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":947.65,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1288.8,"additional_payer_notes":"APC"}]}]},{"description":"Beta-amyloid 1-40 (abeta 40)","code_information":[{"code":"82233","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":96.69,"maximum":248.82,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":128.92,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":248.82,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":96.69,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":131.5,"additional_payer_notes":"APC"}]}]},{"description":"Beta-amyloid 1-42 (abeta 42)","code_information":[{"code":"82234","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":96.69,"maximum":248.82,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":128.92,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":248.82,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":96.69,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":131.5,"additional_payer_notes":"APC"}]}]},{"description":"Assay neurflmnt light chain","code_information":[{"code":"83884","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":87.17,"maximum":224.32,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":116.23,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":224.32,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":87.17,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":118.55,"additional_payer_notes":"APC"}]}]},{"description":"Tau phosphorylated ea","code_information":[{"code":"84393","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":96.69,"maximum":248.82,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":128.92,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":248.82,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":96.69,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":131.5,"additional_payer_notes":"APC"}]}]},{"description":"Total tau","code_information":[{"code":"84394","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":96.69,"maximum":248.82,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":128.92,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":248.82,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":96.69,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":131.5,"additional_payer_notes":"APC"}]}]},{"description":"Strptcs pneum antb serot ia","code_information":[{"code":"86581","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":69.02,"maximum":177.62,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":92.03,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":177.62,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":69.02,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":93.87,"additional_payer_notes":"APC"}]}]},{"description":"Sc std carbapenem resist gen","code_information":[{"code":"87183","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":26.32,"maximum":67.72,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":35.09,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":67.72,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26.32,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":35.79,"additional_payer_notes":"APC"}]}]},{"description":"Chlmy trch&neisra gonor mult","code_information":[{"code":"87494","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":52.64,"maximum":135.45,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":70.18,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":135.45,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":52.64,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":71.58,"additional_payer_notes":"APC"}]}]},{"description":"Jt spc pthgn&rx rsist gen26+","code_information":[{"code":"87627","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":509.83,"maximum":1311.96,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":679.77,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1311.96,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":509.83,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":693.37,"additional_payer_notes":"APC"}]}]},{"description":"Sarscov2&inf typ a&b w/optic","code_information":[{"code":"87812","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":55.86,"maximum":143.75,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":74.48,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":143.75,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":55.86,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":75.97,"additional_payer_notes":"APC"}]}]},{"description":"Screening Hep C detect","code_information":[{"code":"G0567","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":26.32,"maximum":67.72,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":35.09,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":67.72,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26.32,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":35.79,"additional_payer_notes":"APC"}]}]},{"description":"Cntct lens hydrophil photoch","code_information":[{"code":"V2524","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":128.62,"maximum":330.98,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":171.49,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":330.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":128.62,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":174.92,"additional_payer_notes":"APC"}]}]},{"description":"Bfb training 1st 15 min","code_information":[{"code":"90912","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":27.01,"maximum":69.5,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":36.01,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":69.5,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27.01,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":36.73,"additional_payer_notes":"APC"}]}]},{"description":"Bfb training ea addl 15 min","code_information":[{"code":"90913","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":15.16,"maximum":39.01,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20.21,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":39.01,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15.16,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20.61,"additional_payer_notes":"APC"}]}]},{"description":"Speech/hearing therapy","code_information":[{"code":"92507","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":55.92,"maximum":143.9,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":74.56,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":143.9,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":55.92,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":76.05,"additional_payer_notes":"APC"}]}]},{"description":"Speech/hearing therapy","code_information":[{"code":"92508","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":17.46,"maximum":44.93,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23.28,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":44.93,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17.46,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23.75,"additional_payer_notes":"APC"}]}]},{"description":"Evaluation of speech fluency","code_information":[{"code":"92521","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":97.95,"maximum":252.06,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":130.6,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":252.06,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":97.95,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":133.21,"additional_payer_notes":"APC"}]}]},{"description":"Evaluate speech production","code_information":[{"code":"92522","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":81.76,"maximum":210.41,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":109.02,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":210.41,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":81.76,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":111.2,"additional_payer_notes":"APC"}]}]},{"description":"Speech sound lang comprehen","code_information":[{"code":"92523","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":166.59,"maximum":428.69,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":222.12,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":428.69,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":166.59,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":226.56,"additional_payer_notes":"APC"}]}]},{"description":"Behavral qualit analys voice","code_information":[{"code":"92524","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":80.25,"maximum":206.51,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":107.0,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":206.51,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":80.25,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":109.14,"additional_payer_notes":"APC"}]}]},{"description":"Oral function therapy","code_information":[{"code":"92526","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":61.72,"maximum":158.84,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":82.3,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":158.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":61.72,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":83.95,"additional_payer_notes":"APC"}]}]},{"description":"Oral speech device eval","code_information":[{"code":"92597","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":52.09,"maximum":134.04,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":69.45,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":134.04,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":52.09,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":70.84,"additional_payer_notes":"APC"}]}]},{"description":"Ex for speech device rx 1hr","code_information":[{"code":"92607","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":89.62,"maximum":230.62,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":119.49,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":230.62,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":89.62,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":121.88,"additional_payer_notes":"APC"}]}]},{"description":"Ex for speech device rx addl","code_information":[{"code":"92608","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":35.06,"maximum":90.21,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":46.74,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":90.21,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":35.06,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":47.67,"additional_payer_notes":"APC"}]}]},{"description":"Use of speech device service","code_information":[{"code":"92609","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":75.09,"maximum":193.23,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":100.12,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":193.23,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":75.09,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":102.12,"additional_payer_notes":"APC"}]}]},{"description":"Evaluate swallowing function","code_information":[{"code":"92610","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":42.72,"maximum":109.93,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":56.96,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":109.93,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":42.72,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":58.1,"additional_payer_notes":"APC"}]}]},{"description":"Motion fluoroscopy/swallow","code_information":[{"code":"92611","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":66.32,"maximum":170.67,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":88.43,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":170.67,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":66.32,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":90.2,"additional_payer_notes":"APC"}]}]},{"description":"Endoscopy swallow (fees) vid","code_information":[{"code":"92612","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":39.37,"maximum":101.31,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":52.49,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":101.31,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":39.37,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":53.54,"additional_payer_notes":"APC"}]}]},{"description":"Laryngoscopic sensory vid","code_information":[{"code":"92614","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":39.2,"maximum":100.88,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":52.27,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":100.88,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":39.2,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":53.32,"additional_payer_notes":"APC"}]}]},{"description":"Fees w/laryngeal sense test","code_information":[{"code":"92616","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":58.14,"maximum":149.61,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":77.52,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":149.61,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":58.14,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":79.07,"additional_payer_notes":"APC"}]}]},{"description":"Range of motion measurements","code_information":[{"code":"95851","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4.81,"maximum":12.37,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6.41,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":12.37,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4.81,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6.54,"additional_payer_notes":"APC"}]}]},{"description":"Range of motion measurements","code_information":[{"code":"95852","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3.56,"maximum":9.15,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4.74,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":9.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4.83,"additional_payer_notes":"APC"}]}]},{"description":"Assessment of aphasia","code_information":[{"code":"96105","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":70.86,"maximum":182.35,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":94.48,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":182.35,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":70.86,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":96.37,"additional_payer_notes":"APC"}]}]},{"description":"Cognitive test by hc pro","code_information":[{"code":"96125","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":75.05,"maximum":193.14,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":100.07,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":193.14,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":75.05,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":102.07,"additional_payer_notes":"APC"}]}]},{"description":"Mlt fam grp bhv train 1st 60","code_information":[{"code":"96202","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":12.77,"maximum":32.87,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17.03,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":32.87,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.77,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17.37,"additional_payer_notes":"APC"}]}]},{"description":"Mlt fam grp bhv train ea add","code_information":[{"code":"96203","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3.56,"maximum":9.17,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4.75,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":9.17,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4.84,"additional_payer_notes":"APC"}]}]},{"description":"Mechanical traction therapy","code_information":[{"code":"97012","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":10.41,"maximum":26.79,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.88,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":26.79,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10.41,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14.16,"additional_payer_notes":"APC"}]}]},{"description":"Vasopneumatic device therapy","code_information":[{"code":"97016","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8.66,"maximum":22.29,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11.55,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":22.29,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8.66,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11.78,"additional_payer_notes":"APC"}]}]},{"description":"Paraffin bath therapy","code_information":[{"code":"97018","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4.22,"maximum":10.87,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5.63,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":10.87,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4.22,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5.74,"additional_payer_notes":"APC"}]}]},{"description":"Whirlpool therapy","code_information":[{"code":"97022","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":11.3,"maximum":29.07,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15.06,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":29.07,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11.3,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15.36,"additional_payer_notes":"APC"}]}]},{"description":"Diathermy eg microwave","code_information":[{"code":"97024","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5.18,"maximum":13.34,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6.91,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13.34,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5.18,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7.05,"additional_payer_notes":"APC"}]}]},{"description":"Infrared therapy","code_information":[{"code":"97026","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4.7,"maximum":12.1,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6.27,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":12.1,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4.7,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6.4,"additional_payer_notes":"APC"}]}]},{"description":"Ultraviolet therapy","code_information":[{"code":"97028","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5.92,"maximum":15.23,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7.89,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":15.23,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5.92,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8.05,"additional_payer_notes":"APC"}]}]},{"description":"Electrical stimulation","code_information":[{"code":"97032","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":10.66,"maximum":27.43,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14.21,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":27.43,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10.66,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14.49,"additional_payer_notes":"APC"}]}]},{"description":"Electric current therapy","code_information":[{"code":"97033","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":13.79,"maximum":35.49,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18.39,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":35.49,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.79,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18.76,"additional_payer_notes":"APC"}]}]},{"description":"Contrast bath therapy","code_information":[{"code":"97034","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":10.14,"maximum":26.09,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.52,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":26.09,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10.14,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.79,"additional_payer_notes":"APC"}]}]},{"description":"Ultrasound therapy","code_information":[{"code":"97035","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":10.38,"maximum":26.71,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.84,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":26.71,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10.38,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14.12,"additional_payer_notes":"APC"}]}]},{"description":"Hydrotherapy","code_information":[{"code":"97036","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":25.09,"maximum":64.56,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":33.45,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":64.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25.09,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":34.12,"additional_payer_notes":"APC"}]}]},{"description":"Therapeutic exercises","code_information":[{"code":"97110","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":21.19,"maximum":54.52,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":28.25,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":54.52,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21.19,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":28.82,"additional_payer_notes":"APC"}]}]},{"description":"Neuromuscular reeducation","code_information":[{"code":"97112","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":23.88,"maximum":61.45,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":31.84,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":61.45,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23.88,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":32.48,"additional_payer_notes":"APC"}]}]},{"description":"Aquatic therapy/exercises","code_information":[{"code":"97113","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":26.98,"maximum":69.42,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":35.97,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":69.42,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26.98,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":36.69,"additional_payer_notes":"APC"}]}]},{"description":"Gait training therapy","code_information":[{"code":"97116","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":21.19,"maximum":54.52,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":28.25,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":54.52,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21.19,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":28.82,"additional_payer_notes":"APC"}]}]},{"description":"Massage therapy","code_information":[{"code":"97124","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":21.56,"maximum":55.49,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":28.75,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":55.49,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":29.32,"additional_payer_notes":"APC"}]}]},{"description":"Ther ivntj 1st 15 min","code_information":[{"code":"97129","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":14.52,"maximum":37.36,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19.36,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":37.36,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14.52,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19.75,"additional_payer_notes":"APC"}]}]},{"description":"Ther ivntj ea addl 15 min","code_information":[{"code":"97130","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":13.7,"maximum":35.26,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18.27,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":35.26,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.7,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18.64,"additional_payer_notes":"APC"}]}]},{"description":"Manual therapy 1/> regions","code_information":[{"code":"97140","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":20.2,"maximum":51.99,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26.94,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":51.99,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20.2,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27.48,"additional_payer_notes":"APC"}]}]},{"description":"Group therapeutic procedures","code_information":[{"code":"97150","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":13.1,"maximum":33.72,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17.47,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":33.72,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.1,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17.82,"additional_payer_notes":"APC"}]}]},{"description":"Pt eval low complex 20 min","code_information":[{"code":"97161","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":71.78,"maximum":184.7,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":95.7,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":184.7,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":71.78,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":97.61,"additional_payer_notes":"APC"}]}]},{"description":"Pt eval mod complex 30 min","code_information":[{"code":"97162","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":71.78,"maximum":184.7,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":95.7,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":184.7,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":71.78,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":97.61,"additional_payer_notes":"APC"}]}]},{"description":"Pt eval high complex 45 min","code_information":[{"code":"97163","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":71.78,"maximum":184.7,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":95.7,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":184.7,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":71.78,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":97.61,"additional_payer_notes":"APC"}]}]},{"description":"Pt re-eval est plan care","code_information":[{"code":"97164","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":49.33,"maximum":126.94,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":65.77,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":126.94,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":49.33,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":67.09,"additional_payer_notes":"APC"}]}]},{"description":"Ot eval low complex 30 min","code_information":[{"code":"97165","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":73.7,"maximum":189.64,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":98.26,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":189.64,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":73.7,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":100.23,"additional_payer_notes":"APC"}]}]},{"description":"Ot eval mod complex 45 min","code_information":[{"code":"97166","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":73.7,"maximum":189.64,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":98.26,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":189.64,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":73.7,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":100.23,"additional_payer_notes":"APC"}]}]},{"description":"Ot eval high complex 60 min","code_information":[{"code":"97167","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":73.7,"maximum":189.64,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":98.26,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":189.64,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":73.7,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":100.23,"additional_payer_notes":"APC"}]}]},{"description":"Ot re-eval est plan care","code_information":[{"code":"97168","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":50.05,"maximum":128.79,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":66.73,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":128.79,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":50.05,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":68.06,"additional_payer_notes":"APC"}]}]},{"description":"Therapeutic activities","code_information":[{"code":"97530","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":25.5,"maximum":65.62,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":34.0,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":65.62,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25.5,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":34.68,"additional_payer_notes":"APC"}]}]},{"description":"Sensory Integration","code_information":[{"code":"97533","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":44.02,"maximum":113.27,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":58.69,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":113.27,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":44.02,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":59.86,"additional_payer_notes":"APC"}]}]},{"description":"Self care mngment training","code_information":[{"code":"97535","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":23.59,"maximum":60.7,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":31.45,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":60.7,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23.59,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":32.08,"additional_payer_notes":"APC"}]}]},{"description":"Community/work reintegration","code_information":[{"code":"97537","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":23.38,"maximum":60.16,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":31.17,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":60.16,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23.38,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":31.79,"additional_payer_notes":"APC"}]}]},{"description":"Wheelchair mngment training","code_information":[{"code":"97542","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":22.66,"maximum":58.31,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":30.21,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":58.31,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22.66,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":30.81,"additional_payer_notes":"APC"}]}]},{"description":"Physical performance test","code_information":[{"code":"97750","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":24.55,"maximum":63.17,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":32.73,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":63.17,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":24.55,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":33.38,"additional_payer_notes":"APC"}]}]},{"description":"Assistive technology assess","code_information":[{"code":"97755","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":27.61,"maximum":71.04,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":36.81,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":71.04,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27.61,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":37.55,"additional_payer_notes":"APC"}]}]},{"description":"Orthotic mgmt and training","code_information":[{"code":"97760","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":33.48,"maximum":86.16,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":44.64,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":86.16,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":33.48,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":45.53,"additional_payer_notes":"APC"}]}]},{"description":"Prosthetic training","code_information":[{"code":"97761","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":29.4,"maximum":75.66,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":39.2,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":75.66,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":29.4,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":39.98,"additional_payer_notes":"APC"}]}]},{"description":"Orthc/prostc mgmt sbsq enc","code_information":[{"code":"97763","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":36.34,"maximum":93.51,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":48.45,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":93.51,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":36.34,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":49.42,"additional_payer_notes":"APC"}]}]},{"description":"Medical nutrition indiv in","code_information":[{"code":"97802","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":19.35,"maximum":49.79,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25.8,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":49.79,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19.35,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26.32,"additional_payer_notes":"APC"}]}]},{"description":"Med nutrition indiv subseq","code_information":[{"code":"97803","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":16.15,"maximum":41.55,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21.53,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":41.55,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16.15,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21.96,"additional_payer_notes":"APC"}]}]},{"description":"Medical nutrition group","code_information":[{"code":"97804","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8.98,"maximum":23.1,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11.97,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":23.1,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8.98,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.21,"additional_payer_notes":"APC"}]}]},{"description":"Vr cbt therapy","code_information":[{"code":"E1905","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":506.08,"maximum":1302.31,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":674.77,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1302.31,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":506.08,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":688.27,"additional_payer_notes":"APC"}]}]},{"description":"Diab manage trn  per indiv","code_information":[{"code":"G0108","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":40.37,"maximum":103.89,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":53.83,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":103.89,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":40.37,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":54.91,"additional_payer_notes":"APC"}]}]},{"description":"Diab manage trn ind/group","code_information":[{"code":"G0109","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":11.62,"maximum":29.9,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15.49,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":29.9,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11.62,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15.8,"additional_payer_notes":"APC"}]}]},{"description":"MNT subs tx for change dx","code_information":[{"code":"G0270","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":16.15,"maximum":41.55,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21.53,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":41.55,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16.15,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21.96,"additional_payer_notes":"APC"}]}]},{"description":"Group MNT 2 or more 30 mins","code_information":[{"code":"G0271","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8.98,"maximum":23.1,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11.97,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":23.1,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8.98,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.21,"additional_payer_notes":"APC"}]}]},{"description":"Elec stim unattend for press","code_information":[{"code":"G0281","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8.42,"maximum":21.67,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11.23,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":21.67,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8.42,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11.45,"additional_payer_notes":"APC"}]}]},{"description":"Elec stim other than wound","code_information":[{"code":"G0283","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":9.14,"maximum":23.53,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.19,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":23.53,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9.14,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.43,"additional_payer_notes":"APC"}]}]},{"description":"Neuromod sti sys adj rehab","code_information":[{"code":"A4593","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":39.61,"maximum":101.92,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":52.81,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":101.92,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":39.61,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":53.87,"additional_payer_notes":"APC"}]}]},{"description":"G com garmnt glove nghttime","code_information":[{"code":"A6520","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":94.84,"maximum":244.05,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":126.45,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":244.05,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":94.84,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":128.98,"additional_payer_notes":"APC"}]}]},{"description":"G com garmnt glove nght cust","code_information":[{"code":"A6521","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":376.31,"maximum":968.38,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":501.75,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":968.38,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":376.31,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":511.78,"additional_payer_notes":"APC"}]}]},{"description":"G com garment arm nighttime","code_information":[{"code":"A6522","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":230.44,"maximum":593.01,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":307.26,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":593.01,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":230.44,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":313.41,"additional_payer_notes":"APC"}]}]},{"description":"G com garment arm nght custm","code_information":[{"code":"A6523","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":546.76,"maximum":1407.01,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":729.02,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1407.01,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":546.76,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":743.6,"additional_payer_notes":"APC"}]}]},{"description":"G com garmnt lwr leg/ft nght","code_information":[{"code":"A6524","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":287.5,"maximum":739.85,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":383.34,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":739.85,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":287.5,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":391.01,"additional_payer_notes":"APC"}]}]},{"description":"G com garm lwrleg/ft ngt cus","code_information":[{"code":"A6525","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":580.42,"maximum":1493.63,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":773.9,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1493.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":580.42,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":789.38,"additional_payer_notes":"APC"}]}]},{"description":"G com garmt full leg/ft nght","code_information":[{"code":"A6526","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":519.8,"maximum":1337.61,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":693.06,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1337.61,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":519.8,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":706.92,"additional_payer_notes":"APC"}]}]},{"description":"G garmt full leg/ft nght cus","code_information":[{"code":"A6527","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":955.84,"maximum":2459.69,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1274.45,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2459.69,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":955.84,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1299.94,"additional_payer_notes":"APC"}]}]},{"description":"G com garment bra nighttime","code_information":[{"code":"A6528","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":499.82,"maximum":1286.19,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":666.42,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1286.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":499.82,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":679.75,"additional_payer_notes":"APC"}]}]},{"description":"G com garmt bra night custm","code_information":[{"code":"A6529","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":789.78,"maximum":2032.37,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1053.04,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2032.37,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":789.78,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1074.1,"additional_payer_notes":"APC"}]}]},{"description":"Compression stocking bk18-30","code_information":[{"code":"A6530","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":29.3,"maximum":75.41,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":39.07,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":75.41,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":29.3,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":39.85,"additional_payer_notes":"APC"}]}]},{"description":"Compression stocking bk30-40","code_information":[{"code":"A6531","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":46.24,"maximum":119.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":61.66,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":119.0,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":46.24,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":62.89,"additional_payer_notes":"APC"}]}]},{"description":"Compression stocking bk40-50","code_information":[{"code":"A6532","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":65.16,"maximum":167.68,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":86.88,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":167.68,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":65.16,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":88.62,"additional_payer_notes":"APC"}]}]},{"description":"Gc stocking thighlngth 18-30","code_information":[{"code":"A6533","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":41.14,"maximum":105.88,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":54.86,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":105.88,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":41.14,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":55.96,"additional_payer_notes":"APC"}]}]},{"description":"Gc stocking thighlngth 30-40","code_information":[{"code":"A6534","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":46.99,"maximum":120.91,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":62.65,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":120.91,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":46.99,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":63.9,"additional_payer_notes":"APC"}]}]},{"description":"Gc stocking thighlngth 40-50","code_information":[{"code":"A6535","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":54.1,"maximum":139.21,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":72.13,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":139.21,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":54.1,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":73.57,"additional_payer_notes":"APC"}]}]},{"description":"Gc stocking full lngth 18-30","code_information":[{"code":"A6536","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":55.46,"maximum":142.72,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":73.95,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":142.72,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":55.46,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":75.43,"additional_payer_notes":"APC"}]}]},{"description":"Gc stocking full lngth 30-40","code_information":[{"code":"A6537","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":65.75,"maximum":169.2,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":87.67,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":169.2,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":65.75,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":89.42,"additional_payer_notes":"APC"}]}]},{"description":"Gc stocking full lngth 40-50","code_information":[{"code":"A6538","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":76.99,"maximum":198.11,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":102.65,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":198.11,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":76.99,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":104.7,"additional_payer_notes":"APC"}]}]},{"description":"Gc stocking waistlngth 18-30","code_information":[{"code":"A6539","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":73.4,"maximum":188.87,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":97.86,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":188.87,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":73.4,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":99.82,"additional_payer_notes":"APC"}]}]},{"description":"Gc stocking waistlngth 30-40","code_information":[{"code":"A6540","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":87.51,"maximum":225.19,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":116.68,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":225.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":87.51,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":119.01,"additional_payer_notes":"APC"}]}]},{"description":"Gc stocking waistlngth 40-50","code_information":[{"code":"A6541","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":103.66,"maximum":266.75,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":138.21,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":266.75,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":103.66,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":140.97,"additional_payer_notes":"APC"}]}]},{"description":"Gc stocking garter belt","code_information":[{"code":"A6544","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":29.18,"maximum":75.08,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":38.9,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":75.08,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":29.18,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":39.68,"additional_payer_notes":"APC"}]}]},{"description":"Grad comp non-elastic BK","code_information":[{"code":"A6545","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":91.06,"maximum":234.32,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":121.41,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":234.32,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":91.06,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":123.84,"additional_payer_notes":"APC"}]}]},{"description":"Acces cust grad silic band","code_information":[{"code":"A6548","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":15.64,"maximum":40.26,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20.86,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":40.26,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15.64,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21.28,"additional_payer_notes":"APC"}]}]},{"description":"Grad com stocking bk 30-40","code_information":[{"code":"A6552","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":43.48,"maximum":111.88,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":57.97,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":111.88,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":43.48,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":59.13,"additional_payer_notes":"APC"}]}]},{"description":"G com stcking bk 30-40 custm","code_information":[{"code":"A6553","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":169.78,"maximum":436.91,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":226.38,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":436.91,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":169.78,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":230.91,"additional_payer_notes":"APC"}]}]},{"description":"Grad com stocking bk 40+","code_information":[{"code":"A6554","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":59.79,"maximum":153.86,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":79.72,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":153.86,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":59.79,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":81.31,"additional_payer_notes":"APC"}]}]},{"description":"G com stcking bk 40+ custm","code_information":[{"code":"A6555","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":169.78,"maximum":436.91,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":226.38,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":436.91,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":169.78,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":230.91,"additional_payer_notes":"APC"}]}]},{"description":"G com stcking thgh18-30 cust","code_information":[{"code":"A6556","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":232.69,"maximum":598.78,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":310.25,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":598.78,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":232.69,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":316.46,"additional_payer_notes":"APC"}]}]},{"description":"G com stcking thgh30-40 cust","code_information":[{"code":"A6557","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":232.69,"maximum":598.78,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":310.25,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":598.78,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":232.69,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":316.46,"additional_payer_notes":"APC"}]}]},{"description":"G com stcking thgh 40+ cust","code_information":[{"code":"A6558","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":240.13,"maximum":617.93,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":320.17,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":617.93,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":240.13,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":326.57,"additional_payer_notes":"APC"}]}]},{"description":"G com stckng waist18-30 cust","code_information":[{"code":"A6562","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":761.53,"maximum":1959.66,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1015.37,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1959.66,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":761.53,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1035.68,"additional_payer_notes":"APC"}]}]},{"description":"G com stckng waist30-40 cust","code_information":[{"code":"A6563","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":761.53,"maximum":1959.66,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1015.37,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1959.66,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":761.53,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1035.68,"additional_payer_notes":"APC"}]}]},{"description":"G com stckng waist 40+ cust","code_information":[{"code":"A6564","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":820.34,"maximum":2111.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1093.78,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2111.0,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":820.34,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1115.66,"additional_payer_notes":"APC"}]}]},{"description":"Grad comp gauntlet custom","code_information":[{"code":"A6565","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":131.59,"maximum":338.62,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":175.45,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":338.62,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":131.59,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":178.96,"additional_payer_notes":"APC"}]}]},{"description":"Grad com garment neck/head","code_information":[{"code":"A6566","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":191.06,"maximum":491.67,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":254.75,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":491.67,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":191.06,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":259.84,"additional_payer_notes":"APC"}]}]},{"description":"G com garment neck/head cust","code_information":[{"code":"A6567","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":600.32,"maximum":1544.81,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":800.42,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1544.81,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":600.32,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":816.43,"additional_payer_notes":"APC"}]}]},{"description":"G com garment torso/shldr","code_information":[{"code":"A6568","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":124.7,"maximum":320.88,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":166.26,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":320.88,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":124.7,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":169.59,"additional_payer_notes":"APC"}]}]},{"description":"G com garmnt torso/shdr cust","code_information":[{"code":"A6569","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":710.06,"maximum":1827.21,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":946.74,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1827.21,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":710.06,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":965.67,"additional_payer_notes":"APC"}]}]},{"description":"Grad com garment genital","code_information":[{"code":"A6570","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":84.96,"maximum":218.63,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":113.28,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":218.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":84.96,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":115.55,"additional_payer_notes":"APC"}]}]},{"description":"G com garment genital custm","code_information":[{"code":"A6571","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":510.63,"maximum":1314.02,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":680.84,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1314.02,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":510.63,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":694.46,"additional_payer_notes":"APC"}]}]},{"description":"Grad com garment toe caps","code_information":[{"code":"A6572","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":78.83,"maximum":202.86,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":105.11,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":202.86,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":78.83,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":107.21,"additional_payer_notes":"APC"}]}]},{"description":"Grad com garmnt toe cap cust","code_information":[{"code":"A6573","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":187.07,"maximum":481.4,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":249.43,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":481.4,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":187.07,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":254.42,"additional_payer_notes":"APC"}]}]},{"description":"Custom gradient sleev/glov","code_information":[{"code":"A6574","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":238.49,"maximum":613.72,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":317.99,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":613.72,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":238.49,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":324.35,"additional_payer_notes":"APC"}]}]},{"description":"Gradient comp sleev/glov","code_information":[{"code":"A6575","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":77.29,"maximum":198.89,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":103.05,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":198.89,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":77.29,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":105.11,"additional_payer_notes":"APC"}]}]},{"description":"Custom grad com sleeve med","code_information":[{"code":"A6576","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":146.37,"maximum":376.66,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":195.16,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":376.66,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":146.37,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":199.06,"additional_payer_notes":"APC"}]}]},{"description":"Custom grad cm sleeve heavy","code_information":[{"code":"A6577","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":121.15,"maximum":311.75,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":161.53,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":311.75,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":121.15,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":164.76,"additional_payer_notes":"APC"}]}]},{"description":"Gradient comp sleeve","code_information":[{"code":"A6578","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":59.66,"maximum":153.53,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":79.55,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":153.53,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":59.66,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":81.14,"additional_payer_notes":"APC"}]}]},{"description":"Custom grad com glove med","code_information":[{"code":"A6579","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":234.94,"maximum":604.59,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":313.26,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":604.59,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":234.94,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":319.53,"additional_payer_notes":"APC"}]}]},{"description":"Custom grad com glove heavy","code_information":[{"code":"A6580","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":233.22,"maximum":600.15,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":310.96,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":600.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":233.22,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":317.18,"additional_payer_notes":"APC"}]}]},{"description":"Gradient comp glove","code_information":[{"code":"A6581","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":54.74,"maximum":140.87,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":72.99,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":140.87,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":54.74,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":74.45,"additional_payer_notes":"APC"}]}]},{"description":"Gradient comp gauntlet","code_information":[{"code":"A6582","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":36.51,"maximum":93.95,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":48.68,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":93.95,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":36.51,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":49.65,"additional_payer_notes":"APC"}]}]},{"description":"Grad com wrap w straps bk","code_information":[{"code":"A6583","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":120.1,"maximum":309.05,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":160.13,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":309.05,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":120.1,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":163.33,"additional_payer_notes":"APC"}]}]},{"description":"Grad com wrap w straps ak","code_information":[{"code":"A6585","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":142.2,"maximum":365.93,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":189.6,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":365.93,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":142.2,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":193.39,"additional_payer_notes":"APC"}]}]},{"description":"Grad com wrap w straps leg","code_information":[{"code":"A6586","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":418.94,"maximum":1078.08,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":558.59,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1078.08,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":418.94,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":569.76,"additional_payer_notes":"APC"}]}]},{"description":"Grad com wrap w straps foot","code_information":[{"code":"A6587","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":54.88,"maximum":141.22,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":73.17,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":141.22,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":54.88,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":74.63,"additional_payer_notes":"APC"}]}]},{"description":"Grad com wrap w straps arm","code_information":[{"code":"A6588","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":182.9,"maximum":470.67,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":243.87,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":470.67,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":182.9,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":248.75,"additional_payer_notes":"APC"}]}]},{"description":"Grad com wrap w straps bra","code_information":[{"code":"A6589","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":72.2,"maximum":185.8,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":96.27,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":185.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":72.2,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":98.2,"additional_payer_notes":"APC"}]}]},{"description":"G comp bandge liner lwr extr","code_information":[{"code":"A6594","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":26.29,"maximum":67.65,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":35.05,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":67.65,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26.29,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":35.75,"additional_payer_notes":"APC"}]}]},{"description":"G comp bandge liner upr extr","code_information":[{"code":"A6595","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":25.86,"maximum":66.55,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":34.48,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":66.55,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25.86,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":35.17,"additional_payer_notes":"APC"}]}]},{"description":"G comp bandge conform gauze","code_information":[{"code":"A6596","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":0.14,"maximum":0.35,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":0.18,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":0.35,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":0.14,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":0.18,"additional_payer_notes":"APC"}]}]},{"description":"G comp bandage long stretch","code_information":[{"code":"A6597","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1.16,"maximum":2.99,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1.55,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2.99,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1.16,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1.58,"additional_payer_notes":"APC"}]}]},{"description":"G comp bandage med stretch","code_information":[{"code":"A6598","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":0.56,"maximum":1.45,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":0.75,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1.45,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":0.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":0.76,"additional_payer_notes":"APC"}]}]},{"description":"G comp bandage short stretch","code_information":[{"code":"A6599","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1.28,"maximum":3.28,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1.7,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3.28,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1.28,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1.73,"additional_payer_notes":"APC"}]}]},{"description":"G com bandge hgh dn foam sht","code_information":[{"code":"A6600","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2.3,"maximum":5.93,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3.07,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5.93,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2.3,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3.13,"additional_payer_notes":"APC"}]}]},{"description":"G com bandge hgh dn foam pad","code_information":[{"code":"A6601","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2.59,"maximum":6.66,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3.45,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6.66,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2.59,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3.52,"additional_payer_notes":"APC"}]}]},{"description":"G com bandge hgh dn foamroll","code_information":[{"code":"A6602","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3.77,"maximum":9.71,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5.03,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":9.71,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3.77,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5.13,"additional_payer_notes":"APC"}]}]},{"description":"G com bandge low dn foamchnl","code_information":[{"code":"A6603","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1.77,"maximum":4.55,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2.36,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4.55,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1.77,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2.41,"additional_payer_notes":"APC"}]}]},{"description":"G com bandge low dn foam flt","code_information":[{"code":"A6604","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1.04,"maximum":2.66,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1.38,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2.66,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1.04,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1.41,"additional_payer_notes":"APC"}]}]},{"description":"G com bandage padded foam","code_information":[{"code":"A6605","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1.18,"maximum":3.03,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1.57,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3.03,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1.18,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1.6,"additional_payer_notes":"APC"}]}]},{"description":"G com bandage padded textile","code_information":[{"code":"A6606","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3.5,"maximum":9.01,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4.67,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":9.01,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3.5,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4.76,"additional_payer_notes":"APC"}]}]},{"description":"G com bandage tub protct lyr","code_information":[{"code":"A6607","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":0.94,"maximum":2.41,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1.25,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2.41,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":0.94,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1.28,"additional_payer_notes":"APC"}]}]},{"description":"G com bandage tub protct pad","code_information":[{"code":"A6608","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3.91,"maximum":10.06,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5.21,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":10.06,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3.91,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5.31,"additional_payer_notes":"APC"}]}]},{"description":"G com stcking bk 18-30 custm","code_information":[{"code":"A6610","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":169.78,"maximum":436.91,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":226.38,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":436.91,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":169.78,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":230.91,"additional_payer_notes":"APC"}]}]},{"description":"Penile contractur devic manu","code_information":[{"code":"E0201","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":109.89,"maximum":282.78,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":146.52,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":282.78,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":109.89,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":149.45,"additional_payer_notes":"APC"}]}]},{"description":"Transcut tibial nerv stimula","code_information":[{"code":"E0736","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":39.28,"maximum":101.09,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":52.38,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":101.09,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":39.28,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":53.43,"additional_payer_notes":"APC"}]}]},{"description":"Upper extremity rehab","code_information":[{"code":"E0738","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1529.73,"maximum":3936.51,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2039.64,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3936.51,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1529.73,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2080.43,"additional_payer_notes":"APC"}]}]},{"description":"Rehab sys active assist rt","code_information":[{"code":"E0739","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1198.24,"maximum":3083.48,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1597.66,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3083.48,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1198.24,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1629.61,"additional_payer_notes":"APC"}]}]},{"description":"Glucose monitor w cartridge","code_information":[{"code":"E2104","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":40.89,"maximum":105.22,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":54.52,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":105.22,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":40.89,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":55.61,"additional_payer_notes":"APC"}]}]},{"description":"Cranial cervical orthosis","code_information":[{"code":"L0112","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1290.04,"maximum":3319.72,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1720.06,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3319.72,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1290.04,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1754.46,"additional_payer_notes":"APC"}]}]},{"description":"Cranial cervical torticollis","code_information":[{"code":"L0113","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":262.85,"maximum":676.41,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":350.47,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":676.41,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":262.85,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":357.48,"additional_payer_notes":"APC"}]}]},{"description":"Cerv flex n/adj foam pre ots","code_information":[{"code":"L0120","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":24.38,"maximum":62.74,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":32.51,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":62.74,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":24.38,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":33.16,"additional_payer_notes":"APC"}]}]},{"description":"Flex thermoplastic collar mo","code_information":[{"code":"L0130","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":140.69,"maximum":362.05,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":187.59,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":362.05,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":140.69,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":191.34,"additional_payer_notes":"APC"}]}]},{"description":"Cervical semi-rigid adjustab","code_information":[{"code":"L0140","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":55.17,"maximum":141.97,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":73.56,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":141.97,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":55.17,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":75.03,"additional_payer_notes":"APC"}]}]},{"description":"Cerv semi-rig adj molded chn","code_information":[{"code":"L0150","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":98.66,"maximum":253.87,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":131.54,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":253.87,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":98.66,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":134.17,"additional_payer_notes":"APC"}]}]},{"description":"Cerv sr wire occ/man pre ots","code_information":[{"code":"L0160","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":144.06,"maximum":370.71,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":192.08,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":370.71,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":144.06,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":195.92,"additional_payer_notes":"APC"}]}]},{"description":"Cervical collar molded to pt","code_information":[{"code":"L0170","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":741.08,"maximum":1907.05,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":988.11,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1907.05,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":741.08,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1007.87,"additional_payer_notes":"APC"}]}]},{"description":"Cerv col sr foam 2pc pre ots","code_information":[{"code":"L0172","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":130.54,"maximum":335.92,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":174.05,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":335.92,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":130.54,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":177.53,"additional_payer_notes":"APC"}]}]},{"description":"Cerv sr 2pc thor ext pre ots","code_information":[{"code":"L0174","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":256.68,"maximum":660.52,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":342.24,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":660.52,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":256.68,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":349.08,"additional_payer_notes":"APC"}]}]},{"description":"Cer post col occ/man sup adj","code_information":[{"code":"L0180","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":415.84,"maximum":1070.09,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":554.45,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1070.09,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":415.84,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":565.54,"additional_payer_notes":"APC"}]}]},{"description":"Cerv collar supp adj cerv ba","code_information":[{"code":"L0190","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":490.44,"maximum":1262.07,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":653.92,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1262.07,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":490.44,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":667.0,"additional_payer_notes":"APC"}]}]},{"description":"Cerv col supp adj bar & thor","code_information":[{"code":"L0200","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":568.87,"maximum":1463.89,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":758.49,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1463.89,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":568.87,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":773.66,"additional_payer_notes":"APC"}]}]},{"description":"Thor rib belt custom fabrica","code_information":[{"code":"L0220","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":119.07,"maximum":306.41,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":158.76,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":306.41,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":119.07,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":161.94,"additional_payer_notes":"APC"}]}]},{"description":"Tlso flex trunk/thor pre ots","code_information":[{"code":"L0450","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":92.38,"maximum":237.72,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":123.17,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":237.72,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":92.38,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":125.63,"additional_payer_notes":"APC"}]}]},{"description":"Tlso trnk sj-t9 pre cst","code_information":[{"code":"L0454","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":319.66,"maximum":822.6,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":426.22,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":822.6,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":319.66,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":434.74,"additional_payer_notes":"APC"}]}]},{"description":"Tlso flex trnk sj-t9 pre ots","code_information":[{"code":"L0455","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":171.5,"maximum":441.31,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":228.66,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":441.31,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":171.5,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":233.23,"additional_payer_notes":"APC"}]}]},{"description":"Tlso flex trnk sj-ss pre cst","code_information":[{"code":"L0456","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":916.73,"maximum":2359.06,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1222.31,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2359.06,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":916.73,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1246.76,"additional_payer_notes":"APC"}]}]},{"description":"Tlso flex trnk sj-ss pre ots","code_information":[{"code":"L0457","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":491.8,"maximum":1265.58,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":655.74,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1265.58,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":491.8,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":668.85,"additional_payer_notes":"APC"}]}]},{"description":"TLSO 2Mod symphis-xipho pre","code_information":[{"code":"L0458","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":822.04,"maximum":2115.4,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1096.06,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2115.4,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":822.04,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1117.98,"additional_payer_notes":"APC"}]}]},{"description":"Tlso 2 shl symphys-stern cst","code_information":[{"code":"L0460","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":925.26,"maximum":2381.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1233.68,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2381.0,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":925.26,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1258.35,"additional_payer_notes":"APC"}]}]},{"description":"TLSO 3Mod sacro-scap pre","code_information":[{"code":"L0462","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1150.85,"maximum":2961.53,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1534.47,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2961.53,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1150.85,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1565.16,"additional_payer_notes":"APC"}]}]},{"description":"TLSO 4Mod sacro-scap pre","code_information":[{"code":"L0464","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1370.09,"maximum":3525.7,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1826.79,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3525.7,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1370.09,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1863.33,"additional_payer_notes":"APC"}]}]},{"description":"Tlso r fram soft ant pre cst","code_information":[{"code":"L0466","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":349.7,"maximum":899.88,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":466.26,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":899.88,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":349.7,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":475.59,"additional_payer_notes":"APC"}]}]},{"description":"Tlso r fram soft pre ots","code_information":[{"code":"L0467","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":192.34,"maximum":494.95,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":256.45,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":494.95,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":192.34,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":261.58,"additional_payer_notes":"APC"}]}]},{"description":"Tlso rig fram pelvic pre cst","code_information":[{"code":"L0468","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":438.26,"maximum":1127.78,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":584.34,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1127.78,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":438.26,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":596.03,"additional_payer_notes":"APC"}]}]},{"description":"Tlso rig fram pelvic pre ots","code_information":[{"code":"L0469","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":245.07,"maximum":630.65,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":326.76,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":630.65,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":245.07,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":333.3,"additional_payer_notes":"APC"}]}]},{"description":"TLSO rigid frame pre subclav","code_information":[{"code":"L0470","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":606.44,"maximum":1560.58,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":808.59,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1560.58,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":606.44,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":824.76,"additional_payer_notes":"APC"}]}]},{"description":"TLSO rigid frame hyperex pre","code_information":[{"code":"L0472","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":373.17,"maximum":960.29,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":497.56,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":960.29,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":373.17,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":507.51,"additional_payer_notes":"APC"}]}]},{"description":"TLSO rigid plastic custom fa","code_information":[{"code":"L0480","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1392.22,"maximum":3582.64,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1856.29,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3582.64,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1392.22,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1893.42,"additional_payer_notes":"APC"}]}]},{"description":"TLSO rigid lined custom fab","code_information":[{"code":"L0482","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1555.12,"maximum":4001.84,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2073.49,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4001.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1555.12,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2114.96,"additional_payer_notes":"APC"}]}]},{"description":"TLSO rigid plastic cust fab","code_information":[{"code":"L0484","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1679.45,"maximum":4321.79,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2239.27,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4321.79,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1679.45,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2284.06,"additional_payer_notes":"APC"}]}]},{"description":"TLSO rigidlined cust fab two","code_information":[{"code":"L0486","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1886.09,"maximum":4853.54,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2514.79,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4853.54,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1886.09,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2565.09,"additional_payer_notes":"APC"}]}]},{"description":"TLSO rigid lined pre one pie","code_information":[{"code":"L0488","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":925.26,"maximum":2381.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1233.68,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2381.0,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":925.26,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1258.35,"additional_payer_notes":"APC"}]}]},{"description":"TLSO rigid plastic pre one","code_information":[{"code":"L0490","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":260.73,"maximum":670.95,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":347.64,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":670.95,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":260.73,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":354.59,"additional_payer_notes":"APC"}]}]},{"description":"TLSO 2 piece rigid shell","code_information":[{"code":"L0491","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":707.88,"maximum":1821.61,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":943.84,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1821.61,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":707.88,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":962.72,"additional_payer_notes":"APC"}]}]},{"description":"TLSO 3 piece rigid shell","code_information":[{"code":"L0492","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":460.94,"maximum":1186.16,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":614.59,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1186.16,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":460.94,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":626.88,"additional_payer_notes":"APC"}]}]},{"description":"Sio flex pelvic/sacr pre ots","code_information":[{"code":"L0621","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":48.7,"maximum":125.33,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":64.94,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":125.33,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":48.7,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":66.24,"additional_payer_notes":"APC"}]}]},{"description":"Sio flex pelvisacral custom","code_information":[{"code":"L0622","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":246.36,"maximum":633.97,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":328.48,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":633.97,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":246.36,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":335.05,"additional_payer_notes":"APC"}]}]},{"description":"Sio rig pnl pelv/sac pre ots","code_information":[{"code":"L0623","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":87.31,"maximum":224.67,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":116.41,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":224.67,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":87.31,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":118.74,"additional_payer_notes":"APC"}]}]},{"description":"Lo flex l1-below l5 pre ots","code_information":[{"code":"L0625","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":27.25,"maximum":70.12,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":36.33,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":70.12,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27.25,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":37.06,"additional_payer_notes":"APC"}]}]},{"description":"Lo sag rig pnl stays pre cst","code_information":[{"code":"L0626","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":71.84,"maximum":184.87,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":95.79,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":184.87,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":71.84,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":97.71,"additional_payer_notes":"APC"}]}]},{"description":"Lo sag ri an/pos pnl pre cst","code_information":[{"code":"L0627","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":378.85,"maximum":974.9,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":505.13,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":974.9,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":378.85,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":515.23,"additional_payer_notes":"APC"}]}]},{"description":"Lso flex no ri stays pre ots","code_information":[{"code":"L0628","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":41.49,"maximum":106.77,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":55.32,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":106.77,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":41.49,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":56.43,"additional_payer_notes":"APC"}]}]},{"description":"Lso r post pnl sj-t9 pre cst","code_information":[{"code":"L0630","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":149.29,"maximum":384.17,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":199.05,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":384.17,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":149.29,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":203.03,"additional_payer_notes":"APC"}]}]},{"description":"Lso sag r an/pos pnl pre cst","code_information":[{"code":"L0631","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":946.2,"maximum":2434.89,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1261.6,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2434.89,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":946.2,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1286.83,"additional_payer_notes":"APC"}]}]},{"description":"Lso sc r pos/lat pnl pre cst","code_information":[{"code":"L0633","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":264.31,"maximum":680.15,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":352.41,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":680.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":264.31,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":359.46,"additional_payer_notes":"APC"}]}]},{"description":"Lso sagit rigid panel prefab","code_information":[{"code":"L0635","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":921.02,"maximum":2370.08,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1228.02,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2370.08,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":921.02,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1252.58,"additional_payer_notes":"APC"}]}]},{"description":"Lso sagittal rigid panel cus","code_information":[{"code":"L0636","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1249.66,"maximum":3215.8,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1666.22,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3215.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1249.66,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1699.54,"additional_payer_notes":"APC"}]}]},{"description":"Lso sc r ant/pos pnl pre cst","code_information":[{"code":"L0637","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1194.1,"maximum":3072.81,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1592.13,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3072.81,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1194.1,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1623.97,"additional_payer_notes":"APC"}]}]},{"description":"Lso sag-coronal panel custom","code_information":[{"code":"L0638","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1215.68,"maximum":3128.36,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1620.91,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3128.36,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1215.68,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1653.33,"additional_payer_notes":"APC"}]}]},{"description":"Lso s/c shell/panel prefab","code_information":[{"code":"L0639","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1194.1,"maximum":3072.81,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1592.13,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3072.81,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1194.1,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1623.97,"additional_payer_notes":"APC"}]}]},{"description":"Lso s/c shell/panel custom","code_information":[{"code":"L0640","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":964.48,"maximum":2481.92,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1285.97,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2481.92,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":964.48,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1311.69,"additional_payer_notes":"APC"}]}]},{"description":"Lo rig pos pnl l1-l5 pre ots","code_information":[{"code":"L0641","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":38.55,"maximum":99.2,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":51.4,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":99.2,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":38.55,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":52.43,"additional_payer_notes":"APC"}]}]},{"description":"Lo sag ri an/pos pnl pre ots","code_information":[{"code":"L0642","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":203.31,"maximum":523.18,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":271.08,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":523.18,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":203.31,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":276.5,"additional_payer_notes":"APC"}]}]},{"description":"Lso sag ctr rigi pos pre ots","code_information":[{"code":"L0643","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":80.1,"maximum":206.12,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":106.8,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":206.12,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":80.1,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":108.94,"additional_payer_notes":"APC"}]}]},{"description":"Lso sag r an/pos pnl pre ots","code_information":[{"code":"L0648","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":507.74,"maximum":1306.59,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":676.99,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1306.59,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":507.74,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":690.53,"additional_payer_notes":"APC"}]}]},{"description":"Lso sc r pos/lat pnl pre ots","code_information":[{"code":"L0649","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":141.83,"maximum":364.98,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":189.11,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":364.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":141.83,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":192.89,"additional_payer_notes":"APC"}]}]},{"description":"Lso sc r ant/pos pnl pre ots","code_information":[{"code":"L0650","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":587.48,"maximum":1511.79,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":783.31,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1511.79,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":587.48,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":798.98,"additional_payer_notes":"APC"}]}]},{"description":"LSO sag-co shell pnl pre ots","code_information":[{"code":"L0651","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":587.48,"maximum":1511.79,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":783.31,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1511.79,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":587.48,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":798.98,"additional_payer_notes":"APC"}]}]},{"description":"Ctlso a-p-l control molded","code_information":[{"code":"L0700","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1834.93,"maximum":4721.88,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2446.57,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4721.88,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1834.93,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2495.5,"additional_payer_notes":"APC"}]}]},{"description":"Ctlso a-p-l control w/ inter","code_information":[{"code":"L0710","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2017.06,"maximum":5190.58,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2689.42,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5190.58,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2017.06,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2743.21,"additional_payer_notes":"APC"}]}]},{"description":"Ctlso a-p-l control custom","code_information":[{"code":"L0720","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1785.93,"maximum":4595.79,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2381.24,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4595.79,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1785.93,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2428.86,"additional_payer_notes":"APC"}]}]},{"description":"Halo cervical into jckt vest","code_information":[{"code":"L0810","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2463.68,"maximum":6339.88,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3284.91,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6339.88,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2463.68,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3350.61,"additional_payer_notes":"APC"}]}]},{"description":"Halo cervical into body jack","code_information":[{"code":"L0820","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1938.02,"maximum":4987.16,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2584.02,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4987.16,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1938.02,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2635.7,"additional_payer_notes":"APC"}]}]},{"description":"Halo cerv into milwaukee typ","code_information":[{"code":"L0830","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2965.44,"maximum":7631.07,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3953.92,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7631.07,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2965.44,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4033.0,"additional_payer_notes":"APC"}]}]},{"description":"MRI compatible system","code_information":[{"code":"L0859","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1049.92,"maximum":2701.79,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1399.89,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2701.79,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1049.92,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1427.89,"additional_payer_notes":"APC"}]}]},{"description":"Halo repl liner/interface","code_information":[{"code":"L0861","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":198.67,"maximum":511.24,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":264.89,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":511.24,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":198.67,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":270.19,"additional_payer_notes":"APC"}]}]},{"description":"Tlso corset front","code_information":[{"code":"L0970","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":98.5,"maximum":253.49,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":131.34,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":253.49,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":98.5,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":133.97,"additional_payer_notes":"APC"}]}]},{"description":"Lso corset front","code_information":[{"code":"L0972","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":89.66,"maximum":230.71,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":119.54,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":230.71,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":89.66,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":121.93,"additional_payer_notes":"APC"}]}]},{"description":"Tlso full corset","code_information":[{"code":"L0974","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":161.07,"maximum":414.49,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":214.76,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":414.49,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":161.07,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":219.06,"additional_payer_notes":"APC"}]}]},{"description":"Lso full corset","code_information":[{"code":"L0976","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":137.81,"maximum":354.64,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":183.75,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":354.64,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":137.81,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":187.42,"additional_payer_notes":"APC"}]}]},{"description":"Axillary crutch extension","code_information":[{"code":"L0978","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":173.44,"maximum":446.31,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":231.25,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":446.31,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":173.44,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":235.88,"additional_payer_notes":"APC"}]}]},{"description":"Peroneal straps pair pre ots","code_information":[{"code":"L0980","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":15.74,"maximum":40.51,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20.99,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":40.51,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15.74,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21.41,"additional_payer_notes":"APC"}]}]},{"description":"Stocking sup grips 4 pre ots","code_information":[{"code":"L0982","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":14.42,"maximum":37.11,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19.23,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":37.11,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14.42,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19.61,"additional_payer_notes":"APC"}]}]},{"description":"Protect body sock ea pre ots","code_information":[{"code":"L0984","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":62.37,"maximum":160.5,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":83.16,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":160.5,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":62.37,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":84.82,"additional_payer_notes":"APC"}]}]},{"description":"Ctlso milwauke initial model","code_information":[{"code":"L1000","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1869.03,"maximum":4809.64,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2492.04,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4809.64,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1869.03,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2541.88,"additional_payer_notes":"APC"}]}]},{"description":"Tension based scoliosis orth","code_information":[{"code":"L1005","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2950.1,"maximum":7591.58,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3933.46,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7591.58,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2950.1,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4012.13,"additional_payer_notes":"APC"}]}]},{"description":"Ctlso axilla sling","code_information":[{"code":"L1010","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":77.12,"maximum":198.46,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":102.83,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":198.46,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":77.12,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":104.89,"additional_payer_notes":"APC"}]}]},{"description":"Kyphosis pad","code_information":[{"code":"L1020","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":99.32,"maximum":255.59,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":132.43,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":255.59,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":99.32,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":135.08,"additional_payer_notes":"APC"}]}]},{"description":"Kyphosis pad floating","code_information":[{"code":"L1025","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":143.3,"maximum":368.75,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":191.06,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":368.75,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":143.3,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":194.88,"additional_payer_notes":"APC"}]}]},{"description":"Lumbar bolster pad","code_information":[{"code":"L1030","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":72.17,"maximum":185.72,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":96.23,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":185.72,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":72.17,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":98.15,"additional_payer_notes":"APC"}]}]},{"description":"Lumbar or lumbar rib pad","code_information":[{"code":"L1040","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":81.72,"maximum":210.29,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":108.96,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":210.29,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":81.72,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":111.14,"additional_payer_notes":"APC"}]}]},{"description":"Sternal pad","code_information":[{"code":"L1050","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":92.48,"maximum":237.99,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":123.31,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":237.99,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":92.48,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":125.78,"additional_payer_notes":"APC"}]}]},{"description":"Thoracic pad","code_information":[{"code":"L1060","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":99.82,"maximum":256.88,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":133.1,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":256.88,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":99.82,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":135.76,"additional_payer_notes":"APC"}]}]},{"description":"Trapezius sling","code_information":[{"code":"L1070","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":103.41,"maximum":266.11,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":137.88,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":266.11,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":103.41,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":140.64,"additional_payer_notes":"APC"}]}]},{"description":"Outrigger","code_information":[{"code":"L1080","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":48.22,"maximum":124.1,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":64.3,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":124.1,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":48.22,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":65.59,"additional_payer_notes":"APC"}]}]},{"description":"Outrigger bil w/ vert extens","code_information":[{"code":"L1085","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":161.45,"maximum":415.47,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":215.27,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":415.47,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":161.45,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":219.58,"additional_payer_notes":"APC"}]}]},{"description":"Lumbar sling","code_information":[{"code":"L1090","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":92.74,"maximum":238.66,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":123.66,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":238.66,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":92.74,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":126.13,"additional_payer_notes":"APC"}]}]},{"description":"Ring flange plastic/leather","code_information":[{"code":"L1100","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":175.04,"maximum":450.44,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":233.39,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":450.44,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":175.04,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":238.06,"additional_payer_notes":"APC"}]}]},{"description":"Ring flange plas/leather mol","code_information":[{"code":"L1110","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":293.48,"maximum":755.23,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":391.31,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":755.23,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":293.48,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":399.14,"additional_payer_notes":"APC"}]}]},{"description":"Covers for upright each","code_information":[{"code":"L1120","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":35.06,"maximum":90.21,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":46.74,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":90.21,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":35.06,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":47.67,"additional_payer_notes":"APC"}]}]},{"description":"Furnsh initial orthosis only","code_information":[{"code":"L1200","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1649.43,"maximum":4244.53,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2199.24,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4244.53,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1649.43,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2243.22,"additional_payer_notes":"APC"}]}]},{"description":"Lateral thoracic extension","code_information":[{"code":"L1210","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":225.51,"maximum":580.31,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":300.68,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":580.31,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":225.51,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":306.69,"additional_payer_notes":"APC"}]}]},{"description":"Anterior thoracic extension","code_information":[{"code":"L1220","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":219.5,"maximum":564.83,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":292.66,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":564.83,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":219.5,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":298.51,"additional_payer_notes":"APC"}]}]},{"description":"Milwaukee type superstructur","code_information":[{"code":"L1230","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":614.9,"maximum":1582.33,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":819.86,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1582.33,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":614.9,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":836.26,"additional_payer_notes":"APC"}]}]},{"description":"Lumbar derotation pad","code_information":[{"code":"L1240","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":83.83,"maximum":215.72,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":111.77,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":215.72,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":83.83,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":114.01,"additional_payer_notes":"APC"}]}]},{"description":"Anterior asis pad","code_information":[{"code":"L1250","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":72.9,"maximum":187.6,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":97.2,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":187.6,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":72.9,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":99.14,"additional_payer_notes":"APC"}]}]},{"description":"Anterior thoracic derotation","code_information":[{"code":"L1260","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":86.93,"maximum":223.71,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":115.91,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":223.71,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":86.93,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":118.23,"additional_payer_notes":"APC"}]}]},{"description":"Abdominal pad","code_information":[{"code":"L1270","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":76.4,"maximum":196.59,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":101.86,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":196.59,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":76.4,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":103.9,"additional_payer_notes":"APC"}]}]},{"description":"Rib gusset (elastic) each","code_information":[{"code":"L1280","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":80.54,"maximum":207.26,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":107.39,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":207.26,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":80.54,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":109.54,"additional_payer_notes":"APC"}]}]},{"description":"Lateral trochanteric pad","code_information":[{"code":"L1290","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":71.62,"maximum":184.3,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":95.49,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":184.3,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":71.62,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":97.4,"additional_payer_notes":"APC"}]}]},{"description":"Body jacket mold to patient","code_information":[{"code":"L1300","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1588.55,"maximum":4087.88,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2118.07,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4087.88,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1588.55,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2160.43,"additional_payer_notes":"APC"}]}]},{"description":"Post-operative body jacket","code_information":[{"code":"L1310","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1654.61,"maximum":4257.87,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2206.15,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4257.87,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1654.61,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2250.27,"additional_payer_notes":"APC"}]}]},{"description":"Ho flex frejka w/cov pre cst","code_information":[{"code":"L1600","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":118.78,"maximum":305.65,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":158.37,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":305.65,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":118.78,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":161.54,"additional_payer_notes":"APC"}]}]},{"description":"Ho frejka cov only pre cst","code_information":[{"code":"L1610","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":50.44,"maximum":129.81,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":67.26,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":129.81,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":50.44,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":68.61,"additional_payer_notes":"APC"}]}]},{"description":"Ho flex pavlik harns pre cst","code_information":[{"code":"L1620","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":144.82,"maximum":372.68,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":193.1,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":372.68,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":144.82,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":196.96,"additional_payer_notes":"APC"}]}]},{"description":"Abduct control hip semi-flex","code_information":[{"code":"L1630","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":194.72,"maximum":501.09,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":259.63,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":501.09,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":194.72,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":264.82,"additional_payer_notes":"APC"}]}]},{"description":"Pelv band/spread bar thigh c","code_information":[{"code":"L1640","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":436.34,"maximum":1122.85,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":581.79,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1122.85,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":436.34,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":593.43,"additional_payer_notes":"APC"}]}]},{"description":"HO abduction hip adjustable","code_information":[{"code":"L1650","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":227.3,"maximum":584.93,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":303.07,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":584.93,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":227.3,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":309.13,"additional_payer_notes":"APC"}]}]},{"description":"HO bi thighcuffs w sprdr bar","code_information":[{"code":"L1652","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":328.57,"maximum":845.51,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":438.09,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":845.51,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":328.57,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":446.85,"additional_payer_notes":"APC"}]}]},{"description":"HO abduction static plastic","code_information":[{"code":"L1660","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":166.56,"maximum":428.61,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":222.08,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":428.61,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":166.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":226.52,"additional_payer_notes":"APC"}]}]},{"description":"Pelvic & hip control thigh c","code_information":[{"code":"L1680","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1050.08,"maximum":2702.21,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1400.11,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2702.21,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1050.08,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1428.11,"additional_payer_notes":"APC"}]}]},{"description":"Ho bilateral hip abduction","code_information":[{"code":"L1681","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1727.34,"maximum":4445.02,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2303.12,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4445.02,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1727.34,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2349.18,"additional_payer_notes":"APC"}]}]},{"description":"Post-op hip abduct custom fa","code_information":[{"code":"L1685","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1025.14,"maximum":2638.04,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1366.86,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2638.04,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1025.14,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1394.2,"additional_payer_notes":"APC"}]}]},{"description":"HO post-op hip abduction","code_information":[{"code":"L1686","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":863.67,"maximum":2222.51,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1151.56,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2222.51,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":863.67,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1174.59,"additional_payer_notes":"APC"}]}]},{"description":"Combination bilateral HO","code_information":[{"code":"L1690","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1782.38,"maximum":4586.66,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2376.51,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4586.66,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1782.38,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2424.04,"additional_payer_notes":"APC"}]}]},{"description":"Leg perthes orth toronto typ","code_information":[{"code":"L1700","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1434.03,"maximum":3690.24,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1912.04,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3690.24,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1434.03,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1950.28,"additional_payer_notes":"APC"}]}]},{"description":"Legg perthes orth newington","code_information":[{"code":"L1710","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1826.09,"maximum":4699.14,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2434.79,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4699.14,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1826.09,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2483.49,"additional_payer_notes":"APC"}]}]},{"description":"Legg perthes orthosis trilat","code_information":[{"code":"L1720","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1359.7,"maximum":3498.97,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1812.94,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3498.97,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1359.7,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1849.2,"additional_payer_notes":"APC"}]}]},{"description":"Legg perthes orth scottish r","code_information":[{"code":"L1730","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1147.89,"maximum":2953.9,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1530.52,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2953.9,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1147.89,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1561.13,"additional_payer_notes":"APC"}]}]},{"description":"Legg perthes patten bottom t","code_information":[{"code":"L1755","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1650.34,"maximum":4246.87,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2200.45,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4246.87,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1650.34,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2244.46,"additional_payer_notes":"APC"}]}]},{"description":"Ko elastic with joints","code_information":[{"code":"L1810","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":94.89,"maximum":244.18,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":126.52,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":244.18,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":94.89,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":129.05,"additional_payer_notes":"APC"}]}]},{"description":"Ko elastic w/joints pre ots","code_information":[{"code":"L1812","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":58.88,"maximum":151.52,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":78.51,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":151.52,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":58.88,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":80.08,"additional_payer_notes":"APC"}]}]},{"description":"Ko elas w/ condyle pads & jo","code_information":[{"code":"L1820","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":130.99,"maximum":337.07,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":174.65,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":337.07,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":130.99,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":178.14,"additional_payer_notes":"APC"}]}]},{"description":"Ko immob canvas long pre ots","code_information":[{"code":"L1830","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":53.06,"maximum":136.55,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":70.75,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":136.55,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":53.06,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":72.16,"additional_payer_notes":"APC"}]}]},{"description":"Knee orth pos locking joint","code_information":[{"code":"L1831","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":271.28,"maximum":698.08,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":361.7,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":698.08,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":271.28,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":368.93,"additional_payer_notes":"APC"}]}]},{"description":"Ko adj jnt pos r sup pre cst","code_information":[{"code":"L1832","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":634.88,"maximum":1633.76,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":846.51,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1633.76,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":634.88,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":863.44,"additional_payer_notes":"APC"}]}]},{"description":"Ko adj jnt pos r sup pre ots","code_information":[{"code":"L1833","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":382.22,"maximum":983.59,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":509.63,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":983.59,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":382.22,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":519.82,"additional_payer_notes":"APC"}]}]},{"description":"Ko w/0 joint rigid molded to","code_information":[{"code":"L1834","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":669.02,"maximum":1721.6,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":892.02,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1721.6,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":669.02,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":909.86,"additional_payer_notes":"APC"}]}]},{"description":"Ko rigid w/o joints pre ots","code_information":[{"code":"L1836","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":75.02,"maximum":193.06,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":100.03,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":193.06,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":75.02,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":102.03,"additional_payer_notes":"APC"}]}]},{"description":"Ko derot ant cruciate custom","code_information":[{"code":"L1840","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":866.79,"maximum":2230.54,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1155.72,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2230.54,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":866.79,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1178.83,"additional_payer_notes":"APC"}]}]},{"description":"Ko single upright pre cst","code_information":[{"code":"L1843","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":827.03,"maximum":2128.23,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1102.71,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2128.23,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":827.03,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1124.76,"additional_payer_notes":"APC"}]}]},{"description":"Ko w/adj jt rot cntrl molded","code_information":[{"code":"L1844","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1403.63,"maximum":3612.01,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1871.51,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3612.01,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1403.63,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1908.94,"additional_payer_notes":"APC"}]}]},{"description":"Ko double upright pre cst","code_information":[{"code":"L1845","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":772.11,"maximum":1986.9,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1029.48,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1986.9,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":772.11,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1050.07,"additional_payer_notes":"APC"}]}]},{"description":"Ko w adj flex/ext rotat mold","code_information":[{"code":"L1846","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1078.44,"maximum":2775.19,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1437.92,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2775.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1078.44,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1466.68,"additional_payer_notes":"APC"}]}]},{"description":"Ko dbl upright w/air pre cst","code_information":[{"code":"L1847","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":530.14,"maximum":1364.24,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":706.86,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1364.24,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":530.14,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":721.0,"additional_payer_notes":"APC"}]}]},{"description":"Ko dbl upright w/air pre ots","code_information":[{"code":"L1848","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":530.14,"maximum":1364.24,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":706.86,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1364.24,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":530.14,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":721.0,"additional_payer_notes":"APC"}]}]},{"description":"Ko swedish type pre ots","code_information":[{"code":"L1850","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":172.8,"maximum":444.67,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":230.4,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":444.67,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":172.8,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":235.01,"additional_payer_notes":"APC"}]}]},{"description":"Ko single upright prefab ots","code_information":[{"code":"L1851","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":504.5,"maximum":1298.25,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":672.67,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1298.25,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":504.5,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":686.12,"additional_payer_notes":"APC"}]}]},{"description":"Ko double upright prefab ots","code_information":[{"code":"L1852","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":481.29,"maximum":1238.52,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":641.72,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1238.52,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":481.29,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":654.55,"additional_payer_notes":"APC"}]}]},{"description":"Ko supracondylar socket mold","code_information":[{"code":"L1860","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1149.37,"maximum":2957.71,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1532.49,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2957.71,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1149.37,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1563.14,"additional_payer_notes":"APC"}]}]},{"description":"Afo sprng wir drsflx calf bd","code_information":[{"code":"L1900","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":262.98,"maximum":676.74,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":350.64,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":676.74,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":262.98,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":357.65,"additional_payer_notes":"APC"}]}]},{"description":"Afo ankle gauntlet pre ots","code_information":[{"code":"L1902","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":68.8,"maximum":177.04,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":91.73,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":177.04,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":68.8,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":93.56,"additional_payer_notes":"APC"}]}]},{"description":"Afo molded ankle gauntlet","code_information":[{"code":"L1904","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":416.04,"maximum":1070.61,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":554.72,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1070.61,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":416.04,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":565.81,"additional_payer_notes":"APC"}]}]},{"description":"Afo multilig ank sup pre ots","code_information":[{"code":"L1906","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":103.65,"maximum":266.73,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":138.2,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":266.73,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":103.65,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":140.96,"additional_payer_notes":"APC"}]}]},{"description":"AFO supramalleolar custom","code_information":[{"code":"L1907","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":518.66,"maximum":1334.69,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":691.55,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1334.69,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":518.66,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":705.38,"additional_payer_notes":"APC"}]}]},{"description":"Afo sing bar clasp attach sh","code_information":[{"code":"L1910","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":258.49,"maximum":665.17,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":344.65,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":665.17,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":258.49,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":351.54,"additional_payer_notes":"APC"}]}]},{"description":"Afo sing upright w/ adjust s","code_information":[{"code":"L1920","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":378.64,"maximum":974.38,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":504.86,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":974.38,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":378.64,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":514.96,"additional_payer_notes":"APC"}]}]},{"description":"Afo plastic","code_information":[{"code":"L1930","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":232.2,"maximum":597.53,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":309.6,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":597.53,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":232.2,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":315.79,"additional_payer_notes":"APC"}]}]},{"description":"Afo rig ant tib prefab TCF/=","code_information":[{"code":"L1932","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":822.48,"maximum":2116.52,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1096.64,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2116.52,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":822.48,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1118.57,"additional_payer_notes":"APC"}]}]},{"description":"Afo rig ant tib tcf/= ots","code_information":[{"code":"L1933","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":822.48,"maximum":2116.52,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1096.64,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2116.52,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":822.48,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1118.57,"additional_payer_notes":"APC"}]}]},{"description":"Afo molded to patient plasti","code_information":[{"code":"L1940","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":448.85,"maximum":1155.05,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":598.47,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1155.05,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":448.85,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":610.44,"additional_payer_notes":"APC"}]}]},{"description":"Afo molded plas rig ant tib","code_information":[{"code":"L1945","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1034.62,"maximum":2662.42,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1379.49,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2662.42,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1034.62,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1407.08,"additional_payer_notes":"APC"}]}]},{"description":"Afo spiral molded to pt plas","code_information":[{"code":"L1950","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":708.86,"maximum":1824.12,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":945.14,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1824.12,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":708.86,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":964.04,"additional_payer_notes":"APC"}]}]},{"description":"AFO spiral prefabricated","code_information":[{"code":"L1951","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":774.07,"maximum":1991.93,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1032.09,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1991.93,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":774.07,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1052.73,"additional_payer_notes":"APC"}]}]},{"description":"Afo spiral prefab ots","code_information":[{"code":"L1952","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":774.07,"maximum":1991.93,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1032.09,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1991.93,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":774.07,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1052.73,"additional_payer_notes":"APC"}]}]},{"description":"Afo pos solid ank plastic mo","code_information":[{"code":"L1960","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":571.35,"maximum":1470.27,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":761.8,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1470.27,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":571.35,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":777.04,"additional_payer_notes":"APC"}]}]},{"description":"Afo plastic molded w/ankle j","code_information":[{"code":"L1970","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":637.96,"maximum":1641.68,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":850.61,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1641.68,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":637.96,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":867.62,"additional_payer_notes":"APC"}]}]},{"description":"AFO w/ankle joint, prefab","code_information":[{"code":"L1971","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":432.08,"maximum":1111.87,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":576.1,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1111.87,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":432.08,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":587.62,"additional_payer_notes":"APC"}]}]},{"description":"Afo sing solid stirrup calf","code_information":[{"code":"L1980","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":372.16,"maximum":957.69,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":496.21,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":957.69,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":372.16,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":506.13,"additional_payer_notes":"APC"}]}]},{"description":"Afo doub solid stirrup calf","code_information":[{"code":"L1990","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":430.72,"maximum":1108.4,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":574.3,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1108.4,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":430.72,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":585.79,"additional_payer_notes":"APC"}]}]},{"description":"Kafo sing fre stirr thi/calf","code_information":[{"code":"L2000","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1031.11,"maximum":2653.38,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1374.81,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2653.38,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1031.11,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1402.31,"additional_payer_notes":"APC"}]}]},{"description":"KAFO sng/dbl mechanical act","code_information":[{"code":"L2005","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3776.95,"maximum":9719.34,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5035.93,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":9719.34,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3776.95,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5136.65,"additional_payer_notes":"APC"}]}]},{"description":"Kafo sng solid stirrup w/o j","code_information":[{"code":"L2010","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":804.26,"maximum":2069.62,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1072.34,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2069.62,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":804.26,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1093.79,"additional_payer_notes":"APC"}]}]},{"description":"Kafo dbl solid stirrup band/","code_information":[{"code":"L2020","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1015.75,"maximum":2613.86,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1354.33,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2613.86,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1015.75,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1381.42,"additional_payer_notes":"APC"}]}]},{"description":"Kafo dbl solid stirrup w/o j","code_information":[{"code":"L2030","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":998.39,"maximum":2569.2,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1331.19,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2569.2,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":998.39,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1357.81,"additional_payer_notes":"APC"}]}]},{"description":"Kafo pla sin up w/wo k/a cus","code_information":[{"code":"L2034","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1872.44,"maximum":4818.42,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2496.59,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4818.42,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1872.44,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2546.52,"additional_payer_notes":"APC"}]}]},{"description":"KAFO plastic pediatric size","code_information":[{"code":"L2035","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":159.68,"maximum":410.92,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":212.91,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":410.92,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":159.68,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":217.17,"additional_payer_notes":"APC"}]}]},{"description":"Kafo plas doub free knee mol","code_information":[{"code":"L2036","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1708.82,"maximum":4397.37,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2278.43,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4397.37,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1708.82,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2324.0,"additional_payer_notes":"APC"}]}]},{"description":"Kafo plas sing free knee mol","code_information":[{"code":"L2037","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1528.52,"maximum":3933.38,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2038.02,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3933.38,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1528.52,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2078.78,"additional_payer_notes":"APC"}]}]},{"description":"Kafo w/o joint multi-axis an","code_information":[{"code":"L2038","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1232.2,"maximum":3170.87,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1642.94,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3170.87,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1232.2,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1675.8,"additional_payer_notes":"APC"}]}]},{"description":"Hkafo torsion bil rot straps","code_information":[{"code":"L2040","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":186.47,"maximum":479.86,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":248.63,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":479.86,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":186.47,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":253.6,"additional_payer_notes":"APC"}]}]},{"description":"Hkafo torsion cable hip pelv","code_information":[{"code":"L2050","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":449.16,"maximum":1155.84,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":598.88,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1155.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":449.16,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":610.86,"additional_payer_notes":"APC"}]}]},{"description":"Hkafo torsion ball bearing j","code_information":[{"code":"L2060","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":561.81,"maximum":1445.72,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":749.08,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1445.72,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":561.81,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":764.06,"additional_payer_notes":"APC"}]}]},{"description":"Hkafo torsion unilat rot str","code_information":[{"code":"L2070","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":143.06,"maximum":368.15,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":190.75,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":368.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":143.06,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":194.56,"additional_payer_notes":"APC"}]}]},{"description":"Hkafo unilat torsion cable","code_information":[{"code":"L2080","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":343.97,"maximum":885.16,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":458.63,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":885.16,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":343.97,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":467.8,"additional_payer_notes":"APC"}]}]},{"description":"Hkafo unilat torsion ball br","code_information":[{"code":"L2090","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":458.3,"maximum":1179.37,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":611.07,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1179.37,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":458.3,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":623.29,"additional_payer_notes":"APC"}]}]},{"description":"Afo tib fx cast plaster mold","code_information":[{"code":"L2106","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":726.51,"maximum":1869.55,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":968.68,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1869.55,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":726.51,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":988.05,"additional_payer_notes":"APC"}]}]},{"description":"Afo tib fx cast molded to pt","code_information":[{"code":"L2108","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1059.64,"maximum":2726.8,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1412.85,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2726.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1059.64,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1441.11,"additional_payer_notes":"APC"}]}]},{"description":"Afo tibial fracture soft","code_information":[{"code":"L2112","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":465.02,"maximum":1196.64,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":620.02,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1196.64,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":465.02,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":632.42,"additional_payer_notes":"APC"}]}]},{"description":"Afo tib fx semi-rigid","code_information":[{"code":"L2114","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":582.44,"maximum":1498.82,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":776.59,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1498.82,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":582.44,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":792.12,"additional_payer_notes":"APC"}]}]},{"description":"Afo tibial fracture rigid","code_information":[{"code":"L2116","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":710.4,"maximum":1828.1,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":947.2,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1828.1,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":710.4,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":966.14,"additional_payer_notes":"APC"}]}]},{"description":"Kafo fem fx cast thermoplas","code_information":[{"code":"L2126","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1176.93,"maximum":3028.63,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1569.24,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3028.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1176.93,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1600.62,"additional_payer_notes":"APC"}]}]},{"description":"Kafo fem fx cast molded to p","code_information":[{"code":"L2128","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1477.83,"maximum":3802.95,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1970.44,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3802.95,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1477.83,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2009.85,"additional_payer_notes":"APC"}]}]},{"description":"Kafo femoral fx cast soft","code_information":[{"code":"L2132","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":897.02,"maximum":2308.32,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1196.02,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2308.32,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":897.02,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1219.94,"additional_payer_notes":"APC"}]}]},{"description":"Kafo fem fx cast semi-rigid","code_information":[{"code":"L2134","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1062.18,"maximum":2733.34,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1416.24,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2733.34,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1062.18,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1444.56,"additional_payer_notes":"APC"}]}]},{"description":"Kafo femoral fx cast rigid","code_information":[{"code":"L2136","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1162.4,"maximum":2991.23,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1549.86,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2991.23,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1162.4,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1580.86,"additional_payer_notes":"APC"}]}]},{"description":"Plas shoe insert w ank joint","code_information":[{"code":"L2180","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":122.19,"maximum":314.44,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":162.92,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":314.44,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":122.19,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":166.18,"additional_payer_notes":"APC"}]}]},{"description":"Drop lock knee","code_information":[{"code":"L2182","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":105.32,"maximum":271.03,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":140.43,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":271.03,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":105.32,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":143.24,"additional_payer_notes":"APC"}]}]},{"description":"Limited motion knee joint","code_information":[{"code":"L2184","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":106.76,"maximum":274.74,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":142.35,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":274.74,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":106.76,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":145.2,"additional_payer_notes":"APC"}]}]},{"description":"Adj motion knee jnt lerman t","code_information":[{"code":"L2186","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":141.98,"maximum":365.37,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":189.31,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":365.37,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":141.98,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":193.1,"additional_payer_notes":"APC"}]}]},{"description":"Quadrilateral brim","code_information":[{"code":"L2188","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":258.11,"maximum":664.21,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":344.15,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":664.21,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":258.11,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":351.03,"additional_payer_notes":"APC"}]}]},{"description":"Waist belt","code_information":[{"code":"L2190","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":78.62,"maximum":202.32,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":104.83,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":202.32,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":78.62,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":106.93,"additional_payer_notes":"APC"}]}]},{"description":"Pelvic band & belt thigh fla","code_information":[{"code":"L2192","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":307.3,"maximum":790.78,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":409.73,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":790.78,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":307.3,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":417.92,"additional_payer_notes":"APC"}]}]},{"description":"Limited ankle motion ea jnt","code_information":[{"code":"L2200","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":46.31,"maximum":119.18,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":61.75,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":119.18,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":46.31,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":62.98,"additional_payer_notes":"APC"}]}]},{"description":"Dorsiflexion assist each joi","code_information":[{"code":"L2210","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":57.93,"maximum":149.07,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":77.24,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":149.07,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":57.93,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":78.78,"additional_payer_notes":"APC"}]}]},{"description":"Dorsi & plantar flex ass/res","code_information":[{"code":"L2220","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":74.57,"maximum":191.9,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":99.43,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":191.9,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":74.57,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":101.42,"additional_payer_notes":"APC"}]}]},{"description":"Ank mcrop plant & dorsi flex","code_information":[{"code":"L2221","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1318.28,"maximum":3392.36,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1757.7,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3392.36,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1318.28,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1792.85,"additional_payer_notes":"APC"}]}]},{"description":"Split flat caliper stirr & p","code_information":[{"code":"L2230","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":88.17,"maximum":226.89,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":117.56,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":226.89,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":88.17,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":119.91,"additional_payer_notes":"APC"}]}]},{"description":"Rocker bottom, contact AFO","code_information":[{"code":"L2232","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":89.54,"maximum":230.4,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":119.38,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":230.4,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":89.54,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":121.77,"additional_payer_notes":"APC"}]}]},{"description":"Round caliper and plate atta","code_information":[{"code":"L2240","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":87.76,"maximum":225.83,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":117.01,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":225.83,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":87.76,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":119.35,"additional_payer_notes":"APC"}]}]},{"description":"Foot plate molded stirrup at","code_information":[{"code":"L2250","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":307.88,"maximum":792.26,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":410.5,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":792.26,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":307.88,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":418.71,"additional_payer_notes":"APC"}]}]},{"description":"Reinforced solid stirrup","code_information":[{"code":"L2260","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":172.76,"maximum":444.58,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":230.35,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":444.58,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":172.76,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":234.96,"additional_payer_notes":"APC"}]}]},{"description":"Long tongue stirrup","code_information":[{"code":"L2265","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":123.91,"maximum":318.86,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":165.21,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":318.86,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":123.91,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":168.51,"additional_payer_notes":"APC"}]}]},{"description":"Varus/valgus strap padded/li","code_information":[{"code":"L2270","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":56.82,"maximum":146.22,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":75.76,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":146.22,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":56.82,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":77.28,"additional_payer_notes":"APC"}]}]},{"description":"Plastic mod low ext pad/line","code_information":[{"code":"L2275","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":120.14,"maximum":309.17,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":160.19,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":309.17,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":120.14,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":163.39,"additional_payer_notes":"APC"}]}]},{"description":"Molded inner boot","code_information":[{"code":"L2280","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":520.34,"maximum":1339.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":693.78,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1339.0,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":520.34,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":707.66,"additional_payer_notes":"APC"}]}]},{"description":"Abduction bar jointed adjust","code_information":[{"code":"L2300","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":232.04,"maximum":597.12,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":309.39,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":597.12,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":232.04,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":315.58,"additional_payer_notes":"APC"}]}]},{"description":"Abduction bar-straight","code_information":[{"code":"L2310","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":106.03,"maximum":272.84,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":141.37,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":272.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":106.03,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":144.2,"additional_payer_notes":"APC"}]}]},{"description":"Non-molded lacer","code_information":[{"code":"L2320","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":177.81,"maximum":457.56,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":237.08,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":457.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":177.81,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":241.82,"additional_payer_notes":"APC"}]}]},{"description":"Lacer molded to patient mode","code_information":[{"code":"L2330","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":338.41,"maximum":870.84,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":451.21,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":870.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":338.41,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":460.23,"additional_payer_notes":"APC"}]}]},{"description":"Anterior swing band","code_information":[{"code":"L2335","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":259.1,"maximum":666.74,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":345.46,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":666.74,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":259.1,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":352.37,"additional_payer_notes":"APC"}]}]},{"description":"Pre-tibial shell molded to p","code_information":[{"code":"L2340","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":385.18,"maximum":991.21,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":513.58,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":991.21,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":385.18,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":523.85,"additional_payer_notes":"APC"}]}]},{"description":"Prosthetic type socket molde","code_information":[{"code":"L2350","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":767.94,"maximum":1976.17,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1023.92,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1976.17,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":767.94,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1044.4,"additional_payer_notes":"APC"}]}]},{"description":"Extended steel shank","code_information":[{"code":"L2360","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":47.53,"maximum":122.3,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":63.37,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":122.3,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":47.53,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":64.64,"additional_payer_notes":"APC"}]}]},{"description":"Patten bottom","code_information":[{"code":"L2370","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":294.98,"maximum":759.09,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":393.31,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":759.09,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":294.98,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":401.18,"additional_payer_notes":"APC"}]}]},{"description":"Torsion ank & half solid sti","code_information":[{"code":"L2375","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":113.42,"maximum":291.85,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":151.22,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":291.85,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":113.42,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":154.24,"additional_payer_notes":"APC"}]}]},{"description":"Torsion straight knee joint","code_information":[{"code":"L2380","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":118.95,"maximum":306.1,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":158.6,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":306.1,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":118.95,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":161.77,"additional_payer_notes":"APC"}]}]},{"description":"Straight knee joint heavy du","code_information":[{"code":"L2385","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":135.44,"maximum":348.52,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":180.58,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":348.52,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":135.44,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":184.19,"additional_payer_notes":"APC"}]}]},{"description":"Add le poly knee custom kafo","code_information":[{"code":"L2387","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":175.95,"maximum":452.78,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":234.6,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":452.78,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":175.95,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":239.29,"additional_payer_notes":"APC"}]}]},{"description":"Offset knee joint each","code_information":[{"code":"L2390","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":94.34,"maximum":242.77,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":125.79,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":242.77,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":94.34,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":128.31,"additional_payer_notes":"APC"}]}]},{"description":"Offset knee joint heavy duty","code_information":[{"code":"L2395","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":134.85,"maximum":347.01,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":179.8,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":347.01,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":134.85,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":183.4,"additional_payer_notes":"APC"}]}]},{"description":"Suspension sleeve lower ext","code_information":[{"code":"L2397","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":112.5,"maximum":289.5,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":150.0,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":289.5,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":112.5,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":153.0,"additional_payer_notes":"APC"}]}]},{"description":"Knee joint drop lock ea jnt","code_information":[{"code":"L2405","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":80.36,"maximum":206.78,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":107.14,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":206.78,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":80.36,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":109.28,"additional_payer_notes":"APC"}]}]},{"description":"Knee joint cam lock each joi","code_information":[{"code":"L2415","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":111.98,"maximum":288.15,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":149.3,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":288.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":111.98,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":152.29,"additional_payer_notes":"APC"}]}]},{"description":"Knee disc/dial lock/adj flex","code_information":[{"code":"L2425","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":132.13,"maximum":340.01,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":176.17,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":340.01,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":132.13,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":179.69,"additional_payer_notes":"APC"}]}]},{"description":"Knee jnt ratchet lock ea jnt","code_information":[{"code":"L2430","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":132.13,"maximum":340.01,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":176.17,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":340.01,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":132.13,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":179.69,"additional_payer_notes":"APC"}]}]},{"description":"Knee lift loop drop lock rin","code_information":[{"code":"L2492","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":108.11,"maximum":278.21,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":144.15,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":278.21,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":108.11,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":147.03,"additional_payer_notes":"APC"}]}]},{"description":"Thi/glut/ischia wgt bearing","code_information":[{"code":"L2500","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":288.44,"maximum":742.24,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":384.58,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":742.24,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":288.44,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":392.27,"additional_payer_notes":"APC"}]}]},{"description":"Th/wght bear quad-lat brim m","code_information":[{"code":"L2510","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":743.39,"maximum":1913.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":991.19,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1913.0,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":743.39,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1011.01,"additional_payer_notes":"APC"}]}]},{"description":"Th/wght bear quad-lat brim c","code_information":[{"code":"L2520","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":495.44,"maximum":1274.92,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":660.58,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1274.92,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":495.44,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":673.79,"additional_payer_notes":"APC"}]}]},{"description":"Th/wght bear nar m-l brim mo","code_information":[{"code":"L2525","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1050.58,"maximum":2703.49,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1400.77,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2703.49,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1050.58,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1428.79,"additional_payer_notes":"APC"}]}]},{"description":"Th/wght bear nar m-l brim cu","code_information":[{"code":"L2526","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":590.32,"maximum":1519.08,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":787.09,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1519.08,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":590.32,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":802.83,"additional_payer_notes":"APC"}]}]},{"description":"Thigh/wght bear lacer non-mo","code_information":[{"code":"L2530","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":221.05,"maximum":568.83,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":294.73,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":568.83,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":221.05,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":300.62,"additional_payer_notes":"APC"}]}]},{"description":"Thigh/wght bear lacer molded","code_information":[{"code":"L2540","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":418.28,"maximum":1076.36,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":557.7,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1076.36,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":418.28,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":568.85,"additional_payer_notes":"APC"}]}]},{"description":"Thigh/wght bear high roll cu","code_information":[{"code":"L2550","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":313.62,"maximum":807.05,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":418.16,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":807.05,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":313.62,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":426.52,"additional_payer_notes":"APC"}]}]},{"description":"Hip clevis type 2 posit jnt","code_information":[{"code":"L2570","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":410.5,"maximum":1056.37,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":547.34,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1056.37,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":410.5,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":558.29,"additional_payer_notes":"APC"}]}]},{"description":"Pelvic control pelvic sling","code_information":[{"code":"L2580","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":399.99,"maximum":1029.31,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":533.32,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1029.31,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":399.99,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":543.99,"additional_payer_notes":"APC"}]}]},{"description":"Hip clevis/thrust bearing fr","code_information":[{"code":"L2600","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":196.59,"maximum":505.89,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":262.12,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":505.89,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":196.59,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":267.36,"additional_payer_notes":"APC"}]}]},{"description":"Hip clevis/thrust bearing lo","code_information":[{"code":"L2610","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":217.24,"maximum":559.02,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":289.65,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":559.02,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":217.24,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":295.44,"additional_payer_notes":"APC"}]}]},{"description":"Pelvic control hip heavy dut","code_information":[{"code":"L2620","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":230.44,"maximum":592.99,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":307.25,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":592.99,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":230.44,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":313.4,"additional_payer_notes":"APC"}]}]},{"description":"Hip joint adjustable flexion","code_information":[{"code":"L2622","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":293.3,"maximum":754.77,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":391.07,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":754.77,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":293.3,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":398.89,"additional_payer_notes":"APC"}]}]},{"description":"Hip adj flex ext abduct cont","code_information":[{"code":"L2624","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":359.64,"maximum":925.47,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":479.52,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":925.47,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":359.64,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":489.11,"additional_payer_notes":"APC"}]}]},{"description":"Plastic mold recipro hip & c","code_information":[{"code":"L2627","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1969.94,"maximum":5069.3,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2626.58,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5069.3,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1969.94,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2679.11,"additional_payer_notes":"APC"}]}]},{"description":"Metal frame recipro hip & ca","code_information":[{"code":"L2628","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1443.92,"maximum":3715.69,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1925.23,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3715.69,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1443.92,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1963.73,"additional_payer_notes":"APC"}]}]},{"description":"Pelvic control band & belt u","code_information":[{"code":"L2630","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":213.41,"maximum":549.18,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":284.55,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":549.18,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":213.41,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":290.24,"additional_payer_notes":"APC"}]}]},{"description":"Pelvic control band & belt b","code_information":[{"code":"L2640","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":289.63,"maximum":745.31,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":386.17,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":745.31,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":289.63,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":393.89,"additional_payer_notes":"APC"}]}]},{"description":"Pelv & thor control gluteal","code_information":[{"code":"L2650","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":127.54,"maximum":328.22,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":170.06,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":328.22,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":127.54,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":173.46,"additional_payer_notes":"APC"}]}]},{"description":"Thoracic control thoracic ba","code_information":[{"code":"L2660","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":165.15,"maximum":424.99,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":220.2,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":424.99,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":165.15,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":224.6,"additional_payer_notes":"APC"}]}]},{"description":"Thorac cont paraspinal uprig","code_information":[{"code":"L2670","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":147.02,"maximum":378.32,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":196.02,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":378.32,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":147.02,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":199.94,"additional_payer_notes":"APC"}]}]},{"description":"Thorac cont lat support upri","code_information":[{"code":"L2680","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":134.86,"maximum":347.05,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":179.82,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":347.05,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":134.86,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":183.42,"additional_payer_notes":"APC"}]}]},{"description":"Plating chrome/nickel pr bar","code_information":[{"code":"L2750","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":72.04,"maximum":185.38,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":96.05,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":185.38,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":72.04,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":97.97,"additional_payer_notes":"APC"}]}]},{"description":"Carbon graphite lamination","code_information":[{"code":"L2755","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":120.44,"maximum":309.92,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":160.58,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":309.92,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":120.44,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":163.79,"additional_payer_notes":"APC"}]}]},{"description":"Extension per extension per","code_information":[{"code":"L2760","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":52.36,"maximum":134.75,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":69.82,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":134.75,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":52.36,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":71.22,"additional_payer_notes":"APC"}]}]},{"description":"Ortho sidebar disconnect","code_information":[{"code":"L2768","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":120.08,"maximum":309.01,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":160.11,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":309.01,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":120.08,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":163.31,"additional_payer_notes":"APC"}]}]},{"description":"Non-corrosive finish","code_information":[{"code":"L2780","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":58.33,"maximum":150.1,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":77.77,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":150.1,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":58.33,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":79.33,"additional_payer_notes":"APC"}]}]},{"description":"Drop lock retainer each","code_information":[{"code":"L2785","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":27.32,"maximum":70.29,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":36.42,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":70.29,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27.32,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":37.15,"additional_payer_notes":"APC"}]}]},{"description":"Knee control full kneecap","code_information":[{"code":"L2795","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":75.6,"maximum":194.54,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":100.8,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":194.54,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":75.6,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":102.82,"additional_payer_notes":"APC"}]}]},{"description":"Knee cap medial or lateral p","code_information":[{"code":"L2800","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":92.82,"maximum":238.86,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":123.76,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":238.86,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":92.82,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":126.24,"additional_payer_notes":"APC"}]}]},{"description":"Knee control condylar pad","code_information":[{"code":"L2810","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":75.28,"maximum":193.73,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":100.38,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":193.73,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":75.28,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":102.39,"additional_payer_notes":"APC"}]}]},{"description":"Soft interface below knee se","code_information":[{"code":"L2820","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":74.84,"maximum":192.59,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":99.79,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":192.59,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":74.84,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":101.79,"additional_payer_notes":"APC"}]}]},{"description":"Soft interface above knee se","code_information":[{"code":"L2830","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":80.97,"maximum":208.36,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":107.96,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":208.36,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":80.97,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":110.12,"additional_payer_notes":"APC"}]}]},{"description":"Tibial length sock fx or equ","code_information":[{"code":"L2840","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":39.76,"maximum":102.33,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":53.02,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":102.33,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":39.76,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":54.08,"additional_payer_notes":"APC"}]}]},{"description":"Femoral lgth sock fx or equa","code_information":[{"code":"L2850","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":55.76,"maximum":143.48,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":74.34,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":143.48,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":55.76,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":75.83,"additional_payer_notes":"APC"}]}]},{"description":"Ft insert ucb berkeley shell","code_information":[{"code":"L3000","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":289.54,"maximum":745.1,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":386.06,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":745.1,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":289.54,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":393.78,"additional_payer_notes":"APC"}]}]},{"description":"Foot insert remov molded spe","code_information":[{"code":"L3001","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":121.92,"maximum":313.74,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":162.56,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":313.74,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":121.92,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":165.81,"additional_payer_notes":"APC"}]}]},{"description":"Foot insert plastazote or eq","code_information":[{"code":"L3002","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":148.86,"maximum":383.07,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":198.48,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":383.07,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":148.86,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":202.45,"additional_payer_notes":"APC"}]}]},{"description":"Foot insert silicone gel eac","code_information":[{"code":"L3003","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":160.58,"maximum":413.23,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":214.11,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":413.23,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":160.58,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":218.39,"additional_payer_notes":"APC"}]}]},{"description":"Foot longitudinal arch suppo","code_information":[{"code":"L3010","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":160.58,"maximum":413.23,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":214.11,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":413.23,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":160.58,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":218.39,"additional_payer_notes":"APC"}]}]},{"description":"Foot longitud/metatarsal sup","code_information":[{"code":"L3020","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":182.87,"maximum":470.59,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":243.83,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":470.59,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":182.87,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":248.71,"additional_payer_notes":"APC"}]}]},{"description":"Foot arch support remov prem","code_information":[{"code":"L3030","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":70.33,"maximum":180.98,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":93.77,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":180.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":70.33,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":95.65,"additional_payer_notes":"APC"}]}]},{"description":"Foot lamin/prepreg composite","code_information":[{"code":"L3031","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":112.88,"maximum":290.48,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":150.51,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":290.48,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":112.88,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":153.52,"additional_payer_notes":"APC"}]}]},{"description":"Ft arch suprt premold longit","code_information":[{"code":"L3040","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":43.38,"maximum":111.63,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":57.84,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":111.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":43.38,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":59.0,"additional_payer_notes":"APC"}]}]},{"description":"Foot arch supp premold metat","code_information":[{"code":"L3050","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":43.38,"maximum":111.63,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":57.84,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":111.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":43.38,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":59.0,"additional_payer_notes":"APC"}]}]},{"description":"Foot arch supp longitud/meta","code_information":[{"code":"L3060","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":67.99,"maximum":174.95,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":90.65,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":174.95,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":67.99,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":92.46,"additional_payer_notes":"APC"}]}]},{"description":"Arch suprt att to sho longit","code_information":[{"code":"L3070","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":29.31,"maximum":75.42,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":39.08,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":75.42,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":29.31,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":39.86,"additional_payer_notes":"APC"}]}]},{"description":"Arch supp att to shoe metata","code_information":[{"code":"L3080","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":29.31,"maximum":75.42,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":39.08,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":75.42,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":29.31,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":39.86,"additional_payer_notes":"APC"}]}]},{"description":"Arch supp att to shoe long/m","code_information":[{"code":"L3090","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":37.52,"maximum":96.54,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":50.02,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":96.54,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":37.52,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":51.02,"additional_payer_notes":"APC"}]}]},{"description":"Hallus-valgus nt dyn pre ots","code_information":[{"code":"L3100","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":39.87,"maximum":102.6,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":53.16,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":102.6,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":39.87,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":54.22,"additional_payer_notes":"APC"}]}]},{"description":"Abduction rotation bar shoe","code_information":[{"code":"L3140","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":82.06,"maximum":211.16,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":109.41,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":211.16,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":82.06,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":111.6,"additional_payer_notes":"APC"}]}]},{"description":"Abduct rotation bar w/o shoe","code_information":[{"code":"L3150","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":75.04,"maximum":193.1,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":100.05,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":193.1,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":75.04,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":102.05,"additional_payer_notes":"APC"}]}]},{"description":"Foot plas heel stabi pre ots","code_information":[{"code":"L3170","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":46.89,"maximum":120.66,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":62.52,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":120.66,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":46.89,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":63.77,"additional_payer_notes":"APC"}]}]},{"description":"Woman's shoe oxford brace","code_information":[{"code":"L3224","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":62.28,"maximum":160.27,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":83.04,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":160.27,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":62.28,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":84.7,"additional_payer_notes":"APC"}]}]},{"description":"Man's shoe oxford brace","code_information":[{"code":"L3225","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":68.02,"maximum":175.05,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":90.7,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":175.05,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":68.02,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":92.51,"additional_payer_notes":"APC"}]}]},{"description":"Sho lift taper to metatarsal","code_information":[{"code":"L3300","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":48.08,"maximum":123.71,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":64.1,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":123.71,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":48.08,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":65.38,"additional_payer_notes":"APC"}]}]},{"description":"Shoe lift elev heel/sole neo","code_information":[{"code":"L3310","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":75.04,"maximum":193.1,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":100.05,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":193.1,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":75.04,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":102.05,"additional_payer_notes":"APC"}]}]},{"description":"Lifts elevation metal extens","code_information":[{"code":"L3330","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":521.63,"maximum":1342.33,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":695.51,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1342.33,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":521.63,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":709.42,"additional_payer_notes":"APC"}]}]},{"description":"Shoe lifts tapered to one-ha","code_information":[{"code":"L3332","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":67.99,"maximum":174.95,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":90.65,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":174.95,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":67.99,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":92.46,"additional_payer_notes":"APC"}]}]},{"description":"Shoe lifts elevation heel /i","code_information":[{"code":"L3334","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":35.15,"maximum":90.46,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":46.87,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":90.46,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":35.15,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":47.81,"additional_payer_notes":"APC"}]}]},{"description":"Shoe wedge sach","code_information":[{"code":"L3340","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":78.56,"maximum":202.15,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":104.74,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":202.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":78.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":106.83,"additional_payer_notes":"APC"}]}]},{"description":"Shoe heel wedge","code_information":[{"code":"L3350","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":21.08,"maximum":54.25,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":28.11,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":54.25,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21.08,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":28.67,"additional_payer_notes":"APC"}]}]},{"description":"Shoe sole wedge outside sole","code_information":[{"code":"L3360","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":32.82,"maximum":84.46,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":43.76,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":84.46,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":32.82,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":44.64,"additional_payer_notes":"APC"}]}]},{"description":"Shoe sole wedge between sole","code_information":[{"code":"L3370","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":45.72,"maximum":117.65,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":60.96,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":117.65,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":45.72,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":62.18,"additional_payer_notes":"APC"}]}]},{"description":"Shoe clubfoot wedge","code_information":[{"code":"L3380","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":45.72,"maximum":117.65,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":60.96,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":117.65,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":45.72,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":62.18,"additional_payer_notes":"APC"}]}]},{"description":"Shoe outflare wedge","code_information":[{"code":"L3390","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":45.72,"maximum":117.65,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":60.96,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":117.65,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":45.72,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":62.18,"additional_payer_notes":"APC"}]}]},{"description":"Shoe metatarsal bar wedge ro","code_information":[{"code":"L3400","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":37.52,"maximum":96.54,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":50.02,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":96.54,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":37.52,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":51.02,"additional_payer_notes":"APC"}]}]},{"description":"Shoe metatarsal bar between","code_information":[{"code":"L3410","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":85.57,"maximum":220.19,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":114.09,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":220.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":85.57,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":116.37,"additional_payer_notes":"APC"}]}]},{"description":"Full sole/heel wedge btween","code_information":[{"code":"L3420","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":50.41,"maximum":129.72,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":67.21,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":129.72,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":50.41,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":68.55,"additional_payer_notes":"APC"}]}]},{"description":"Sho heel count plast reinfor","code_information":[{"code":"L3430","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":147.7,"maximum":380.09,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":196.94,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":380.09,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":147.7,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":200.88,"additional_payer_notes":"APC"}]}]},{"description":"Heel leather reinforced","code_information":[{"code":"L3440","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":70.33,"maximum":180.98,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":93.77,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":180.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":70.33,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":95.65,"additional_payer_notes":"APC"}]}]},{"description":"Shoe heel sach cushion type","code_information":[{"code":"L3450","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":97.27,"maximum":250.3,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":129.69,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":250.3,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":97.27,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":132.28,"additional_payer_notes":"APC"}]}]},{"description":"Shoe heel new leather standa","code_information":[{"code":"L3455","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":37.52,"maximum":96.54,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":50.02,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":96.54,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":37.52,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":51.02,"additional_payer_notes":"APC"}]}]},{"description":"Shoe heel new rubber standar","code_information":[{"code":"L3460","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":31.66,"maximum":81.48,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":42.22,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":81.48,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":31.66,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":43.06,"additional_payer_notes":"APC"}]}]},{"description":"Shoe heel thomas with wedge","code_information":[{"code":"L3465","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":53.96,"maximum":138.84,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":71.94,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":138.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":53.96,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":73.38,"additional_payer_notes":"APC"}]}]},{"description":"Shoe heel thomas extend to b","code_information":[{"code":"L3470","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":57.43,"maximum":147.78,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":76.57,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":147.78,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":57.43,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":78.1,"additional_payer_notes":"APC"}]}]},{"description":"Shoe heel pad & depress for","code_information":[{"code":"L3480","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":57.43,"maximum":147.78,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":76.57,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":147.78,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":57.43,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":78.1,"additional_payer_notes":"APC"}]}]},{"description":"Ortho shoe add leather insol","code_information":[{"code":"L3500","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":26.95,"maximum":69.34,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":35.93,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":69.34,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26.95,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":36.65,"additional_payer_notes":"APC"}]}]},{"description":"Orthopedic shoe add rub insl","code_information":[{"code":"L3510","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":26.95,"maximum":69.34,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":35.93,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":69.34,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26.95,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":36.65,"additional_payer_notes":"APC"}]}]},{"description":"O shoe add felt w leath insl","code_information":[{"code":"L3520","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":29.31,"maximum":75.42,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":39.08,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":75.42,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":29.31,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":39.86,"additional_payer_notes":"APC"}]}]},{"description":"Ortho shoe add half sole","code_information":[{"code":"L3530","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":29.31,"maximum":75.42,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":39.08,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":75.42,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":29.31,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":39.86,"additional_payer_notes":"APC"}]}]},{"description":"Ortho shoe add full sole","code_information":[{"code":"L3540","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":46.89,"maximum":120.66,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":62.52,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":120.66,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":46.89,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":63.77,"additional_payer_notes":"APC"}]}]},{"description":"O shoe add standard toe tap","code_information":[{"code":"L3550","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8.24,"maximum":21.21,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10.99,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":21.21,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8.24,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11.21,"additional_payer_notes":"APC"}]}]},{"description":"O shoe add horseshoe toe tap","code_information":[{"code":"L3560","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":21.08,"maximum":54.25,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":28.11,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":54.25,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21.08,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":28.67,"additional_payer_notes":"APC"}]}]},{"description":"O shoe add instep extension","code_information":[{"code":"L3570","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":78.56,"maximum":202.15,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":104.74,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":202.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":78.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":106.83,"additional_payer_notes":"APC"}]}]},{"description":"O shoe add instep velcro clo","code_information":[{"code":"L3580","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":59.78,"maximum":153.82,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":79.7,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":153.82,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":59.78,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":81.29,"additional_payer_notes":"APC"}]}]},{"description":"O shoe convert to sof counte","code_information":[{"code":"L3590","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":49.24,"maximum":126.72,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":65.66,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":126.72,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":49.24,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":66.97,"additional_payer_notes":"APC"}]}]},{"description":"Ortho shoe add march bar","code_information":[{"code":"L3595","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":38.66,"maximum":99.47,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":51.54,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":99.47,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":38.66,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":52.57,"additional_payer_notes":"APC"}]}]},{"description":"Trans shoe calip plate exist","code_information":[{"code":"L3600","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":70.33,"maximum":180.98,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":93.77,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":180.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":70.33,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":95.65,"additional_payer_notes":"APC"}]}]},{"description":"Trans shoe caliper plate new","code_information":[{"code":"L3610","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":92.61,"maximum":238.32,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":123.48,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":238.32,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":92.61,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":125.95,"additional_payer_notes":"APC"}]}]},{"description":"Trans shoe solid stirrup exi","code_information":[{"code":"L3620","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":70.33,"maximum":180.98,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":93.77,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":180.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":70.33,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":95.65,"additional_payer_notes":"APC"}]}]},{"description":"Trans shoe solid stirrup new","code_information":[{"code":"L3630","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":92.61,"maximum":238.32,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":123.48,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":238.32,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":92.61,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":125.95,"additional_payer_notes":"APC"}]}]},{"description":"Shoe dennis browne splint bo","code_information":[{"code":"L3640","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":39.87,"maximum":102.6,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":53.16,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":102.6,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":39.87,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":54.22,"additional_payer_notes":"APC"}]}]},{"description":"So 8 abd restraint pre ots","code_information":[{"code":"L3650","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":60.45,"maximum":155.56,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":80.6,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":155.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":60.45,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":82.21,"additional_payer_notes":"APC"}]}]},{"description":"So 8 ab rstr can/web pre ots","code_information":[{"code":"L3660","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":86.68,"maximum":223.05,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":115.57,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":223.05,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":86.68,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":117.88,"additional_payer_notes":"APC"}]}]},{"description":"So acro/clav can web pre ots","code_information":[{"code":"L3670","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":95.36,"maximum":245.4,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":127.15,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":245.4,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":95.36,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":129.69,"additional_payer_notes":"APC"}]}]},{"description":"SO cap design w/o jnts CF","code_information":[{"code":"L3671","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":755.84,"maximum":1945.03,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1007.79,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1945.03,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":755.84,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1027.95,"additional_payer_notes":"APC"}]}]},{"description":"SO airplane w/wo joint CF","code_information":[{"code":"L3674","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":991.54,"maximum":2551.58,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1322.06,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2551.58,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":991.54,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1348.5,"additional_payer_notes":"APC"}]}]},{"description":"So vest canvas/web pre ots","code_information":[{"code":"L3675","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":147.23,"maximum":378.88,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":196.31,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":378.88,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":147.23,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":200.24,"additional_payer_notes":"APC"}]}]},{"description":"EO w/o joints CF","code_information":[{"code":"L3702","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":242.23,"maximum":623.33,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":322.97,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":623.33,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":242.23,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":329.43,"additional_payer_notes":"APC"}]}]},{"description":"Eo elas w/metal jnts pre ots","code_information":[{"code":"L3710","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":119.78,"maximum":308.22,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":159.7,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":308.22,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":119.78,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":162.89,"additional_payer_notes":"APC"}]}]},{"description":"Forearm/arm cuffs free motio","code_information":[{"code":"L3720","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":573.16,"maximum":1474.94,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":764.22,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1474.94,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":573.16,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":779.5,"additional_payer_notes":"APC"}]}]},{"description":"Forearm/arm cuffs ext/flex a","code_information":[{"code":"L3730","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":760.24,"maximum":1956.36,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1013.66,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1956.36,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":760.24,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1033.93,"additional_payer_notes":"APC"}]}]},{"description":"Cuffs adj lock w/ active con","code_information":[{"code":"L3740","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":901.34,"maximum":2319.44,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1201.78,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2319.44,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":901.34,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1225.82,"additional_payer_notes":"APC"}]}]},{"description":"EO withjoint, Prefabricated","code_information":[{"code":"L3760","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":419.52,"maximum":1079.56,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":559.36,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1079.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":419.52,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":570.55,"additional_payer_notes":"APC"}]}]},{"description":"Eo, adj lock joint prefab ot","code_information":[{"code":"L3761","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":419.52,"maximum":1079.56,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":559.36,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1079.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":419.52,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":570.55,"additional_payer_notes":"APC"}]}]},{"description":"Eo rigid w/o joints pre ots","code_information":[{"code":"L3762","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":90.19,"maximum":232.08,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":120.25,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":232.08,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":90.19,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":122.66,"additional_payer_notes":"APC"}]}]},{"description":"EWHO rigid w/o jnts CF","code_information":[{"code":"L3763","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":627.74,"maximum":1615.39,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":836.99,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1615.39,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":627.74,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":853.73,"additional_payer_notes":"APC"}]}]},{"description":"EWHO w/joint(s) CF","code_information":[{"code":"L3764","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":656.96,"maximum":1690.56,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":875.94,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1690.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":656.96,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":893.46,"additional_payer_notes":"APC"}]}]},{"description":"EWHFO rigid w/o jnts CF","code_information":[{"code":"L3765","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1075.61,"maximum":2767.91,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1434.15,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2767.91,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1075.61,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1462.83,"additional_payer_notes":"APC"}]}]},{"description":"EWHFO w/joint(s) CF","code_information":[{"code":"L3766","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1139.01,"maximum":2931.05,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1518.68,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2931.05,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1139.01,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1549.05,"additional_payer_notes":"APC"}]}]},{"description":"WHFO w/joint(s) custom fab","code_information":[{"code":"L3806","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":381.02,"maximum":980.5,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":508.03,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":980.5,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":381.02,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":518.19,"additional_payer_notes":"APC"}]}]},{"description":"Whfo w/o joints pre cst","code_information":[{"code":"L3807","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":209.75,"maximum":539.76,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":279.67,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":539.76,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":209.75,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":285.26,"additional_payer_notes":"APC"}]}]},{"description":"WHFO, rigid w/o joints","code_information":[{"code":"L3808","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":298.82,"maximum":768.97,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":398.43,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":768.97,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":298.82,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":406.4,"additional_payer_notes":"APC"}]}]},{"description":"Whfo w/o joints pre ots","code_information":[{"code":"L3809","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":209.75,"maximum":539.76,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":279.67,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":539.76,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":209.75,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":285.26,"additional_payer_notes":"APC"}]}]},{"description":"Hinge extension/flex wrist/f","code_information":[{"code":"L3900","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1358.89,"maximum":3496.87,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1811.85,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3496.87,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1358.89,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1848.09,"additional_payer_notes":"APC"}]}]},{"description":"Hinge ext/flex wrist finger","code_information":[{"code":"L3901","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1780.9,"maximum":4582.84,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2374.53,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4582.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1780.9,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2422.02,"additional_payer_notes":"APC"}]}]},{"description":"Whfo electric custom fitted","code_information":[{"code":"L3904","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2831.42,"maximum":7286.19,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3775.23,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7286.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2831.42,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3850.73,"additional_payer_notes":"APC"}]}]},{"description":"Who w/nontorsion jnt(s) cf","code_information":[{"code":"L3905","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":831.87,"maximum":2140.68,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1109.16,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2140.68,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":831.87,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1131.34,"additional_payer_notes":"APC"}]}]},{"description":"Who w/o joints cf","code_information":[{"code":"L3906","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":425.09,"maximum":1093.9,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":566.79,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1093.9,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":425.09,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":578.13,"additional_payer_notes":"APC"}]}]},{"description":"Who cock-up nonmolde pre ots","code_information":[{"code":"L3908","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":61.5,"maximum":158.26,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":82.0,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":158.26,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":61.5,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":83.64,"additional_payer_notes":"APC"}]}]},{"description":"Hfo flexion glove pre ots","code_information":[{"code":"L3912","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":88.38,"maximum":227.43,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":117.84,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":227.43,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":88.38,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":120.2,"additional_payer_notes":"APC"}]}]},{"description":"HFO w/o joints CF","code_information":[{"code":"L3913","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":227.18,"maximum":584.6,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":302.9,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":584.6,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":227.18,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":308.96,"additional_payer_notes":"APC"}]}]},{"description":"Who nontorsion jnts pre cst","code_information":[{"code":"L3915","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":445.9,"maximum":1147.46,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":594.54,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1147.46,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":445.9,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":606.43,"additional_payer_notes":"APC"}]}]},{"description":"Who nontorsion jnts pre ots","code_information":[{"code":"L3916","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":445.9,"maximum":1147.46,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":594.54,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1147.46,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":445.9,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":606.43,"additional_payer_notes":"APC"}]}]},{"description":"Metacarp fx orthosis pre cst","code_information":[{"code":"L3917","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":88.58,"maximum":227.95,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":118.11,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":227.95,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":88.58,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":120.47,"additional_payer_notes":"APC"}]}]},{"description":"Metacarp fx orthosis pre ots","code_information":[{"code":"L3918","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":88.58,"maximum":227.95,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":118.11,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":227.95,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":88.58,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":120.47,"additional_payer_notes":"APC"}]}]},{"description":"HO w/o joints CF","code_information":[{"code":"L3919","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":227.18,"maximum":584.6,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":302.9,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":584.6,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":227.18,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":308.96,"additional_payer_notes":"APC"}]}]},{"description":"HFO w/joint(s) CF","code_information":[{"code":"L3921","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":269.46,"maximum":693.41,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":359.28,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":693.41,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":269.46,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":366.47,"additional_payer_notes":"APC"}]}]},{"description":"Hfo without joints pre cst","code_information":[{"code":"L3923","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":81.03,"maximum":208.52,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":108.04,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":208.52,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":81.03,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":110.2,"additional_payer_notes":"APC"}]}]},{"description":"Hfo without joints pre ots","code_information":[{"code":"L3924","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":81.03,"maximum":208.52,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":108.04,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":208.52,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":81.03,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":110.2,"additional_payer_notes":"APC"}]}]},{"description":"Fo pip dip jnt/sprng pre ots","code_information":[{"code":"L3925","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":55.1,"maximum":141.8,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":73.47,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":141.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":55.1,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":74.94,"additional_payer_notes":"APC"}]}]},{"description":"Fo pip dip no jt spr pre ots","code_information":[{"code":"L3927","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":29.36,"maximum":75.56,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":39.15,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":75.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":29.36,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":39.93,"additional_payer_notes":"APC"}]}]},{"description":"Hfo nontorsion jnts pre cst","code_information":[{"code":"L3929","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":76.62,"maximum":197.17,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":102.16,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":197.17,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":76.62,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":104.2,"additional_payer_notes":"APC"}]}]},{"description":"Hfo nontorsion jnts pre ots","code_information":[{"code":"L3930","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":76.62,"maximum":197.17,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":102.16,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":197.17,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":76.62,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":104.2,"additional_payer_notes":"APC"}]}]},{"description":"WHFO nontorsion joint prefab","code_information":[{"code":"L3931","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":174.9,"maximum":450.08,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":233.2,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":450.08,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":174.9,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":237.86,"additional_payer_notes":"APC"}]}]},{"description":"FO w/o joints CF","code_information":[{"code":"L3933","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":178.98,"maximum":460.58,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":238.64,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":460.58,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":178.98,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":243.41,"additional_payer_notes":"APC"}]}]},{"description":"FO nontorsion joint CF","code_information":[{"code":"L3935","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":185.3,"maximum":476.85,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":247.07,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":476.85,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":185.3,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":252.01,"additional_payer_notes":"APC"}]}]},{"description":"Sewho airplan desig abdu pos","code_information":[{"code":"L3960","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":669.04,"maximum":1721.66,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":892.05,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1721.66,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":669.04,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":909.89,"additional_payer_notes":"APC"}]}]},{"description":"Sewho cap design w/o jnts cf","code_information":[{"code":"L3961","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1409.38,"maximum":3626.8,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1879.17,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3626.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1409.38,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1916.75,"additional_payer_notes":"APC"}]}]},{"description":"Sewho erbs palsey design abd","code_information":[{"code":"L3962","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":605.1,"maximum":1557.12,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":806.8,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1557.12,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":605.1,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":822.94,"additional_payer_notes":"APC"}]}]},{"description":"Sewho airplane w/o jnts cf","code_information":[{"code":"L3967","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1663.97,"maximum":4281.96,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2218.63,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4281.96,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1663.97,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2263.0,"additional_payer_notes":"APC"}]}]},{"description":"Sewho cap design w/jnt(s) cf","code_information":[{"code":"L3971","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1579.5,"maximum":4064.58,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2106.0,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4064.58,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1579.5,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2148.12,"additional_payer_notes":"APC"}]}]},{"description":"Sewho airplane w/jnt(s) cf","code_information":[{"code":"L3973","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1663.97,"maximum":4281.96,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2218.63,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4281.96,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1663.97,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2263.0,"additional_payer_notes":"APC"}]}]},{"description":"Sewhfo cap design w/o jnt cf","code_information":[{"code":"L3975","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1409.38,"maximum":3626.8,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1879.17,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3626.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1409.38,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1916.75,"additional_payer_notes":"APC"}]}]},{"description":"Sewhfo airplane w/o jnts cf","code_information":[{"code":"L3976","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1409.38,"maximum":3626.8,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1879.17,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3626.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1409.38,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1916.75,"additional_payer_notes":"APC"}]}]},{"description":"Sewhfo cap desgn w/jnt(s) cf","code_information":[{"code":"L3977","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1579.5,"maximum":4064.58,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2106.0,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4064.58,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1579.5,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2148.12,"additional_payer_notes":"APC"}]}]},{"description":"Sewhfo airplane w/jnt(s) cf","code_information":[{"code":"L3978","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1663.97,"maximum":4281.96,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2218.63,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4281.96,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1663.97,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2263.0,"additional_payer_notes":"APC"}]}]},{"description":"Up ext fx orthos humeral nos","code_information":[{"code":"L3980","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":324.52,"maximum":835.09,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":432.69,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":835.09,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":324.52,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":441.34,"additional_payer_notes":"APC"}]}]},{"description":"Ue fx orth shoul cap forearm","code_information":[{"code":"L3981","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":844.35,"maximum":2172.79,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1125.8,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2172.79,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":844.35,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1148.32,"additional_payer_notes":"APC"}]}]},{"description":"Upper ext fx orthosis rad/ul","code_information":[{"code":"L3982","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":329.51,"maximum":847.95,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":439.35,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":847.95,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":329.51,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":448.14,"additional_payer_notes":"APC"}]}]},{"description":"Upper ext fx orthosis wrist","code_information":[{"code":"L3984","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":290.27,"maximum":746.97,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":387.03,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":746.97,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":290.27,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":394.77,"additional_payer_notes":"APC"}]}]},{"description":"Sock fracture or equal each","code_information":[{"code":"L3995","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":34.44,"maximum":88.63,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":45.92,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":88.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":34.44,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":46.84,"additional_payer_notes":"APC"}]}]},{"description":"Repl girdle milwaukee orth","code_information":[{"code":"L4000","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1217.98,"maximum":3134.26,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1623.97,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3134.26,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1217.98,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1656.45,"additional_payer_notes":"APC"}]}]},{"description":"Replace trilateral socket br","code_information":[{"code":"L4010","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":740.3,"maximum":1905.05,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":987.07,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1905.05,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":740.3,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1006.81,"additional_payer_notes":"APC"}]}]},{"description":"Replace quadlat socket brim","code_information":[{"code":"L4020","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":889.3,"maximum":2288.48,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1185.74,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2288.48,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":889.3,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1209.45,"additional_payer_notes":"APC"}]}]},{"description":"Replace socket brim cust fit","code_information":[{"code":"L4030","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":565.12,"maximum":1454.26,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":753.5,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1454.26,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":565.12,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":768.57,"additional_payer_notes":"APC"}]}]},{"description":"Replace molded thigh lacer","code_information":[{"code":"L4040","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":382.72,"maximum":984.86,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":510.29,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":984.86,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":382.72,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":520.5,"additional_payer_notes":"APC"}]}]},{"description":"Replace non-molded thigh lac","code_information":[{"code":"L4045","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":282.7,"maximum":727.49,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":376.94,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":727.49,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":282.7,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":384.48,"additional_payer_notes":"APC"}]}]},{"description":"Replace molded calf lacer","code_information":[{"code":"L4050","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":379.03,"maximum":975.36,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":505.37,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":975.36,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":379.03,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":515.48,"additional_payer_notes":"APC"}]}]},{"description":"Replace non-molded calf lace","code_information":[{"code":"L4055","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":230.4,"maximum":592.9,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":307.2,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":592.9,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":230.4,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":313.34,"additional_payer_notes":"APC"}]}]},{"description":"Replace high roll cuff","code_information":[{"code":"L4060","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":299.49,"maximum":770.69,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":399.32,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":770.69,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":299.49,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":407.31,"additional_payer_notes":"APC"}]}]},{"description":"Replace prox & dist upright","code_information":[{"code":"L4070","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":242.54,"maximum":624.14,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":323.39,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":624.14,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":242.54,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":329.86,"additional_payer_notes":"APC"}]}]},{"description":"Repl met band kafo-afo prox","code_information":[{"code":"L4080","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":91.57,"maximum":235.63,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":122.09,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":235.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":91.57,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":124.53,"additional_payer_notes":"APC"}]}]},{"description":"Repl met band kafo-afo calf/","code_information":[{"code":"L4090","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":77.91,"maximum":200.49,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":103.88,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":200.49,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":77.91,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":105.96,"additional_payer_notes":"APC"}]}]},{"description":"Repl leath cuff kafo prox th","code_information":[{"code":"L4100","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":93.61,"maximum":240.88,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":124.81,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":240.88,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":93.61,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":127.31,"additional_payer_notes":"APC"}]}]},{"description":"Repl leath cuff kafo-afo cal","code_information":[{"code":"L4110","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":73.09,"maximum":188.08,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":97.45,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":188.08,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":73.09,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":99.4,"additional_payer_notes":"APC"}]}]},{"description":"Replace pretibial shell","code_information":[{"code":"L4130","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":441.79,"maximum":1136.87,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":589.05,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1136.87,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":441.79,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":600.83,"additional_payer_notes":"APC"}]}]},{"description":"Ortho dvc repair per 15 min","code_information":[{"code":"L4205","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":22.44,"maximum":57.75,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":29.92,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":57.75,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22.44,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":30.52,"additional_payer_notes":"APC"}]}]},{"description":"Ankle control ortho pre ots","code_information":[{"code":"L4350","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":89.18,"maximum":229.48,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":118.9,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":229.48,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":89.18,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":121.28,"additional_payer_notes":"APC"}]}]},{"description":"Pneumat walking boot pre cst","code_information":[{"code":"L4360","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":238.64,"maximum":614.09,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":318.18,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":614.09,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":238.64,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":324.54,"additional_payer_notes":"APC"}]}]},{"description":"Pneuma/vac walk boot pre ots","code_information":[{"code":"L4361","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":238.64,"maximum":614.09,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":318.18,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":614.09,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":238.64,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":324.54,"additional_payer_notes":"APC"}]}]},{"description":"Pneum full leg splnt pre ots","code_information":[{"code":"L4370","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":216.94,"maximum":558.25,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":289.25,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":558.25,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":216.94,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":295.04,"additional_payer_notes":"APC"}]}]},{"description":"Non-pneum walk boot pre cst","code_information":[{"code":"L4386","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":146.14,"maximum":376.08,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":194.86,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":376.08,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":146.14,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":198.76,"additional_payer_notes":"APC"}]}]},{"description":"Non-pneum walk boot pre ots","code_information":[{"code":"L4387","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":146.14,"maximum":376.08,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":194.86,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":376.08,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":146.14,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":198.76,"additional_payer_notes":"APC"}]}]},{"description":"Replace AFO soft interface","code_information":[{"code":"L4392","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":21.68,"maximum":55.8,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":28.91,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":55.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21.68,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":29.49,"additional_payer_notes":"APC"}]}]},{"description":"Replace foot drop spint","code_information":[{"code":"L4394","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":15.82,"maximum":40.7,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21.09,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":40.7,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15.82,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21.51,"additional_payer_notes":"APC"}]}]},{"description":"Static or dynami afo pre cst","code_information":[{"code":"L4396","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":154.67,"maximum":398.02,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":206.23,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":398.02,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":154.67,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":210.35,"additional_payer_notes":"APC"}]}]},{"description":"Static or dynami afo pre ots","code_information":[{"code":"L4397","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":154.67,"maximum":398.02,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":206.23,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":398.02,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":154.67,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":210.35,"additional_payer_notes":"APC"}]}]},{"description":"Foot drop splint pre ots","code_information":[{"code":"L4398","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":71.19,"maximum":183.2,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":94.92,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":183.2,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":71.19,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":96.82,"additional_payer_notes":"APC"}]}]},{"description":"Afo, walk boot type, cus fab","code_information":[{"code":"L4631","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1358.75,"maximum":3496.52,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1811.67,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3496.52,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1358.75,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1847.9,"additional_payer_notes":"APC"}]}]},{"description":"Sho insert w arch toe filler","code_information":[{"code":"L5000","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":529.28,"maximum":1362.02,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":705.71,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1362.02,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":529.28,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":719.82,"additional_payer_notes":"APC"}]}]},{"description":"Mold socket ank hgt w/ toe f","code_information":[{"code":"L5010","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1478.86,"maximum":3805.61,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1971.82,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3805.61,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1478.86,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2011.26,"additional_payer_notes":"APC"}]}]},{"description":"Tibial tubercle hgt w/ toe f","code_information":[{"code":"L5020","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2316.9,"maximum":5962.16,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3089.2,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5962.16,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2316.9,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3150.98,"additional_payer_notes":"APC"}]}]},{"description":"Ank symes mold sckt sach ft","code_information":[{"code":"L5050","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2530.5,"maximum":6511.82,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3374.0,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6511.82,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2530.5,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3441.48,"additional_payer_notes":"APC"}]}]},{"description":"Symes met fr leath socket ar","code_information":[{"code":"L5060","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3119.37,"maximum":8027.18,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4159.16,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":8027.18,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3119.37,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4242.34,"additional_payer_notes":"APC"}]}]},{"description":"Molded socket shin sach foot","code_information":[{"code":"L5100","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2519.67,"maximum":6483.95,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3359.56,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6483.95,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2519.67,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3426.75,"additional_payer_notes":"APC"}]}]},{"description":"Plast socket jts/thgh lacer","code_information":[{"code":"L5105","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3555.8,"maximum":9150.27,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4741.07,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":9150.27,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3555.8,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4835.89,"additional_payer_notes":"APC"}]}]},{"description":"Mold sckt ext knee shin sach","code_information":[{"code":"L5150","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3953.2,"maximum":10172.91,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5270.94,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":10172.91,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3953.2,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5376.36,"additional_payer_notes":"APC"}]}]},{"description":"Mold socket bent knee shin s","code_information":[{"code":"L5160","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4340.44,"maximum":11169.39,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5787.25,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11169.39,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4340.44,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5903.0,"additional_payer_notes":"APC"}]}]},{"description":"Kne sing axis fric shin sach","code_information":[{"code":"L5200","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3357.02,"maximum":8638.72,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4476.02,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":8638.72,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3357.02,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4565.54,"additional_payer_notes":"APC"}]}]},{"description":"No knee/ankle joints w/ ft b","code_information":[{"code":"L5210","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2665.46,"maximum":6859.12,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3553.95,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6859.12,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2665.46,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3625.03,"additional_payer_notes":"APC"}]}]},{"description":"No knee joint with artic ali","code_information":[{"code":"L5220","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2936.18,"maximum":7555.78,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3914.91,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7555.78,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2936.18,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3993.21,"additional_payer_notes":"APC"}]}]},{"description":"Fem focal defic constant fri","code_information":[{"code":"L5230","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4403.82,"maximum":11332.5,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5871.76,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11332.5,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4403.82,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5989.2,"additional_payer_notes":"APC"}]}]},{"description":"Hip canad sing axi cons fric","code_information":[{"code":"L5250","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5163.61,"maximum":13287.68,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6884.81,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13287.68,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5163.61,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7022.51,"additional_payer_notes":"APC"}]}]},{"description":"Tilt table locking hip sing","code_information":[{"code":"L5270","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5753.26,"maximum":14805.05,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7671.01,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":14805.05,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5753.26,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7824.43,"additional_payer_notes":"APC"}]}]},{"description":"Hemipelvect canad sing axis","code_information":[{"code":"L5280","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5592.4,"maximum":14391.1,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7456.53,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":14391.1,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5592.4,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7605.66,"additional_payer_notes":"APC"}]}]},{"description":"Bk mold socket sach ft endo","code_information":[{"code":"L5301","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2474.26,"maximum":6367.09,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3299.01,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6367.09,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2474.26,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3364.99,"additional_payer_notes":"APC"}]}]},{"description":"Knee disart, SACH ft, endo","code_information":[{"code":"L5312","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3898.37,"maximum":10031.81,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5197.83,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":10031.81,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3898.37,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5301.79,"additional_payer_notes":"APC"}]}]},{"description":"Ak open end sach","code_information":[{"code":"L5321","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3299.35,"maximum":8490.32,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4399.13,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":8490.32,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3299.35,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4487.11,"additional_payer_notes":"APC"}]}]},{"description":"Hip disart canadian sach ft","code_information":[{"code":"L5331","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4832.34,"maximum":12435.22,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6443.12,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":12435.22,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4832.34,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6571.98,"additional_payer_notes":"APC"}]}]},{"description":"Hemipelvectomy canadian sach","code_information":[{"code":"L5341","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5136.7,"maximum":13218.45,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6848.94,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13218.45,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5136.7,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6985.92,"additional_payer_notes":"APC"}]}]},{"description":"Postop dress & 1 cast chg bk","code_information":[{"code":"L5400","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1473.43,"maximum":3791.62,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1964.57,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3791.62,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1473.43,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2003.86,"additional_payer_notes":"APC"}]}]},{"description":"Postop dsg bk ea add cast ch","code_information":[{"code":"L5410","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":407.06,"maximum":1047.51,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":542.75,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1047.51,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":407.06,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":553.6,"additional_payer_notes":"APC"}]}]},{"description":"Postop dsg & 1 cast chg ak/d","code_information":[{"code":"L5420","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1860.88,"maximum":4788.66,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2481.17,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4788.66,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1860.88,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2530.79,"additional_payer_notes":"APC"}]}]},{"description":"Postop dsg ak ea add cast ch","code_information":[{"code":"L5430","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":505.13,"maximum":1299.87,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":673.51,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1299.87,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":505.13,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":686.98,"additional_payer_notes":"APC"}]}]},{"description":"Postop app non-wgt bear dsg","code_information":[{"code":"L5450","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":436.76,"maximum":1123.94,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":582.35,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1123.94,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":436.76,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":594.0,"additional_payer_notes":"APC"}]}]},{"description":"Postop app non-wgt bear dsg","code_information":[{"code":"L5460","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":572.86,"maximum":1474.17,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":763.82,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1474.17,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":572.86,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":779.1,"additional_payer_notes":"APC"}]}]},{"description":"Init bk ptb plaster direct","code_information":[{"code":"L5500","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1361.87,"maximum":3504.55,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1815.83,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3504.55,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1361.87,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1852.15,"additional_payer_notes":"APC"}]}]},{"description":"Init ak ischal plstr direct","code_information":[{"code":"L5505","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1915.78,"maximum":4929.95,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2554.38,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4929.95,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1915.78,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2605.47,"additional_payer_notes":"APC"}]}]},{"description":"Prep BK ptb plaster molded","code_information":[{"code":"L5510","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1626.32,"maximum":4185.05,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2168.42,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4185.05,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1626.32,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2211.79,"additional_payer_notes":"APC"}]}]},{"description":"Perp BK ptb thermopls direct","code_information":[{"code":"L5520","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1457.79,"maximum":3751.38,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1943.72,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3751.38,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1457.79,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1982.59,"additional_payer_notes":"APC"}]}]},{"description":"Prep BK ptb thermopls molded","code_information":[{"code":"L5530","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1916.36,"maximum":4931.44,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2555.15,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4931.44,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1916.36,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2606.25,"additional_payer_notes":"APC"}]}]},{"description":"Prep BK ptb open end socket","code_information":[{"code":"L5535","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1786.46,"maximum":4597.14,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2381.94,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4597.14,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1786.46,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2429.58,"additional_payer_notes":"APC"}]}]},{"description":"Prep BK ptb laminated socket","code_information":[{"code":"L5540","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1892.12,"maximum":4869.04,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2522.82,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4869.04,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1892.12,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2573.28,"additional_payer_notes":"APC"}]}]},{"description":"Prep AK ischial plast molded","code_information":[{"code":"L5560","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2155.96,"maximum":5548.02,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2874.62,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5548.02,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2155.96,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2932.11,"additional_payer_notes":"APC"}]}]},{"description":"Prep AK ischial direct form","code_information":[{"code":"L5570","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2092.44,"maximum":5384.55,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2789.92,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5384.55,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2092.44,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2845.72,"additional_payer_notes":"APC"}]}]},{"description":"Prep AK ischial thermo mold","code_information":[{"code":"L5580","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2597.03,"maximum":6683.03,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3462.71,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6683.03,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2597.03,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3531.96,"additional_payer_notes":"APC"}]}]},{"description":"Prep AK ischial open end","code_information":[{"code":"L5585","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3041.32,"maximum":7826.32,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4055.09,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7826.32,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3041.32,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4136.19,"additional_payer_notes":"APC"}]}]},{"description":"Prep AK ischial laminated","code_information":[{"code":"L5590","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2707.66,"maximum":6967.71,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3610.21,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6967.71,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2707.66,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3682.41,"additional_payer_notes":"APC"}]}]},{"description":"Hip disartic sach thermopls","code_information":[{"code":"L5595","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4231.36,"maximum":10888.71,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5641.82,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":10888.71,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4231.36,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5754.66,"additional_payer_notes":"APC"}]}]},{"description":"Hip disart sach laminat mold","code_information":[{"code":"L5600","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4815.92,"maximum":12392.97,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6421.23,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":12392.97,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4815.92,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6549.65,"additional_payer_notes":"APC"}]}]},{"description":"Above knee hydracadence","code_information":[{"code":"L5610","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2322.69,"maximum":5977.06,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3096.92,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5977.06,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2322.69,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3158.86,"additional_payer_notes":"APC"}]}]},{"description":"Ak 4 bar link w/fric swing","code_information":[{"code":"L5611","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1479.35,"maximum":3806.87,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1972.47,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3806.87,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1479.35,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2011.92,"additional_payer_notes":"APC"}]}]},{"description":"Ak 4 bar ling w/hydraul swig","code_information":[{"code":"L5613","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2250.2,"maximum":5790.5,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3000.26,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5790.5,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2250.2,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3060.27,"additional_payer_notes":"APC"}]}]},{"description":"4-bar link above knee w/swng","code_information":[{"code":"L5614","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1558.41,"maximum":4010.31,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2077.88,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4010.31,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1558.41,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2119.44,"additional_payer_notes":"APC"}]}]},{"description":"Ak 4 bar link hydl swg/stanc","code_information":[{"code":"L5615","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5195.99,"maximum":13371.02,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6927.99,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13371.02,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5195.99,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7066.55,"additional_payer_notes":"APC"}]}]},{"description":"Ak univ multiplex sys frict","code_information":[{"code":"L5616","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1356.8,"maximum":3491.49,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1809.06,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3491.49,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1356.8,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1845.24,"additional_payer_notes":"APC"}]}]},{"description":"AK/BK self-aligning unit ea","code_information":[{"code":"L5617","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":516.72,"maximum":1329.69,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":688.96,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1329.69,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":516.72,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":702.74,"additional_payer_notes":"APC"}]}]},{"description":"Test socket symes","code_information":[{"code":"L5618","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":308.57,"maximum":794.06,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":411.43,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":794.06,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":308.57,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":419.66,"additional_payer_notes":"APC"}]}]},{"description":"Test socket below knee","code_information":[{"code":"L5620","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":273.78,"maximum":704.53,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":365.04,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":704.53,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":273.78,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":372.34,"additional_payer_notes":"APC"}]}]},{"description":"Test socket knee disarticula","code_information":[{"code":"L5622","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":368.84,"maximum":949.15,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":491.79,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":949.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":368.84,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":501.63,"additional_payer_notes":"APC"}]}]},{"description":"Test socket above knee","code_information":[{"code":"L5624","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":368.71,"maximum":948.81,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":491.61,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":948.81,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":368.71,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":501.44,"additional_payer_notes":"APC"}]}]},{"description":"Test socket hip disarticulat","code_information":[{"code":"L5626","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":583.7,"maximum":1502.06,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":778.27,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1502.06,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":583.7,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":793.84,"additional_payer_notes":"APC"}]}]},{"description":"Test socket hemipelvectomy","code_information":[{"code":"L5628","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":591.08,"maximum":1521.05,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":788.11,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1521.05,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":591.08,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":803.87,"additional_payer_notes":"APC"}]}]},{"description":"Below knee acrylic socket","code_information":[{"code":"L5629","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":291.8,"maximum":750.89,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":389.06,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":750.89,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":291.8,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":396.84,"additional_payer_notes":"APC"}]}]},{"description":"Syme typ expandabl wall sckt","code_information":[{"code":"L5630","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":507.01,"maximum":1304.7,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":676.01,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1304.7,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":507.01,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":689.53,"additional_payer_notes":"APC"}]}]},{"description":"Ak/knee disartic acrylic soc","code_information":[{"code":"L5631","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":403.43,"maximum":1038.17,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":537.91,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1038.17,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":403.43,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":548.67,"additional_payer_notes":"APC"}]}]},{"description":"Symes type ptb brim design s","code_information":[{"code":"L5632","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":248.66,"maximum":639.87,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":331.54,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":639.87,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":248.66,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":338.17,"additional_payer_notes":"APC"}]}]},{"description":"Symes type poster opening so","code_information":[{"code":"L5634","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":310.96,"maximum":800.22,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":414.62,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":800.22,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":310.96,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":422.91,"additional_payer_notes":"APC"}]}]},{"description":"Symes type medial opening so","code_information":[{"code":"L5636","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":237.68,"maximum":611.64,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":316.91,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":611.64,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":237.68,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":323.25,"additional_payer_notes":"APC"}]}]},{"description":"Below knee total contact","code_information":[{"code":"L5637","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":353.67,"maximum":910.11,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":471.56,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":910.11,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":353.67,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":480.99,"additional_payer_notes":"APC"}]}]},{"description":"Below knee leather socket","code_information":[{"code":"L5638","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":595.79,"maximum":1533.17,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":794.39,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1533.17,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":595.79,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":810.28,"additional_payer_notes":"APC"}]}]},{"description":"Below knee wood socket","code_information":[{"code":"L5639","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1029.45,"maximum":2649.12,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1372.6,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2649.12,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1029.45,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1400.05,"additional_payer_notes":"APC"}]}]},{"description":"Knee disarticulat leather so","code_information":[{"code":"L5640","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":676.66,"maximum":1741.27,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":902.21,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1741.27,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":676.66,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":920.25,"additional_payer_notes":"APC"}]}]},{"description":"Above knee leather socket","code_information":[{"code":"L5642","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":627.24,"maximum":1614.1,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":836.32,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1614.1,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":627.24,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":853.05,"additional_payer_notes":"APC"}]}]},{"description":"Hip flex inner socket ext fr","code_information":[{"code":"L5643","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1850.05,"maximum":4760.79,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2466.73,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4760.79,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1850.05,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2516.06,"additional_payer_notes":"APC"}]}]},{"description":"Above knee wood socket","code_information":[{"code":"L5644","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":542.32,"maximum":1395.56,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":723.09,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1395.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":542.32,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":737.55,"additional_payer_notes":"APC"}]}]},{"description":"Bk flex inner socket ext fra","code_information":[{"code":"L5645","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":899.67,"maximum":2315.15,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1199.56,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2315.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":899.67,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1223.55,"additional_payer_notes":"APC"}]}]},{"description":"Below knee cushion socket","code_information":[{"code":"L5646","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":570.15,"maximum":1467.19,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":760.2,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1467.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":570.15,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":775.4,"additional_payer_notes":"APC"}]}]},{"description":"Below knee suction socket","code_information":[{"code":"L5647","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":730.38,"maximum":1879.51,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":973.84,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1879.51,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":730.38,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":993.32,"additional_payer_notes":"APC"}]}]},{"description":"Above knee cushion socket","code_information":[{"code":"L5648","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":673.67,"maximum":1733.58,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":898.23,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1733.58,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":673.67,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":916.19,"additional_payer_notes":"APC"}]}]},{"description":"Isch containmt/narrow m-l so","code_information":[{"code":"L5649","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2263.6,"maximum":5825.01,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3018.14,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5825.01,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2263.6,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3078.5,"additional_payer_notes":"APC"}]}]},{"description":"Tot contact ak/knee disart s","code_information":[{"code":"L5650","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":448.24,"maximum":1153.48,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":597.66,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1153.48,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":448.24,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":609.61,"additional_payer_notes":"APC"}]}]},{"description":"Ak flex inner socket ext fra","code_information":[{"code":"L5651","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1313.3,"maximum":3379.55,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1751.06,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3379.55,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1313.3,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1786.08,"additional_payer_notes":"APC"}]}]},{"description":"Suction susp ak/knee disart","code_information":[{"code":"L5652","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":400.31,"maximum":1030.14,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":533.75,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1030.14,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":400.31,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":544.42,"additional_payer_notes":"APC"}]}]},{"description":"Knee disart expand wall sock","code_information":[{"code":"L5653","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":624.61,"maximum":1607.32,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":832.81,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1607.32,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":624.61,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":849.47,"additional_payer_notes":"APC"}]}]},{"description":"Socket insert symes","code_information":[{"code":"L5654","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":362.08,"maximum":931.75,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":482.77,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":931.75,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":362.08,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":492.43,"additional_payer_notes":"APC"}]}]},{"description":"Socket insert below knee","code_information":[{"code":"L5655","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":261.42,"maximum":672.72,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":348.56,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":672.72,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":261.42,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":355.53,"additional_payer_notes":"APC"}]}]},{"description":"Socket insert knee articulat","code_information":[{"code":"L5656","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":397.16,"maximum":1022.01,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":529.54,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1022.01,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":397.16,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":540.13,"additional_payer_notes":"APC"}]}]},{"description":"Add low ext man aut vol any","code_information":[{"code":"L5657","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":229.74,"maximum":591.2,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":306.32,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":591.2,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":229.74,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":312.45,"additional_payer_notes":"APC"}]}]},{"description":"Socket insert above knee","code_information":[{"code":"L5658","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":419.2,"maximum":1078.75,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":558.94,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1078.75,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":419.2,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":570.12,"additional_payer_notes":"APC"}]}]},{"description":"Multi-durometer symes","code_information":[{"code":"L5661","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":601.47,"maximum":1547.78,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":801.96,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1547.78,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":601.47,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":818.0,"additional_payer_notes":"APC"}]}]},{"description":"Multi-durometer below knee","code_information":[{"code":"L5665","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":534.73,"maximum":1376.03,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":712.97,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1376.03,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":534.73,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":727.23,"additional_payer_notes":"APC"}]}]},{"description":"Below knee cuff suspension","code_information":[{"code":"L5666","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":70.8,"maximum":182.19,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":94.4,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":182.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":70.8,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":96.29,"additional_payer_notes":"APC"}]}]},{"description":"Bk molded distal cushion","code_information":[{"code":"L5668","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":105.46,"maximum":271.4,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":140.62,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":271.4,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":105.46,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":143.43,"additional_payer_notes":"APC"}]}]},{"description":"Bk molded supracondylar susp","code_information":[{"code":"L5670","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":249.15,"maximum":641.15,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":332.2,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":641.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":249.15,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":338.84,"additional_payer_notes":"APC"}]}]},{"description":"Bk/ak locking mechanism","code_information":[{"code":"L5671","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":456.72,"maximum":1175.29,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":608.96,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1175.29,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":456.72,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":621.14,"additional_payer_notes":"APC"}]}]},{"description":"Bk removable medial brim sus","code_information":[{"code":"L5672","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":329.7,"maximum":848.43,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":439.6,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":848.43,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":329.7,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":448.39,"additional_payer_notes":"APC"}]}]},{"description":"Socket insert w lock mech","code_information":[{"code":"L5673","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":725.86,"maximum":1867.89,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":967.82,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1867.89,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":725.86,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":987.18,"additional_payer_notes":"APC"}]}]},{"description":"Bk knee joints single axis p","code_information":[{"code":"L5676","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":332.72,"maximum":856.21,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":443.63,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":856.21,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":332.72,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":452.5,"additional_payer_notes":"APC"}]}]},{"description":"Bk knee joints polycentric p","code_information":[{"code":"L5677","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":509.56,"maximum":1311.28,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":679.42,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1311.28,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":509.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":693.01,"additional_payer_notes":"APC"}]}]},{"description":"Bk joint covers pair","code_information":[{"code":"L5678","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":36.46,"maximum":93.82,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":48.61,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":93.82,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":36.46,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":49.58,"additional_payer_notes":"APC"}]}]},{"description":"Socket insert w/o lock mech","code_information":[{"code":"L5679","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":604.87,"maximum":1556.53,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":806.49,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1556.53,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":604.87,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":822.62,"additional_payer_notes":"APC"}]}]},{"description":"Bk thigh lacer non-molded","code_information":[{"code":"L5680","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":279.47,"maximum":719.18,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":372.63,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":719.18,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":279.47,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":380.08,"additional_payer_notes":"APC"}]}]},{"description":"Intl custm cong/latyp insert","code_information":[{"code":"L5681","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1214.8,"maximum":3126.1,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1619.74,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3126.1,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1214.8,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1652.13,"additional_payer_notes":"APC"}]}]},{"description":"Bk thigh lacer glut/ischia m","code_information":[{"code":"L5682","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":574.22,"maximum":1477.67,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":765.63,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1477.67,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":574.22,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":780.94,"additional_payer_notes":"APC"}]}]},{"description":"Initial custom socket insert","code_information":[{"code":"L5683","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1214.8,"maximum":3126.1,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1619.74,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3126.1,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1214.8,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1652.13,"additional_payer_notes":"APC"}]}]},{"description":"Bk fork strap","code_information":[{"code":"L5684","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":44.2,"maximum":113.73,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":58.93,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":113.73,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":44.2,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":60.11,"additional_payer_notes":"APC"}]}]},{"description":"Below knee sus/seal sleeve","code_information":[{"code":"L5685","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":118.3,"maximum":304.44,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":157.74,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":304.44,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":118.3,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":160.89,"additional_payer_notes":"APC"}]}]},{"description":"Bk back check","code_information":[{"code":"L5686","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":53.15,"maximum":136.78,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":70.87,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":136.78,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":53.15,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":72.29,"additional_payer_notes":"APC"}]}]},{"description":"Bk waist belt webbing","code_information":[{"code":"L5688","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":56.46,"maximum":145.29,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":75.28,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":145.29,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":56.46,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":76.79,"additional_payer_notes":"APC"}]}]},{"description":"Bk waist belt padded and lin","code_information":[{"code":"L5690","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":115.24,"maximum":296.54,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":153.65,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":296.54,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":115.24,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":156.72,"additional_payer_notes":"APC"}]}]},{"description":"Ak pelvic control belt light","code_information":[{"code":"L5692","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":122.0,"maximum":313.95,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":162.67,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":313.95,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":122.0,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":165.92,"additional_payer_notes":"APC"}]}]},{"description":"Ak pelvic control belt pad/l","code_information":[{"code":"L5694","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":166.58,"maximum":428.65,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":222.1,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":428.65,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":166.58,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":226.54,"additional_payer_notes":"APC"}]}]},{"description":"Ak sleeve susp neoprene/equa","code_information":[{"code":"L5695","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":149.74,"maximum":385.32,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":199.65,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":385.32,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":149.74,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":203.64,"additional_payer_notes":"APC"}]}]},{"description":"Ak/knee disartic pelvic join","code_information":[{"code":"L5696","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":180.88,"maximum":465.46,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":241.17,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":465.46,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":180.88,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":245.99,"additional_payer_notes":"APC"}]}]},{"description":"Ak/knee disartic pelvic band","code_information":[{"code":"L5697","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":85.9,"maximum":221.04,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":114.53,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":221.04,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":85.9,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":116.82,"additional_payer_notes":"APC"}]}]},{"description":"Ak/knee disartic silesian ba","code_information":[{"code":"L5698","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":110.19,"maximum":283.56,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":146.92,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":283.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":110.19,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":149.86,"additional_payer_notes":"APC"}]}]},{"description":"Shoulder harness","code_information":[{"code":"L5699","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":188.32,"maximum":484.62,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":251.1,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":484.62,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":188.32,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":256.12,"additional_payer_notes":"APC"}]}]},{"description":"Replace socket below knee","code_information":[{"code":"L5700","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2832.74,"maximum":7289.59,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3776.99,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7289.59,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2832.74,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3852.53,"additional_payer_notes":"APC"}]}]},{"description":"Replace socket above knee","code_information":[{"code":"L5701","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3514.28,"maximum":9043.4,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4685.7,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":9043.4,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3514.28,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4779.41,"additional_payer_notes":"APC"}]}]},{"description":"Replace socket hip","code_information":[{"code":"L5702","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4429.21,"maximum":11397.83,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5905.61,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11397.83,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4429.21,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6023.72,"additional_payer_notes":"APC"}]}]},{"description":"Symes ankle w/o (sach) foot","code_information":[{"code":"L5703","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2329.89,"maximum":5995.58,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3106.52,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5995.58,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2329.89,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3168.65,"additional_payer_notes":"APC"}]}]},{"description":"Custom shape cover bk","code_information":[{"code":"L5704","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":577.58,"maximum":1486.31,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":770.11,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1486.31,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":577.58,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":785.51,"additional_payer_notes":"APC"}]}]},{"description":"Custom shape cover ak","code_information":[{"code":"L5705","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1058.92,"maximum":2724.97,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1411.9,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2724.97,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1058.92,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1440.14,"additional_payer_notes":"APC"}]}]},{"description":"Custom shape cvr knee disart","code_information":[{"code":"L5706","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1032.84,"maximum":2657.84,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1377.12,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2657.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1032.84,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1404.66,"additional_payer_notes":"APC"}]}]},{"description":"Custom shape cvr hip disart","code_information":[{"code":"L5707","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1387.66,"maximum":3570.91,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1850.21,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3570.91,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1387.66,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1887.21,"additional_payer_notes":"APC"}]}]},{"description":"Kne-shin exo sng axi mnl loc","code_information":[{"code":"L5710","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":330.23,"maximum":849.8,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":440.31,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":849.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":330.23,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":449.12,"additional_payer_notes":"APC"}]}]},{"description":"Knee-shin exo mnl lock ultra","code_information":[{"code":"L5711","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":554.23,"maximum":1426.21,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":738.97,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1426.21,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":554.23,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":753.75,"additional_payer_notes":"APC"}]}]},{"description":"Knee-shin exo frict swg & st","code_information":[{"code":"L5712","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":395.64,"maximum":1018.11,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":527.52,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1018.11,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":395.64,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":538.07,"additional_payer_notes":"APC"}]}]},{"description":"Knee-shin exo variable frict","code_information":[{"code":"L5714","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":402.56,"maximum":1035.93,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":536.75,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1035.93,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":402.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":547.48,"additional_payer_notes":"APC"}]}]},{"description":"Knee-shin exo mech stance ph","code_information":[{"code":"L5716","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":796.02,"maximum":2048.42,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1061.36,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2048.42,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":796.02,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1082.59,"additional_payer_notes":"APC"}]}]},{"description":"Knee-shin exo frct swg & sta","code_information":[{"code":"L5718","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":851.19,"maximum":2190.4,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1134.92,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2190.4,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":851.19,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1157.62,"additional_payer_notes":"APC"}]}]},{"description":"Knee-shin pneum swg frct exo","code_information":[{"code":"L5722","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1035.11,"maximum":2663.69,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1380.15,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2663.69,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1035.11,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1407.75,"additional_payer_notes":"APC"}]}]},{"description":"Knee-shin exo fluid swing ph","code_information":[{"code":"L5724","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1595.45,"maximum":4105.63,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2127.27,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4105.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1595.45,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2169.82,"additional_payer_notes":"APC"}]}]},{"description":"Knee-shin ext jnts fld swg e","code_information":[{"code":"L5726","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1899.45,"maximum":4887.92,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2532.6,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4887.92,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1899.45,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2583.25,"additional_payer_notes":"APC"}]}]},{"description":"Knee-shin fluid swg & stance","code_information":[{"code":"L5728","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2225.95,"maximum":5728.1,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2967.93,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5728.1,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2225.95,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3027.29,"additional_payer_notes":"APC"}]}]},{"description":"Knee-shin pneum/hydra pneum","code_information":[{"code":"L5780","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1225.55,"maximum":3153.76,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1634.07,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3153.76,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1225.55,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1666.75,"additional_payer_notes":"APC"}]}]},{"description":"Lower limb pros vacuum pump","code_information":[{"code":"L5781","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3695.18,"maximum":9508.92,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4926.9,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":9508.92,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3695.18,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5025.44,"additional_payer_notes":"APC"}]}]},{"description":"HD low limb pros vacuum pump","code_information":[{"code":"L5782","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3895.54,"maximum":10024.54,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5194.06,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":10024.54,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3895.54,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5297.94,"additional_payer_notes":"APC"}]}]},{"description":"Add low ext mec limb vol sys","code_information":[{"code":"L5783","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2362.55,"maximum":6079.64,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3150.07,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6079.64,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2362.55,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3213.07,"additional_payer_notes":"APC"}]}]},{"description":"Exoskeletal bk ultralt mater","code_information":[{"code":"L5785","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":477.04,"maximum":1227.6,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":636.06,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1227.6,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":477.04,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":648.78,"additional_payer_notes":"APC"}]}]},{"description":"Exoskeletal ak ultra-light m","code_information":[{"code":"L5790","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":688.49,"maximum":1771.72,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":917.99,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1771.72,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":688.49,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":936.35,"additional_payer_notes":"APC"}]}]},{"description":"Exoskel hip ultra-light mate","code_information":[{"code":"L5795","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":985.84,"maximum":2536.91,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1314.46,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2536.91,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":985.84,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1340.75,"additional_payer_notes":"APC"}]}]},{"description":"Endoskel knee-shin mnl lock","code_information":[{"code":"L5810","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":525.25,"maximum":1351.64,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":700.33,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1351.64,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":525.25,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":714.34,"additional_payer_notes":"APC"}]}]},{"description":"Endo knee-shin mnl lck ultra","code_information":[{"code":"L5811","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":724.85,"maximum":1865.29,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":966.47,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1865.29,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":724.85,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":985.8,"additional_payer_notes":"APC"}]}]},{"description":"Endo knee-shin frct swg & st","code_information":[{"code":"L5812","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":545.48,"maximum":1403.71,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":727.31,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1403.71,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":545.48,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":741.86,"additional_payer_notes":"APC"}]}]},{"description":"Endo knee-shin hydral swg ph","code_information":[{"code":"L5814","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3429.84,"maximum":8826.12,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4573.12,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":8826.12,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3429.84,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4664.58,"additional_payer_notes":"APC"}]}]},{"description":"Endo knee-shin polyc mch sta","code_information":[{"code":"L5816","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":780.87,"maximum":2009.44,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1041.16,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2009.44,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":780.87,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1061.98,"additional_payer_notes":"APC"}]}]},{"description":"Endo knee-shin frct swg & st","code_information":[{"code":"L5818","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":881.75,"maximum":2269.04,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1175.67,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2269.04,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":881.75,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1199.18,"additional_payer_notes":"APC"}]}]},{"description":"Endo knee-shin pneum swg frc","code_information":[{"code":"L5822","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1617.56,"maximum":4162.53,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2156.75,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4162.53,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1617.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2199.88,"additional_payer_notes":"APC"}]}]},{"description":"Endo knee-shin fluid swing p","code_information":[{"code":"L5824","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1529.07,"maximum":3934.81,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2038.76,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3934.81,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1529.07,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2079.54,"additional_payer_notes":"APC"}]}]},{"description":"Miniature knee joint","code_information":[{"code":"L5826","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2884.06,"maximum":7421.66,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3845.42,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7421.66,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2884.06,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3922.33,"additional_payer_notes":"APC"}]}]},{"description":"Endo knee shin single axis","code_information":[{"code":"L5827","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5369.74,"maximum":13818.14,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7159.66,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13818.14,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5369.74,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7302.85,"additional_payer_notes":"APC"}]}]},{"description":"Endo knee-shin fluid swg/sta","code_information":[{"code":"L5828","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2721.37,"maximum":7002.99,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3628.49,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7002.99,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2721.37,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3701.06,"additional_payer_notes":"APC"}]}]},{"description":"Endo knee-shin pneum/swg pha","code_information":[{"code":"L5830","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1834.93,"maximum":4721.88,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2446.57,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4721.88,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1834.93,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2495.5,"additional_payer_notes":"APC"}]}]},{"description":"Multi-axial knee/shin system","code_information":[{"code":"L5840","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3601.47,"maximum":9267.78,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4801.96,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":9267.78,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3601.47,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4898.0,"additional_payer_notes":"APC"}]}]},{"description":"Addition endoskletl knee-shi","code_information":[{"code":"L5841","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2110.78,"maximum":5431.75,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2814.38,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5431.75,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2110.78,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2870.67,"additional_payer_notes":"APC"}]}]},{"description":"Knee-shin sys stance flexion","code_information":[{"code":"L5845","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1655.29,"maximum":4259.61,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2207.05,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4259.61,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1655.29,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2251.19,"additional_payer_notes":"APC"}]}]},{"description":"Knee-shin sys hydraul stance","code_information":[{"code":"L5848","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":993.09,"maximum":2555.55,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1324.12,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2555.55,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":993.09,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1350.6,"additional_payer_notes":"APC"}]}]},{"description":"Endo ak/hip knee extens assi","code_information":[{"code":"L5850","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":117.46,"maximum":302.26,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":156.61,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":302.26,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":117.46,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":159.74,"additional_payer_notes":"APC"}]}]},{"description":"Mech hip extension assist","code_information":[{"code":"L5855","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":283.57,"maximum":729.71,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":378.09,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":729.71,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":283.57,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":385.65,"additional_payer_notes":"APC"}]}]},{"description":"Elec knee-shin swing/stance","code_information":[{"code":"L5856","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":22169.84,"maximum":57050.38,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":29559.78,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":57050.38,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22169.84,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":30150.98,"additional_payer_notes":"APC"}]}]},{"description":"Elec knee-shin swing only","code_information":[{"code":"L5857","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7866.69,"maximum":20243.62,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10488.92,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":20243.62,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7866.69,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10698.7,"additional_payer_notes":"APC"}]}]},{"description":"Stance phase only","code_information":[{"code":"L5858","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":17163.79,"maximum":44168.15,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22885.05,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":44168.15,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17163.79,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23342.75,"additional_payer_notes":"APC"}]}]},{"description":"Knee-shin pro flex/ext cont","code_information":[{"code":"L5859","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":13399.6,"maximum":34481.65,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17866.14,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":34481.65,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13399.6,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18223.46,"additional_payer_notes":"APC"}]}]},{"description":"Endo below knee alignable sy","code_information":[{"code":"L5910","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":332.54,"maximum":855.74,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":443.39,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":855.74,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":332.54,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":452.26,"additional_payer_notes":"APC"}]}]},{"description":"Endo ak/hip alignable system","code_information":[{"code":"L5920","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":487.18,"maximum":1253.69,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":649.58,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1253.69,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":487.18,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":662.57,"additional_payer_notes":"APC"}]}]},{"description":"Above knee manual lock","code_information":[{"code":"L5925","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":308.52,"maximum":793.92,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":411.36,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":793.92,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":308.52,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":419.59,"additional_payer_notes":"APC"}]}]},{"description":"Endoskel posit rotat unit","code_information":[{"code":"L5926","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":593.8,"maximum":1528.06,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":791.74,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1528.06,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":593.8,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":807.57,"additional_payer_notes":"APC"}]}]},{"description":"High activity knee frame","code_information":[{"code":"L5930","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3108.5,"maximum":7999.19,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4144.66,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7999.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3108.5,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4227.55,"additional_payer_notes":"APC"}]}]},{"description":"Endo bk ultra-light material","code_information":[{"code":"L5940","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":460.58,"maximum":1185.21,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":614.1,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1185.21,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":460.58,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":626.38,"additional_payer_notes":"APC"}]}]},{"description":"Endo ak ultra-light material","code_information":[{"code":"L5950","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":714.35,"maximum":1838.27,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":952.47,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1838.27,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":714.35,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":971.52,"additional_payer_notes":"APC"}]}]},{"description":"Endo hip ultra-light materia","code_information":[{"code":"L5960","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1068.14,"maximum":2748.69,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1424.19,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2748.69,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1068.14,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1452.67,"additional_payer_notes":"APC"}]}]},{"description":"Endo poly hip, pneu/hyd/rot","code_information":[{"code":"L5961","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4408.21,"maximum":11343.79,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5877.61,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11343.79,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4408.21,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5995.16,"additional_payer_notes":"APC"}]}]},{"description":"Below knee flex cover system","code_information":[{"code":"L5962","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":539.7,"maximum":1388.83,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":719.6,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1388.83,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":539.7,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":733.99,"additional_payer_notes":"APC"}]}]},{"description":"Above knee flex cover system","code_information":[{"code":"L5964","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1035.26,"maximum":2664.06,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1380.34,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2664.06,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1035.26,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1407.95,"additional_payer_notes":"APC"}]}]},{"description":"Hip flexible cover system","code_information":[{"code":"L5966","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1333.59,"maximum":3431.77,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1778.12,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3431.77,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1333.59,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1813.68,"additional_payer_notes":"APC"}]}]},{"description":"Multiaxial ankle w dorsiflex","code_information":[{"code":"L5968","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3355.96,"maximum":8636.02,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4474.62,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":8636.02,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3355.96,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4564.11,"additional_payer_notes":"APC"}]}]},{"description":"Foot external keel sach foot","code_information":[{"code":"L5970","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":200.6,"maximum":516.22,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":267.47,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":516.22,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":200.6,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":272.82,"additional_payer_notes":"APC"}]}]},{"description":"SACH foot, replacement","code_information":[{"code":"L5971","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":200.6,"maximum":516.22,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":267.47,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":516.22,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":200.6,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":272.82,"additional_payer_notes":"APC"}]}]},{"description":"Flexible keel foot","code_information":[{"code":"L5972","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":365.42,"maximum":940.35,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":487.23,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":940.35,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":365.42,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":496.97,"additional_payer_notes":"APC"}]}]},{"description":"Ank-foot sys dors-plant flex","code_information":[{"code":"L5973","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":16304.64,"maximum":41957.27,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21739.52,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":41957.27,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16304.64,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22174.31,"additional_payer_notes":"APC"}]}]},{"description":"Foot single axis ankle/foot","code_information":[{"code":"L5974","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":213.97,"maximum":550.61,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":285.29,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":550.61,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":213.97,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":291.0,"additional_payer_notes":"APC"}]}]},{"description":"Combo ankle/foot prosthesis","code_information":[{"code":"L5975","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":428.14,"maximum":1101.76,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":570.86,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1101.76,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":428.14,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":582.28,"additional_payer_notes":"APC"}]}]},{"description":"Energy storing foot","code_information":[{"code":"L5976","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":542.73,"maximum":1396.63,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":723.64,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1396.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":542.73,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":738.11,"additional_payer_notes":"APC"}]}]},{"description":"Ft prosth multiaxial ankl/ft","code_information":[{"code":"L5978","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":287.58,"maximum":740.04,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":383.44,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":740.04,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":287.58,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":391.11,"additional_payer_notes":"APC"}]}]},{"description":"Multi-axial ankle/ft prosth","code_information":[{"code":"L5979","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2302.58,"maximum":5925.31,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3070.11,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5925.31,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2302.58,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3131.51,"additional_payer_notes":"APC"}]}]},{"description":"Flex foot system","code_information":[{"code":"L5980","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3508.19,"maximum":9027.75,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4677.59,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":9027.75,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3508.19,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4771.14,"additional_payer_notes":"APC"}]}]},{"description":"Flex-walk sys low ext prosth","code_information":[{"code":"L5981","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3151.2,"maximum":8109.09,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4201.6,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":8109.09,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3151.2,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4285.63,"additional_payer_notes":"APC"}]}]},{"description":"Exoskeletal axial rotation u","code_information":[{"code":"L5982","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":591.98,"maximum":1523.37,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":789.31,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1523.37,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":591.98,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":805.1,"additional_payer_notes":"APC"}]}]},{"description":"Endoskeletal axial rotation","code_information":[{"code":"L5984","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":593.8,"maximum":1528.06,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":791.74,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1528.06,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":593.8,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":807.57,"additional_payer_notes":"APC"}]}]},{"description":"Lwr ext dynamic prosth pylon","code_information":[{"code":"L5985","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":260.8,"maximum":671.12,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":347.73,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":671.12,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":260.8,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":354.68,"additional_payer_notes":"APC"}]}]},{"description":"Multi-axial rotation unit","code_information":[{"code":"L5986","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":716.31,"maximum":1843.3,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":955.08,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1843.3,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":716.31,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":974.18,"additional_payer_notes":"APC"}]}]},{"description":"Shank ft w vert load pylon","code_information":[{"code":"L5987","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6643.58,"maximum":17096.13,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8858.1,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":17096.13,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6643.58,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9035.26,"additional_payer_notes":"APC"}]}]},{"description":"Vertical shock reducing pylo","code_information":[{"code":"L5988","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1844.9,"maximum":4747.55,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2459.87,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4747.55,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1844.9,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2509.07,"additional_payer_notes":"APC"}]}]},{"description":"User adjustable heel height","code_information":[{"code":"L5990","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1675.4,"maximum":4311.37,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2233.87,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4311.37,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1675.4,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2278.55,"additional_payer_notes":"APC"}]}]},{"description":"Low pros ext osseo connector","code_information":[{"code":"L5991","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8816.28,"maximum":22687.23,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11755.04,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":22687.23,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8816.28,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11990.14,"additional_payer_notes":"APC"}]}]},{"description":"Low prosth foot shell repl","code_information":[{"code":"L5992","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":95.33,"maximum":245.32,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":127.11,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":245.32,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":95.33,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":129.65,"additional_payer_notes":"APC"}]}]},{"description":"Part hand myo exclu term dev","code_information":[{"code":"L6026","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4017.19,"maximum":10337.56,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5356.25,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":10337.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4017.19,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5463.38,"additional_payer_notes":"APC"}]}]},{"description":"Part handfng endoskel molded","code_information":[{"code":"L6028","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1715.62,"maximum":4414.86,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2287.49,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4414.86,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1715.62,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2333.24,"additional_payer_notes":"APC"}]}]},{"description":"Test interface part handfing","code_information":[{"code":"L6029","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":284.03,"maximum":730.91,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":378.71,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":730.91,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":284.03,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":386.28,"additional_payer_notes":"APC"}]}]},{"description":"External frame part handfing","code_information":[{"code":"L6030","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":529.62,"maximum":1362.89,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":706.16,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1362.89,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":529.62,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":720.28,"additional_payer_notes":"APC"}]}]},{"description":"Rep interface handfng molded","code_information":[{"code":"L6031","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1151.4,"maximum":2962.94,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1535.2,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2962.94,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1151.4,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1565.9,"additional_payer_notes":"APC"}]}]},{"description":"Part handfng ultralite tcf/=","code_information":[{"code":"L6032","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":283.04,"maximum":728.36,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":377.39,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":728.36,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":283.04,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":384.94,"additional_payer_notes":"APC"}]}]},{"description":"Part handfing acrylic","code_information":[{"code":"L6033","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":340.11,"maximum":875.22,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":453.48,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":875.22,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":340.11,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":462.55,"additional_payer_notes":"APC"}]}]},{"description":"Part hand finger distal amp","code_information":[{"code":"L6034","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":343.12,"maximum":882.98,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":457.5,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":882.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":343.12,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":466.65,"additional_payer_notes":"APC"}]}]},{"description":"Prosthetic digit mechanical","code_information":[{"code":"L6035","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1210.59,"maximum":3115.25,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1614.12,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3115.25,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1210.59,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1646.4,"additional_payer_notes":"APC"}]}]},{"description":"Prosthetic thumb mechanical","code_information":[{"code":"L6036","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1210.59,"maximum":3115.25,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1614.12,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3115.25,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1210.59,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1646.4,"additional_payer_notes":"APC"}]}]},{"description":"Postop dsg cast chg handfing","code_information":[{"code":"L6037","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1307.93,"maximum":3365.75,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1743.91,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3365.75,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1307.93,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1778.79,"additional_payer_notes":"APC"}]}]},{"description":"Multiax rotation attachment","code_information":[{"code":"L6038","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":277.28,"maximum":713.54,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":369.71,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":713.54,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":277.28,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":377.1,"additional_payer_notes":"APC"}]}]},{"description":"Passive custom digit/thumb","code_information":[{"code":"L6039","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1781.78,"maximum":4585.12,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2375.71,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4585.12,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1781.78,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2423.22,"additional_payer_notes":"APC"}]}]},{"description":"Wrst MLd sck flx hng tri pad","code_information":[{"code":"L6050","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2295.63,"maximum":5907.42,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3060.84,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5907.42,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2295.63,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3122.06,"additional_payer_notes":"APC"}]}]},{"description":"Wrst mold sock w/exp interfa","code_information":[{"code":"L6055","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2928.2,"maximum":7535.24,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3904.27,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7535.24,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2928.2,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3982.36,"additional_payer_notes":"APC"}]}]},{"description":"Elb mold sock flex hinge pad","code_information":[{"code":"L6100","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2323.1,"maximum":5978.1,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3097.46,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5978.1,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2323.1,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3159.41,"additional_payer_notes":"APC"}]}]},{"description":"Elbow mold sock suspension t","code_information":[{"code":"L6110","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2457.68,"maximum":6324.44,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3276.91,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6324.44,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2457.68,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3342.45,"additional_payer_notes":"APC"}]}]},{"description":"Elbow mold doub splt soc ste","code_information":[{"code":"L6120","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2779.65,"maximum":7152.97,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3706.2,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7152.97,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2779.65,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3780.32,"additional_payer_notes":"APC"}]}]},{"description":"Elbow stump activated lock h","code_information":[{"code":"L6130","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2932.59,"maximum":7546.53,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3910.12,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7546.53,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2932.59,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3988.32,"additional_payer_notes":"APC"}]}]},{"description":"Elbow mold outsid lock hinge","code_information":[{"code":"L6200","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3020.91,"maximum":7773.81,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4027.88,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7773.81,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3020.91,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4108.44,"additional_payer_notes":"APC"}]}]},{"description":"Elbow molded w/ expand inter","code_information":[{"code":"L6205","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4167.28,"maximum":10723.81,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5556.38,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":10723.81,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4167.28,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5667.51,"additional_payer_notes":"APC"}]}]},{"description":"Elbow inter loc elbow forarm","code_information":[{"code":"L6250","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2972.05,"maximum":7648.07,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3962.73,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7648.07,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2972.05,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4041.98,"additional_payer_notes":"APC"}]}]},{"description":"Shlder disart int lock elbow","code_information":[{"code":"L6300","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4099.28,"maximum":10548.8,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5465.7,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":10548.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4099.28,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5575.01,"additional_payer_notes":"APC"}]}]},{"description":"Shoulder passive restor comp","code_information":[{"code":"L6310","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3715.1,"maximum":9560.2,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4953.47,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":9560.2,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3715.1,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5052.54,"additional_payer_notes":"APC"}]}]},{"description":"Shoulder passive restor cap","code_information":[{"code":"L6320","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1936.19,"maximum":4982.47,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2581.59,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4982.47,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1936.19,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2633.22,"additional_payer_notes":"APC"}]}]},{"description":"Thoracic intern lock elbow","code_information":[{"code":"L6350","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4491.54,"maximum":11558.23,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5988.72,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":11558.23,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4491.54,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6108.49,"additional_payer_notes":"APC"}]}]},{"description":"Thoracic passive restor comp","code_information":[{"code":"L6360","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3899.44,"maximum":10034.57,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5199.26,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":10034.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3899.44,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5303.25,"additional_payer_notes":"APC"}]}]},{"description":"Thoracic passive restor cap","code_information":[{"code":"L6370","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2261.42,"maximum":5819.37,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3015.22,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5819.37,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2261.42,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3075.52,"additional_payer_notes":"APC"}]}]},{"description":"Postop dsg cast chg wrst/elb","code_information":[{"code":"L6380","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1307.93,"maximum":3365.75,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1743.91,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3365.75,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1307.93,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1778.79,"additional_payer_notes":"APC"}]}]},{"description":"Postop dsg cast chg elb dis/","code_information":[{"code":"L6382","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1557.04,"maximum":4006.78,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2076.05,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4006.78,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1557.04,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2117.57,"additional_payer_notes":"APC"}]}]},{"description":"Postop dsg cast chg shlder/t","code_information":[{"code":"L6384","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1969.75,"maximum":5068.82,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2626.33,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5068.82,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1969.75,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2678.86,"additional_payer_notes":"APC"}]}]},{"description":"Postop ea cast chg & realign","code_information":[{"code":"L6386","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":431.78,"maximum":1111.12,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":575.71,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1111.12,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":431.78,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":587.22,"additional_payer_notes":"APC"}]}]},{"description":"Postop applicat rigid dsg on","code_information":[{"code":"L6388","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":475.49,"maximum":1223.6,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":633.99,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1223.6,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":475.49,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":646.67,"additional_payer_notes":"APC"}]}]},{"description":"Below elbow prosth tiss shap","code_information":[{"code":"L6400","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2513.0,"maximum":6466.79,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3350.67,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6466.79,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2513.0,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3417.68,"additional_payer_notes":"APC"}]}]},{"description":"Elb disart prosth tiss shap","code_information":[{"code":"L6450","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3284.37,"maximum":8451.78,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4379.16,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":8451.78,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3284.37,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4466.74,"additional_payer_notes":"APC"}]}]},{"description":"Above elbow prosth tiss shap","code_information":[{"code":"L6500","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3225.19,"maximum":8299.48,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4300.25,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":8299.48,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3225.19,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4386.26,"additional_payer_notes":"APC"}]}]},{"description":"Shldr disar prosth tiss shap","code_information":[{"code":"L6550","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4177.28,"maximum":10749.54,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5569.71,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":10749.54,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4177.28,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5681.1,"additional_payer_notes":"APC"}]}]},{"description":"Scap thorac prosth tiss shap","code_information":[{"code":"L6570","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4663.39,"maximum":12000.45,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6217.85,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":12000.45,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4663.39,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6342.21,"additional_payer_notes":"APC"}]}]},{"description":"Wrist/elbow bowden cable mol","code_information":[{"code":"L6580","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1864.53,"maximum":4798.06,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2486.04,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4798.06,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1864.53,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2535.76,"additional_payer_notes":"APC"}]}]},{"description":"Wrist/elbow bowden cbl dir f","code_information":[{"code":"L6582","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1565.96,"maximum":4029.72,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2087.94,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4029.72,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1565.96,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2129.7,"additional_payer_notes":"APC"}]}]},{"description":"Elbow fair lead cable molded","code_information":[{"code":"L6584","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2318.75,"maximum":5966.92,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3091.67,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5966.92,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2318.75,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3153.5,"additional_payer_notes":"APC"}]}]},{"description":"Elbow fair lead cable dir fo","code_information":[{"code":"L6586","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2066.15,"maximum":5316.9,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2754.87,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5316.9,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2066.15,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2809.97,"additional_payer_notes":"APC"}]}]},{"description":"Shdr fair lead cable molded","code_information":[{"code":"L6588","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3290.62,"maximum":8467.86,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4387.49,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":8467.86,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3290.62,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4475.24,"additional_payer_notes":"APC"}]}]},{"description":"Shdr fair lead cable direct","code_information":[{"code":"L6590","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2867.89,"maximum":7380.03,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3823.85,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7380.03,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2867.89,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3900.33,"additional_payer_notes":"APC"}]}]},{"description":"Polycentric hinge pair","code_information":[{"code":"L6600","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":209.48,"maximum":539.05,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":279.3,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":539.05,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":209.48,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":284.89,"additional_payer_notes":"APC"}]}]},{"description":"Single pivot hinge pair","code_information":[{"code":"L6605","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":215.61,"maximum":554.84,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":287.48,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":554.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":215.61,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":293.23,"additional_payer_notes":"APC"}]}]},{"description":"Flexible metal hinge pair","code_information":[{"code":"L6610","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":203.83,"maximum":524.52,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":271.77,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":524.52,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":203.83,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":277.21,"additional_payer_notes":"APC"}]}]},{"description":"Additional switch, ext power","code_information":[{"code":"L6611","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":380.23,"maximum":978.45,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":506.97,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":978.45,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":380.23,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":517.11,"additional_payer_notes":"APC"}]}]},{"description":"Disconnect locking wrist uni","code_information":[{"code":"L6615","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":197.85,"maximum":509.13,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":263.8,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":509.13,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":197.85,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":269.08,"additional_payer_notes":"APC"}]}]},{"description":"Disconnect insert locking wr","code_information":[{"code":"L6616","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":59.56,"maximum":153.26,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":79.41,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":153.26,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":59.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":81.0,"additional_payer_notes":"APC"}]}]},{"description":"Flexion/extension wrist unit","code_information":[{"code":"L6620","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":345.88,"maximum":890.06,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":461.17,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":890.06,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":345.88,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":470.39,"additional_payer_notes":"APC"}]}]},{"description":"Flex/ext wrist w/wo friction","code_information":[{"code":"L6621","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2112.38,"maximum":5435.84,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2816.5,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5435.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2112.38,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2872.83,"additional_payer_notes":"APC"}]}]},{"description":"Spring-ass rot wrst w/ latch","code_information":[{"code":"L6623","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":658.9,"maximum":1695.56,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":878.53,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1695.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":658.9,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":896.1,"additional_payer_notes":"APC"}]}]},{"description":"Flex/ext/rotation wrist unit","code_information":[{"code":"L6624","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3478.04,"maximum":8950.16,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4637.39,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":8950.16,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3478.04,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4730.14,"additional_payer_notes":"APC"}]}]},{"description":"Rotation wrst w/ cable lock","code_information":[{"code":"L6625","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":488.33,"maximum":1256.64,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":651.11,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1256.64,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":488.33,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":664.13,"additional_payer_notes":"APC"}]}]},{"description":"Quick disconn hook adapter o","code_information":[{"code":"L6628","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":525.64,"maximum":1352.66,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":700.86,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1352.66,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":525.64,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":714.88,"additional_payer_notes":"APC"}]}]},{"description":"Lamination collar w/ couplin","code_information":[{"code":"L6629","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":179.11,"maximum":460.9,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":238.81,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":460.9,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":179.11,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":243.59,"additional_payer_notes":"APC"}]}]},{"description":"Stainless steel any wrist","code_information":[{"code":"L6630","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":263.85,"maximum":678.97,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":351.8,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":678.97,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":263.85,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":358.84,"additional_payer_notes":"APC"}]}]},{"description":"Latex suspension sleeve each","code_information":[{"code":"L6632","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":59.66,"maximum":153.51,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":79.54,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":153.51,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":59.66,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":81.13,"additional_payer_notes":"APC"}]}]},{"description":"Lift assist for elbow","code_information":[{"code":"L6635","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":190.7,"maximum":490.72,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":254.26,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":490.72,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":190.7,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":259.35,"additional_payer_notes":"APC"}]}]},{"description":"Nudge control elbow lock","code_information":[{"code":"L6637","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":373.35,"maximum":960.75,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":497.8,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":960.75,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":373.35,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":507.76,"additional_payer_notes":"APC"}]}]},{"description":"Elec lock on manual pw elbow","code_information":[{"code":"L6638","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2309.48,"maximum":5943.07,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3079.31,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5943.07,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2309.48,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3140.9,"additional_payer_notes":"APC"}]}]},{"description":"Shoulder abduction joint pai","code_information":[{"code":"L6640","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":310.94,"maximum":800.14,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":414.58,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":800.14,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":310.94,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":422.87,"additional_payer_notes":"APC"}]}]},{"description":"Excursion amplifier pulley t","code_information":[{"code":"L6641","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":181.06,"maximum":465.92,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":241.41,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":465.92,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":181.06,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":246.24,"additional_payer_notes":"APC"}]}]},{"description":"Excursion amplifier lever ty","code_information":[{"code":"L6642","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":266.2,"maximum":685.03,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":354.94,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":685.03,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":266.2,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":362.04,"additional_payer_notes":"APC"}]}]},{"description":"Shoulder flexion-abduction j","code_information":[{"code":"L6645","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":336.26,"maximum":865.32,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":448.35,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":865.32,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":336.26,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":457.32,"additional_payer_notes":"APC"}]}]},{"description":"Multipo locking shoulder jnt","code_information":[{"code":"L6646","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2912.78,"maximum":7495.54,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3883.7,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7495.54,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2912.78,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3961.37,"additional_payer_notes":"APC"}]}]},{"description":"Shoulder lock actuator","code_information":[{"code":"L6647","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":479.54,"maximum":1234.02,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":639.39,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1234.02,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":479.54,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":652.18,"additional_payer_notes":"APC"}]}]},{"description":"Ext pwrd shlder lock/unlock","code_information":[{"code":"L6648","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3004.12,"maximum":7730.6,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4005.49,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7730.6,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3004.12,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4085.6,"additional_payer_notes":"APC"}]}]},{"description":"Shoulder universal joint","code_information":[{"code":"L6650","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":364.72,"maximum":938.54,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":486.29,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":938.54,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":364.72,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":496.02,"additional_payer_notes":"APC"}]}]},{"description":"Standard control cable extra","code_information":[{"code":"L6655","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":70.76,"maximum":182.08,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":94.34,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":182.08,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":70.76,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":96.23,"additional_payer_notes":"APC"}]}]},{"description":"Heavy duty control cable","code_information":[{"code":"L6660","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":94.68,"maximum":243.64,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":126.24,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":243.64,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":94.68,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":128.76,"additional_payer_notes":"APC"}]}]},{"description":"Teflon or equal cable lining","code_information":[{"code":"L6665","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":42.28,"maximum":108.81,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":56.38,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":108.81,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":42.28,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":57.51,"additional_payer_notes":"APC"}]}]},{"description":"Hook to hand cable adapter","code_information":[{"code":"L6670","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":44.03,"maximum":113.31,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":58.71,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":113.31,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":44.03,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":59.88,"additional_payer_notes":"APC"}]}]},{"description":"Harness chest/shlder saddle","code_information":[{"code":"L6672","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":202.07,"maximum":520.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":269.43,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":520.0,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":202.07,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":274.82,"additional_payer_notes":"APC"}]}]},{"description":"Harness figure of 8 sing con","code_information":[{"code":"L6675","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":110.26,"maximum":283.75,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":147.02,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":283.75,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":110.26,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":149.96,"additional_payer_notes":"APC"}]}]},{"description":"Harness figure of 8 dual con","code_information":[{"code":"L6676","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":115.36,"maximum":296.87,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":153.82,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":296.87,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":115.36,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":156.9,"additional_payer_notes":"APC"}]}]},{"description":"UE triple control harness","code_information":[{"code":"L6677","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":273.94,"maximum":704.95,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":365.26,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":704.95,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":273.94,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":372.57,"additional_payer_notes":"APC"}]}]},{"description":"Test sock wrist disart/bel e","code_information":[{"code":"L6680","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":284.03,"maximum":730.91,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":378.71,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":730.91,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":284.03,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":386.28,"additional_payer_notes":"APC"}]}]},{"description":"Test sock elbw disart/above","code_information":[{"code":"L6682","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":314.03,"maximum":808.11,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":418.71,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":808.11,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":314.03,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":427.08,"additional_payer_notes":"APC"}]}]},{"description":"Test socket shldr disart/tho","code_information":[{"code":"L6684","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":426.74,"maximum":1098.13,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":568.98,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1098.13,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":426.74,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":580.36,"additional_payer_notes":"APC"}]}]},{"description":"Suction socket","code_information":[{"code":"L6686","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":633.22,"maximum":1629.48,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":844.29,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1629.48,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":633.22,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":861.18,"additional_payer_notes":"APC"}]}]},{"description":"Frame typ socket bel elbow/w","code_information":[{"code":"L6687","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":529.62,"maximum":1362.89,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":706.16,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1362.89,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":529.62,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":720.28,"additional_payer_notes":"APC"}]}]},{"description":"Frame typ sock above elb/dis","code_information":[{"code":"L6688","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":586.15,"maximum":1508.35,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":781.53,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1508.35,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":586.15,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":797.16,"additional_payer_notes":"APC"}]}]},{"description":"Frame typ socket shoulder di","code_information":[{"code":"L6689","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":698.58,"maximum":1797.68,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":931.44,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1797.68,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":698.58,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":950.07,"additional_payer_notes":"APC"}]}]},{"description":"Frame typ sock interscap-tho","code_information":[{"code":"L6690","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":822.47,"maximum":2116.5,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1096.63,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2116.5,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":822.47,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1118.56,"additional_payer_notes":"APC"}]}]},{"description":"Removable insert each","code_information":[{"code":"L6691","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":324.66,"maximum":835.46,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":432.88,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":835.46,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":324.66,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":441.54,"additional_payer_notes":"APC"}]}]},{"description":"Silicone gel insert or equal","code_information":[{"code":"L6692","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":590.65,"maximum":1519.93,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":787.53,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1519.93,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":590.65,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":803.28,"additional_payer_notes":"APC"}]}]},{"description":"Lockingelbow forearm cntrbal","code_information":[{"code":"L6693","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2621.89,"maximum":6746.99,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3495.85,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6746.99,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2621.89,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3565.77,"additional_payer_notes":"APC"}]}]},{"description":"Elbow socket ins use w/lock","code_information":[{"code":"L6694","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":725.86,"maximum":1867.89,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":967.82,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1867.89,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":725.86,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":987.18,"additional_payer_notes":"APC"}]}]},{"description":"Elbow socket ins use w/o lck","code_information":[{"code":"L6695","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":604.87,"maximum":1556.53,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":806.49,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1556.53,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":604.87,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":822.62,"additional_payer_notes":"APC"}]}]},{"description":"Cus elbo skt in for con/atyp","code_information":[{"code":"L6696","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1214.8,"maximum":3126.1,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1619.74,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3126.1,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1214.8,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1652.13,"additional_payer_notes":"APC"}]}]},{"description":"Cus elbo skt in not con/atyp","code_information":[{"code":"L6697","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1214.8,"maximum":3126.1,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1619.74,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3126.1,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1214.8,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1652.13,"additional_payer_notes":"APC"}]}]},{"description":"Below/above elbow lock mech","code_information":[{"code":"L6698","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":456.72,"maximum":1175.29,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":608.96,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1175.29,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":456.72,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":621.14,"additional_payer_notes":"APC"}]}]},{"description":"Ue add ext power myoel","code_information":[{"code":"L6700","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":22132.64,"maximum":56954.67,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":29510.19,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":56954.67,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22132.64,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":30100.39,"additional_payer_notes":"APC"}]}]},{"description":"Term dev, passive hand mitt","code_information":[{"code":"L6703","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":323.02,"maximum":831.25,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":430.7,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":831.25,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":323.02,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":439.31,"additional_payer_notes":"APC"}]}]},{"description":"Term dev, sport/rec/work att","code_information":[{"code":"L6704","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":623.51,"maximum":1604.51,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":831.35,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1604.51,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":623.51,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":847.98,"additional_payer_notes":"APC"}]}]},{"description":"Term dev mech hook vol open","code_information":[{"code":"L6706","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":386.93,"maximum":995.71,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":515.91,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":995.71,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":386.93,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":526.23,"additional_payer_notes":"APC"}]}]},{"description":"Term dev mech hook vol close","code_information":[{"code":"L6707","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1368.79,"maximum":3522.35,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1825.05,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3522.35,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1368.79,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1861.55,"additional_payer_notes":"APC"}]}]},{"description":"Term dev mech hand vol open","code_information":[{"code":"L6708","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":904.82,"maximum":2328.39,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1206.42,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2328.39,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":904.82,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1230.55,"additional_payer_notes":"APC"}]}]},{"description":"Term dev mech hand vol close","code_information":[{"code":"L6709","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1284.16,"maximum":3304.57,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1712.21,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3304.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1284.16,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1746.45,"additional_payer_notes":"APC"}]}]},{"description":"Ped term dev, hook, vol open","code_information":[{"code":"L6711","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":620.89,"maximum":1597.75,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":827.85,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1597.75,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":620.89,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":844.41,"additional_payer_notes":"APC"}]}]},{"description":"Ped term dev, hook, vol clos","code_information":[{"code":"L6712","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1143.21,"maximum":2941.86,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1524.28,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2941.86,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1143.21,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1554.77,"additional_payer_notes":"APC"}]}]},{"description":"Ped term dev, hand, vol open","code_information":[{"code":"L6713","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1442.8,"maximum":3712.82,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1923.74,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3712.82,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1442.8,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1962.21,"additional_payer_notes":"APC"}]}]},{"description":"Ped term dev, hand, vol clos","code_information":[{"code":"L6714","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1222.05,"maximum":3144.74,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1629.4,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3144.74,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1222.05,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1661.99,"additional_payer_notes":"APC"}]}]},{"description":"Term device, multi art digit","code_information":[{"code":"L6715","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2915.7,"maximum":7503.07,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3887.6,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7503.07,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2915.7,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3965.35,"additional_payer_notes":"APC"}]}]},{"description":"Hook/hand, hvy dty, vol open","code_information":[{"code":"L6721","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2172.11,"maximum":5589.57,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2896.15,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5589.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2172.11,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2954.07,"additional_payer_notes":"APC"}]}]},{"description":"Hook/hand, hvy dty, vol clos","code_information":[{"code":"L6722","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1872.48,"maximum":4818.52,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2496.64,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4818.52,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1872.48,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2546.57,"additional_payer_notes":"APC"}]}]},{"description":"Term dev modifier wrist unit","code_information":[{"code":"L6805","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":354.2,"maximum":911.46,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":472.26,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":911.46,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":354.2,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":481.71,"additional_payer_notes":"APC"}]}]},{"description":"Term dev precision pinch dev","code_information":[{"code":"L6810","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":188.3,"maximum":484.55,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":251.06,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":484.55,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":188.3,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":256.08,"additional_payer_notes":"APC"}]}]},{"description":"Elec hand ind art digits","code_information":[{"code":"L6880","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":22065.16,"maximum":56781.01,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":29420.21,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":56781.01,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22065.16,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":30008.61,"additional_payer_notes":"APC"}]}]},{"description":"Term dev auto grasp feature","code_information":[{"code":"L6881","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3775.59,"maximum":9715.85,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5034.12,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":9715.85,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3775.59,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5134.8,"additional_payer_notes":"APC"}]}]},{"description":"Microprocessor control uplmb","code_information":[{"code":"L6882","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2863.96,"maximum":7369.92,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3818.61,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7369.92,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2863.96,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3894.98,"additional_payer_notes":"APC"}]}]},{"description":"Replc sockt below e/w disa","code_information":[{"code":"L6883","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1834.55,"maximum":4720.92,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2446.07,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4720.92,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1834.55,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2494.99,"additional_payer_notes":"APC"}]}]},{"description":"Replc sockt above elbow disa","code_information":[{"code":"L6884","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2510.08,"maximum":6459.27,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3346.77,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6459.27,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2510.08,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3413.71,"additional_payer_notes":"APC"}]}]},{"description":"Replc sockt shldr dis/interc","code_information":[{"code":"L6885","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3899.44,"maximum":10034.57,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5199.26,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":10034.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3899.44,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5303.25,"additional_payer_notes":"APC"}]}]},{"description":"Prefab glove for term device","code_information":[{"code":"L6890","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":184.45,"maximum":474.64,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":245.93,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":474.64,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":184.45,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":250.85,"additional_payer_notes":"APC"}]}]},{"description":"Custom glove for term device","code_information":[{"code":"L6895","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":616.75,"maximum":1587.1,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":822.33,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1587.1,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":616.75,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":838.78,"additional_payer_notes":"APC"}]}]},{"description":"Hand restorat thumb/1 finger","code_information":[{"code":"L6900","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1790.98,"maximum":4608.8,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2387.98,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4608.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1790.98,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2435.74,"additional_payer_notes":"APC"}]}]},{"description":"Hand restoration multiple fi","code_information":[{"code":"L6905","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1772.57,"maximum":4561.42,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2363.43,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4561.42,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1772.57,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2410.7,"additional_payer_notes":"APC"}]}]},{"description":"Hand restoration no fingers","code_information":[{"code":"L6910","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1742.56,"maximum":4484.2,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2323.42,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4484.2,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1742.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2369.89,"additional_payer_notes":"APC"}]}]},{"description":"Hand restoration replacmnt g","code_information":[{"code":"L6915","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":748.71,"maximum":1926.68,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":998.28,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1926.68,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":748.71,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1018.25,"additional_payer_notes":"APC"}]}]},{"description":"Wrist disarticul switch ctrl","code_information":[{"code":"L6920","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7736.26,"maximum":19907.97,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10315.01,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":19907.97,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7736.26,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10521.31,"additional_payer_notes":"APC"}]}]},{"description":"Wrist disart myoelectronic c","code_information":[{"code":"L6925","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8264.9,"maximum":21268.35,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11019.87,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":21268.35,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8264.9,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11240.27,"additional_payer_notes":"APC"}]}]},{"description":"Below elbow switch control","code_information":[{"code":"L6930","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7451.1,"maximum":19174.16,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9934.8,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":19174.16,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7451.1,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10133.5,"additional_payer_notes":"APC"}]}]},{"description":"Below elbow myoelectronic ct","code_information":[{"code":"L6935","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8226.06,"maximum":21168.39,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10968.08,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":21168.39,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8226.06,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11187.44,"additional_payer_notes":"APC"}]}]},{"description":"Elbow disarticulation switch","code_information":[{"code":"L6940","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":9621.81,"maximum":24760.12,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12829.08,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":24760.12,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9621.81,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13085.66,"additional_payer_notes":"APC"}]}]},{"description":"Elbow disart myoelectronic c","code_information":[{"code":"L6945","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":10734.38,"maximum":27623.12,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14312.5,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":27623.12,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10734.38,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14598.75,"additional_payer_notes":"APC"}]}]},{"description":"Above elbow switch control","code_information":[{"code":"L6950","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":9603.96,"maximum":24714.19,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12805.28,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":24714.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9603.96,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13061.39,"additional_payer_notes":"APC"}]}]},{"description":"Above elbow myoelectronic ct","code_information":[{"code":"L6955","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":11137.58,"maximum":28660.69,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14850.1,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":28660.69,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11137.58,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15147.1,"additional_payer_notes":"APC"}]}]},{"description":"Shldr disartic switch contro","code_information":[{"code":"L6960","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":11716.3,"maximum":30149.96,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15621.74,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":30149.96,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11716.3,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15934.17,"additional_payer_notes":"APC"}]}]},{"description":"Shldr disartic myoelectronic","code_information":[{"code":"L6965","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":13879.78,"maximum":35717.29,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18506.37,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":35717.29,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13879.78,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18876.5,"additional_payer_notes":"APC"}]}]},{"description":"Interscapular-thor switch ct","code_information":[{"code":"L6970","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":14856.76,"maximum":38231.41,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19809.02,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":38231.41,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14856.76,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20205.2,"additional_payer_notes":"APC"}]}]},{"description":"Interscap-thor myoelectronic","code_information":[{"code":"L6975","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":16375.66,"maximum":42140.03,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21834.21,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":42140.03,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16375.66,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22270.89,"additional_payer_notes":"APC"}]}]},{"description":"Adult electric hand","code_information":[{"code":"L7007","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3373.16,"maximum":8680.27,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4497.55,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":8680.27,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3373.16,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4587.5,"additional_payer_notes":"APC"}]}]},{"description":"Pediatric electric hand","code_information":[{"code":"L7008","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5230.76,"maximum":13460.5,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6974.35,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":13460.5,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5230.76,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7113.84,"additional_payer_notes":"APC"}]}]},{"description":"Adult electric hook","code_information":[{"code":"L7009","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3451.15,"maximum":8880.95,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4601.53,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":8880.95,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3451.15,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4693.56,"additional_payer_notes":"APC"}]}]},{"description":"Prehensile actuator","code_information":[{"code":"L7040","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2809.01,"maximum":7228.53,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3745.35,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7228.53,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2809.01,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3820.26,"additional_payer_notes":"APC"}]}]},{"description":"Pediatric electric hook","code_information":[{"code":"L7045","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1484.09,"maximum":3819.06,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1978.79,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3819.06,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1484.09,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2018.37,"additional_payer_notes":"APC"}]}]},{"description":"Electronic elbow hosmer swit","code_information":[{"code":"L7170","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5555.15,"maximum":14295.26,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7406.87,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":14295.26,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5555.15,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7555.01,"additional_payer_notes":"APC"}]}]},{"description":"Electronic elbow sequential","code_information":[{"code":"L7180","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":35939.99,"maximum":92485.58,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":47919.99,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":92485.58,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":35939.99,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":48878.39,"additional_payer_notes":"APC"}]}]},{"description":"Electronic elbo simultaneous","code_information":[{"code":"L7181","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":37003.64,"maximum":95222.69,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":49338.18,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":95222.69,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":37003.64,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":50324.94,"additional_payer_notes":"APC"}]}]},{"description":"Electron elbow adolescent sw","code_information":[{"code":"L7185","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5840.28,"maximum":15028.99,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7787.04,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":15028.99,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5840.28,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7942.78,"additional_payer_notes":"APC"}]}]},{"description":"Electron elbow child switch","code_information":[{"code":"L7186","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":9818.33,"maximum":25265.84,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13091.11,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":25265.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9818.33,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13352.93,"additional_payer_notes":"APC"}]}]},{"description":"Elbow adolescent myoelectron","code_information":[{"code":"L7190","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7749.49,"maximum":19942.01,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10332.65,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":19942.01,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7749.49,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10539.3,"additional_payer_notes":"APC"}]}]},{"description":"Elbow child myoelectronic ct","code_information":[{"code":"L7191","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":10327.33,"maximum":26575.66,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13769.77,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":26575.66,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10327.33,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14045.17,"additional_payer_notes":"APC"}]}]},{"description":"Electronic wrist rotator any","code_information":[{"code":"L7259","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3784.81,"maximum":9739.57,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5046.41,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":9739.57,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3784.81,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5147.34,"additional_payer_notes":"APC"}]}]},{"description":"Six volt bat otto bock/eq ea","code_information":[{"code":"L7360","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":244.32,"maximum":628.72,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":325.76,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":628.72,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":244.32,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":332.28,"additional_payer_notes":"APC"}]}]},{"description":"Battery chrgr six volt otto","code_information":[{"code":"L7362","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":266.9,"maximum":686.83,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":355.87,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":686.83,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":266.9,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":362.99,"additional_payer_notes":"APC"}]}]},{"description":"Twelve volt battery utah/equ","code_information":[{"code":"L7364","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":472.27,"maximum":1215.3,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":629.69,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1215.3,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":472.27,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":642.28,"additional_payer_notes":"APC"}]}]},{"description":"Battery chrgr 12 volt utah/e","code_information":[{"code":"L7366","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":649.48,"maximum":1671.34,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":865.98,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1671.34,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":649.48,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":883.3,"additional_payer_notes":"APC"}]}]},{"description":"Replacemnt lithium ionbatter","code_information":[{"code":"L7367","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":359.56,"maximum":925.28,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":479.42,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":925.28,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":359.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":489.01,"additional_payer_notes":"APC"}]}]},{"description":"Lithium ion battery charger","code_information":[{"code":"L7368","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":466.1,"maximum":1199.42,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":621.46,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1199.42,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":466.1,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":633.89,"additional_payer_notes":"APC"}]}]},{"description":"Add ue prost be/wd, ultlite","code_information":[{"code":"L7400","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":283.04,"maximum":728.36,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":377.39,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":728.36,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":283.04,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":384.94,"additional_payer_notes":"APC"}]}]},{"description":"Add ue prost a/e ultlite mat","code_information":[{"code":"L7401","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":316.84,"maximum":815.33,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":422.45,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":815.33,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":316.84,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":430.9,"additional_payer_notes":"APC"}]}]},{"description":"Add ue prost s/d ultlite mat","code_information":[{"code":"L7402","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":342.2,"maximum":880.6,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":456.27,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":880.6,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":342.2,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":465.4,"additional_payer_notes":"APC"}]}]},{"description":"Add UE prost b/e acrylic","code_information":[{"code":"L7403","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":340.11,"maximum":875.22,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":453.48,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":875.22,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":340.11,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":462.55,"additional_payer_notes":"APC"}]}]},{"description":"Add UE prost a/e acrylic","code_information":[{"code":"L7404","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":513.34,"maximum":1320.99,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":684.45,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1320.99,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":513.34,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":698.14,"additional_payer_notes":"APC"}]}]},{"description":"Add UE prost s/d acrylic","code_information":[{"code":"L7405","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":671.31,"maximum":1727.5,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":895.08,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1727.5,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":671.31,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":912.98,"additional_payer_notes":"APC"}]}]},{"description":"Add to upp extr user adj mec","code_information":[{"code":"L7406","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2362.55,"maximum":6079.64,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3150.07,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6079.64,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2362.55,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3213.07,"additional_payer_notes":"APC"}]}]},{"description":"Repair prosthesis per 15 min","code_information":[{"code":"L7520","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":30.5,"maximum":78.49,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":40.67,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":78.49,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":30.5,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":41.48,"additional_payer_notes":"APC"}]}]},{"description":"Pros soc insert gasket/seal","code_information":[{"code":"L7700","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":138.16,"maximum":355.54,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":184.22,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":355.54,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":138.16,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":187.9,"additional_payer_notes":"APC"}]}]},{"description":"Mastectomy bra","code_information":[{"code":"L8000","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":39.1,"maximum":100.61,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":52.13,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":100.61,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":39.1,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":53.17,"additional_payer_notes":"APC"}]}]},{"description":"Breast prosthesis bra & form","code_information":[{"code":"L8001","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":115.87,"maximum":298.17,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":154.49,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":298.17,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":115.87,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":157.58,"additional_payer_notes":"APC"}]}]},{"description":"Brst prsth bra & bilat form","code_information":[{"code":"L8002","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":152.36,"maximum":392.08,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":203.15,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":392.08,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":152.36,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":207.21,"additional_payer_notes":"APC"}]}]},{"description":"Ext breastprosthesis garment","code_information":[{"code":"L8015","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":55.36,"maximum":142.45,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":73.81,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":142.45,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":55.36,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":75.29,"additional_payer_notes":"APC"}]}]},{"description":"Mastectomy form","code_information":[{"code":"L8020","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":208.8,"maximum":537.31,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":278.4,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":537.31,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":208.8,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":283.97,"additional_payer_notes":"APC"}]}]},{"description":"Breast prosthes w/o adhesive","code_information":[{"code":"L8030","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":322.79,"maximum":830.65,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":430.39,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":830.65,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":322.79,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":439.0,"additional_payer_notes":"APC"}]}]},{"description":"Breast prosthesis w adhesive","code_information":[{"code":"L8031","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":322.79,"maximum":830.65,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":430.39,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":830.65,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":322.79,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":439.0,"additional_payer_notes":"APC"}]}]},{"description":"Reusable nipple prosthesis","code_information":[{"code":"L8032","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":36.17,"maximum":93.08,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":48.23,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":93.08,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":36.17,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":49.19,"additional_payer_notes":"APC"}]}]},{"description":"Custom breast prosthesis","code_information":[{"code":"L8035","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3383.41,"maximum":8706.64,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4511.21,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":8706.64,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3383.41,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4601.43,"additional_payer_notes":"APC"}]}]},{"description":"Nasal prosthesis","code_information":[{"code":"L8040","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2289.56,"maximum":5891.81,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3052.75,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5891.81,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2289.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3113.8,"additional_payer_notes":"APC"}]}]},{"description":"Midfacial prosthesis","code_information":[{"code":"L8041","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2759.4,"maximum":7100.86,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3679.2,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7100.86,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2759.4,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3752.78,"additional_payer_notes":"APC"}]}]},{"description":"Orbital prosthesis","code_information":[{"code":"L8042","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3100.45,"maximum":7978.48,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4133.93,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7978.48,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3100.45,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4216.61,"additional_payer_notes":"APC"}]}]},{"description":"Upper facial prosthesis","code_information":[{"code":"L8043","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3472.51,"maximum":8935.92,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4630.01,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":8935.92,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3472.51,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4722.61,"additional_payer_notes":"APC"}]}]},{"description":"Hemi-facial prosthesis","code_information":[{"code":"L8044","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3844.56,"maximum":9893.33,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5126.08,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":9893.33,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3844.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5228.6,"additional_payer_notes":"APC"}]}]},{"description":"Auricular prosthesis","code_information":[{"code":"L8045","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3010.54,"maximum":7747.14,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4014.06,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":7747.14,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3010.54,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4094.34,"additional_payer_notes":"APC"}]}]},{"description":"Partial facial prosthesis","code_information":[{"code":"L8046","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2480.38,"maximum":6382.86,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3307.18,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":6382.86,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2480.38,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3373.32,"additional_payer_notes":"APC"}]}]},{"description":"Nasal septal prosthesis","code_information":[{"code":"L8047","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1271.19,"maximum":3271.2,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1694.92,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3271.2,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1271.19,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1728.82,"additional_payer_notes":"APC"}]}]},{"description":"Truss single w/ standard pad","code_information":[{"code":"L8300","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":77.46,"maximum":199.33,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":103.28,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":199.33,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":77.46,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":105.35,"additional_payer_notes":"APC"}]}]},{"description":"Truss double w/ standard pad","code_information":[{"code":"L8310","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":137.21,"maximum":353.09,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":182.95,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":353.09,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":137.21,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":186.61,"additional_payer_notes":"APC"}]}]},{"description":"Truss addition to std pad wa","code_information":[{"code":"L8320","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":56.92,"maximum":146.49,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":75.9,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":146.49,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":56.92,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":77.42,"additional_payer_notes":"APC"}]}]},{"description":"Truss add to std pad scrotal","code_information":[{"code":"L8330","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":45.33,"maximum":116.65,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":60.44,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":116.65,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":45.33,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":61.65,"additional_payer_notes":"APC"}]}]},{"description":"Sheath below knee","code_information":[{"code":"L8400","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":14.45,"maximum":37.19,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19.27,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":37.19,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14.45,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19.66,"additional_payer_notes":"APC"}]}]},{"description":"Sheath above knee","code_information":[{"code":"L8410","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":19.02,"maximum":48.94,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25.36,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":48.94,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19.02,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25.87,"additional_payer_notes":"APC"}]}]},{"description":"Sheath upper limb","code_information":[{"code":"L8415","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":19.68,"maximum":50.64,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26.24,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":50.64,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19.68,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26.76,"additional_payer_notes":"APC"}]}]},{"description":"Pros sheath/sock w gel cushn","code_information":[{"code":"L8417","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":69.46,"maximum":178.76,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":92.62,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":178.76,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":69.46,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":94.47,"additional_payer_notes":"APC"}]}]},{"description":"Prosthetic sock multi ply BK","code_information":[{"code":"L8420","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":19.26,"maximum":49.56,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25.68,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":49.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19.26,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26.19,"additional_payer_notes":"APC"}]}]},{"description":"Prosthetic sock multi ply AK","code_information":[{"code":"L8430","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":21.82,"maximum":56.14,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":29.09,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":56.14,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21.82,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":29.67,"additional_payer_notes":"APC"}]}]},{"description":"Pros sock multi ply upper lm","code_information":[{"code":"L8435","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":20.73,"maximum":53.35,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27.64,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":53.35,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20.73,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":28.19,"additional_payer_notes":"APC"}]}]},{"description":"Shrinker below knee","code_information":[{"code":"L8440","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":43.05,"maximum":110.78,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":57.4,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":110.78,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":43.05,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":58.55,"additional_payer_notes":"APC"}]}]},{"description":"Shrinker above knee","code_information":[{"code":"L8460","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":61.19,"maximum":157.47,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":81.59,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":157.47,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":61.19,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":83.22,"additional_payer_notes":"APC"}]}]},{"description":"Shrinker upper limb","code_information":[{"code":"L8465","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":56.56,"maximum":145.54,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":75.41,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":145.54,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":56.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":76.92,"additional_payer_notes":"APC"}]}]},{"description":"Pros sock single ply BK","code_information":[{"code":"L8470","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6.13,"maximum":15.77,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8.17,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":15.77,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6.13,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8.33,"additional_payer_notes":"APC"}]}]},{"description":"Pros sock single ply AK","code_information":[{"code":"L8480","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8.45,"maximum":21.75,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11.27,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":21.75,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8.45,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11.5,"additional_payer_notes":"APC"}]}]},{"description":"Pros sock single ply upper l","code_information":[{"code":"L8485","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":11.38,"maximum":29.28,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15.17,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":29.28,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11.38,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15.47,"additional_payer_notes":"APC"}]}]},{"description":"Artificial larynx","code_information":[{"code":"L8500","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":607.74,"maximum":1563.92,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":810.32,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1563.92,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":607.74,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":826.53,"additional_payer_notes":"APC"}]}]},{"description":"Tracheostomy speaking valve","code_information":[{"code":"L8501","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":110.91,"maximum":285.41,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":147.88,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":285.41,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":110.91,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":150.84,"additional_payer_notes":"APC"}]}]},{"description":"Trach-esoph voice pros pt in","code_information":[{"code":"L8507","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":38.66,"maximum":99.49,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":51.55,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":99.49,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":38.66,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":52.58,"additional_payer_notes":"APC"}]}]},{"description":"Trach-esoph voice pros md in","code_information":[{"code":"L8509","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":100.86,"maximum":259.55,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":134.48,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":259.55,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":100.86,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":137.17,"additional_payer_notes":"APC"}]}]},{"description":"Voice amplifier","code_information":[{"code":"L8510","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":233.38,"maximum":600.56,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":311.17,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":600.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":233.38,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":317.39,"additional_payer_notes":"APC"}]}]},{"description":"Indwelling trach insert","code_information":[{"code":"L8511","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":67.16,"maximum":172.83,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":89.55,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":172.83,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":67.16,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":91.34,"additional_payer_notes":"APC"}]}]},{"description":"Gel cap for trach voice pros","code_information":[{"code":"L8512","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":2.01,"maximum":5.17,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2.68,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":5.17,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2.01,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2.73,"additional_payer_notes":"APC"}]}]},{"description":"Trach pros cleaning device","code_information":[{"code":"L8513","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4.81,"maximum":12.37,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6.41,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":12.37,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4.81,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6.54,"additional_payer_notes":"APC"}]}]},{"description":"Repl trach puncture dilator","code_information":[{"code":"L8514","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":87.1,"maximum":224.13,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":116.13,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":224.13,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":87.1,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":118.45,"additional_payer_notes":"APC"}]}]},{"description":"Gel cap app device for trach","code_information":[{"code":"L8515","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":58.3,"maximum":150.04,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":77.74,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":150.04,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":58.3,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":79.29,"additional_payer_notes":"APC"}]}]},{"description":"Coch implant headset replace","code_information":[{"code":"L8615","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":416.51,"maximum":1071.83,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":555.35,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1071.83,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":416.51,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":566.46,"additional_payer_notes":"APC"}]}]},{"description":"Coch implant microphone repl","code_information":[{"code":"L8616","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":97.0,"maximum":249.63,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":129.34,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":249.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":97.0,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":131.93,"additional_payer_notes":"APC"}]}]},{"description":"Coch implant trans coil repl","code_information":[{"code":"L8617","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":84.74,"maximum":218.05,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":112.98,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":218.05,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":84.74,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":115.24,"additional_payer_notes":"APC"}]}]},{"description":"Coch implant tran cable repl","code_information":[{"code":"L8618","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":24.22,"maximum":62.32,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":32.29,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":62.32,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":24.22,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":32.94,"additional_payer_notes":"APC"}]}]},{"description":"Coch imp ext proc/contr rplc","code_information":[{"code":"L8619","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7762.54,"maximum":19975.62,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10350.06,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":19975.62,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7762.54,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10557.06,"additional_payer_notes":"APC"}]}]},{"description":"Repl zinc air battery","code_information":[{"code":"L8621","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":0.58,"maximum":1.49,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":0.77,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1.49,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":0.58,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":0.79,"additional_payer_notes":"APC"}]}]},{"description":"Repl alkaline battery","code_information":[{"code":"L8622","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":0.3,"maximum":0.77,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":0.4,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":0.77,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":0.3,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":0.41,"additional_payer_notes":"APC"}]}]},{"description":"Lith ion batt cid,non-earlvl","code_information":[{"code":"L8623","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":59.74,"maximum":153.72,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":79.65,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":153.72,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":59.74,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":81.24,"additional_payer_notes":"APC"}]}]},{"description":"Lith ion batt cid, ear level","code_information":[{"code":"L8624","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":148.93,"maximum":383.24,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":198.57,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":383.24,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":148.93,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":202.54,"additional_payer_notes":"APC"}]}]},{"description":"Charger coch impl/aoi battry","code_information":[{"code":"L8625","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":174.43,"maximum":448.86,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":232.57,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":448.86,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":174.43,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":237.22,"additional_payer_notes":"APC"}]}]},{"description":"CID ext speech process repl","code_information":[{"code":"L8627","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6588.68,"maximum":16954.88,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8784.91,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":16954.88,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6588.68,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8960.61,"additional_payer_notes":"APC"}]}]},{"description":"CID ext controller repl","code_information":[{"code":"L8628","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1173.85,"maximum":3020.7,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1565.13,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3020.7,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1173.85,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1596.43,"additional_payer_notes":"APC"}]}]},{"description":"CID transmit coil and cable","code_information":[{"code":"L8629","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":165.36,"maximum":425.53,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":220.48,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":425.53,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":165.36,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":224.89,"additional_payer_notes":"APC"}]}]},{"description":"Pt prgrm for implt neurostim","code_information":[{"code":"L8681","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1053.28,"maximum":2710.45,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1404.38,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2710.45,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1053.28,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1432.47,"additional_payer_notes":"APC"}]}]},{"description":"Radiofq trsmtr for implt neu","code_information":[{"code":"L8683","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4976.71,"maximum":12806.73,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6635.61,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":12806.73,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4976.71,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6768.32,"additional_payer_notes":"APC"}]}]},{"description":"Radiof trsmtr implt scrl neu","code_information":[{"code":"L8684","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":780.91,"maximum":2009.54,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1041.21,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2009.54,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":780.91,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1062.03,"additional_payer_notes":"APC"}]}]},{"description":"External recharg sys intern","code_information":[{"code":"L8689","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1593.02,"maximum":4099.38,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2124.03,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4099.38,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1593.02,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2166.51,"additional_payer_notes":"APC"}]}]},{"description":"Osseointegrated snd proc rpl","code_information":[{"code":"L8691","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1590.44,"maximum":4092.72,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2120.58,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":4092.72,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1590.44,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":2162.99,"additional_payer_notes":"APC"}]}]},{"description":"Aoi transducer/actuator repl","code_information":[{"code":"L8694","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":872.15,"maximum":2244.34,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1162.87,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2244.34,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":872.15,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1186.13,"additional_payer_notes":"APC"}]}]},{"description":"External recharg sys extern","code_information":[{"code":"L8695","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":15.4,"maximum":39.62,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20.53,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":39.62,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15.4,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20.94,"additional_payer_notes":"APC"}]}]},{"description":"Pow ue rom dev ewh uprt cust","code_information":[{"code":"L8701","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":26227.6,"maximum":67492.35,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":34970.13,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":67492.35,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26227.6,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":35669.53,"additional_payer_notes":"APC"}]}]},{"description":"Pow ue rom dev ewhf uprt cus","code_information":[{"code":"L8702","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":51601.28,"maximum":132787.3,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":68801.71,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":132787.3,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":51601.28,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":70177.74,"additional_payer_notes":"APC"}]}]},{"description":"Pwr module pt cable lvad rpl","code_information":[{"code":"Q0477","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":716.51,"maximum":1843.83,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":955.35,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1843.83,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":716.51,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":974.46,"additional_payer_notes":"APC"}]}]},{"description":"Power adapter, combo vad","code_information":[{"code":"Q0478","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":169.71,"maximum":436.72,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":226.28,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":436.72,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":169.71,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":230.81,"additional_payer_notes":"APC"}]}]},{"description":"Power module combo vad, rep","code_information":[{"code":"Q0479","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":11085.67,"maximum":28527.12,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14780.89,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":28527.12,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11085.67,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15076.51,"additional_payer_notes":"APC"}]}]},{"description":"driver pneumatic vad, rep","code_information":[{"code":"Q0480","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":83176.32,"maximum":214040.4,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":110901.76,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":214040.4,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":83176.32,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":113119.8,"additional_payer_notes":"APC"}]}]},{"description":"microprcsr cu elec vad, rep","code_information":[{"code":"Q0481","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":13419.56,"maximum":34533.01,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17892.75,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":34533.01,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13419.56,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18250.6,"additional_payer_notes":"APC"}]}]},{"description":"microprcsr cu combo vad, rep","code_information":[{"code":"Q0482","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":4203.26,"maximum":10816.38,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5604.34,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":10816.38,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4203.26,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5716.43,"additional_payer_notes":"APC"}]}]},{"description":"monitor elec vad, rep","code_information":[{"code":"Q0483","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":17315.49,"maximum":44558.53,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23087.32,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":44558.53,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17315.49,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23549.07,"additional_payer_notes":"APC"}]}]},{"description":"monitor elec or comb vad rep","code_information":[{"code":"Q0484","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3362.61,"maximum":8653.12,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4483.48,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":8653.12,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3362.61,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4573.15,"additional_payer_notes":"APC"}]}]},{"description":"monitor cable elec vad, rep","code_information":[{"code":"Q0485","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":324.68,"maximum":835.5,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":432.9,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":835.5,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":324.68,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":441.56,"additional_payer_notes":"APC"}]}]},{"description":"mon cable elec/pneum vad rep","code_information":[{"code":"Q0486","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":270.21,"maximum":695.34,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":360.28,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":695.34,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":270.21,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":367.49,"additional_payer_notes":"APC"}]}]},{"description":"leads any type vad, rep only","code_information":[{"code":"Q0487","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":315.23,"maximum":811.2,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":420.31,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":811.2,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":315.23,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":428.72,"additional_payer_notes":"APC"}]}]},{"description":"pwr pck base combo vad, rep","code_information":[{"code":"Q0489","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":15011.6,"maximum":38629.84,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20015.46,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":38629.84,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15011.6,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20415.77,"additional_payer_notes":"APC"}]}]},{"description":"emr pwr source elec vad, rep","code_information":[{"code":"Q0490","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":649.34,"maximum":1670.96,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":865.78,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1670.96,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":649.34,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":883.1,"additional_payer_notes":"APC"}]}]},{"description":"emr pwr source combo vad rep","code_information":[{"code":"Q0491","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1020.82,"maximum":2626.92,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1361.1,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2626.92,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1020.82,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1388.32,"additional_payer_notes":"APC"}]}]},{"description":"emr pwr cbl elec vad, rep","code_information":[{"code":"Q0492","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":82.25,"maximum":211.66,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":109.67,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":211.66,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":82.25,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":111.86,"additional_payer_notes":"APC"}]}]},{"description":"emr pwr cbl combo vad, rep","code_information":[{"code":"Q0493","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":234.16,"maximum":602.58,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":312.22,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":602.58,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":234.16,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":318.46,"additional_payer_notes":"APC"}]}]},{"description":"emr hd pmp elec/combo, rep","code_information":[{"code":"Q0494","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":198.14,"maximum":509.89,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":264.19,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":509.89,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":198.14,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":269.47,"additional_payer_notes":"APC"}]}]},{"description":"charger elec/combo vad, rep","code_information":[{"code":"Q0495","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":3857.6,"maximum":9926.9,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5143.47,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":9926.9,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3857.6,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5246.34,"additional_payer_notes":"APC"}]}]},{"description":"battery elec/combo vad, rep","code_information":[{"code":"Q0496","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1384.57,"maximum":3562.95,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1846.09,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3562.95,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1384.57,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1883.01,"additional_payer_notes":"APC"}]}]},{"description":"bat clps elec/comb vad, rep","code_information":[{"code":"Q0497","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":432.33,"maximum":1112.53,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":576.44,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1112.53,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":432.33,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":587.97,"additional_payer_notes":"APC"}]}]},{"description":"holster elec/combo vad, rep","code_information":[{"code":"Q0498","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":474.36,"maximum":1220.69,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":632.48,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1220.69,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":474.36,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":645.13,"additional_payer_notes":"APC"}]}]},{"description":"belt/vest elec/combo vad rep","code_information":[{"code":"Q0499","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":154.13,"maximum":396.63,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":205.51,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":396.63,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":154.13,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":209.62,"additional_payer_notes":"APC"}]}]},{"description":"filters elec/combo vad, rep","code_information":[{"code":"Q0500","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":28.18,"maximum":72.53,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":37.58,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":72.53,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":28.18,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":38.33,"additional_payer_notes":"APC"}]}]},{"description":"shwr cov elec/combo vad, rep","code_information":[{"code":"Q0501","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":471.63,"maximum":1213.66,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":628.84,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1213.66,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":471.63,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":641.42,"additional_payer_notes":"APC"}]}]},{"description":"mobility cart pneum vad, rep","code_information":[{"code":"Q0502","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":600.49,"maximum":1545.25,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":800.65,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1545.25,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":600.49,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":816.66,"additional_payer_notes":"APC"}]}]},{"description":"battery pneum vad replacemnt","code_information":[{"code":"Q0503","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1200.9,"maximum":3090.32,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1601.2,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3090.32,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1200.9,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1633.22,"additional_payer_notes":"APC"}]}]},{"description":"pwr adpt pneum vad, rep veh","code_information":[{"code":"Q0504","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":633.72,"maximum":1630.77,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":844.96,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":1630.77,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":633.72,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":861.86,"additional_payer_notes":"APC"}]}]},{"description":"Lith-ion batt elec/pneum VAD","code_information":[{"code":"Q0506","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":788.78,"maximum":2029.8,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1051.71,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":2029.8,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":788.78,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1072.74,"additional_payer_notes":"APC"}]}]},{"description":"Biofeedback train any meth","code_information":[{"code":"90901","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":12.03,"maximum":30.96,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16.04,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":30.96,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12.03,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16.36,"additional_payer_notes":"APC"}]}]},{"description":"Review patient spirometry","code_information":[{"code":"94016","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":17.97,"maximum":46.24,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23.96,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":46.24,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17.97,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":24.44,"additional_payer_notes":"APC"}]}]},{"description":"Canalith repositioning proc","code_information":[{"code":"95992","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":21.8,"maximum":56.11,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":29.07,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":56.11,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21.8,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":29.65,"additional_payer_notes":"APC"}]}]},{"description":"Caregiver traing 1st 30 min","code_information":[{"code":"97550","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":29.44,"maximum":75.77,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":39.26,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":75.77,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":29.44,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":40.05,"additional_payer_notes":"APC"}]}]},{"description":"Caregiver traing ea addl 15","code_information":[{"code":"97551","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":15.69,"maximum":40.38,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20.92,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":40.38,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15.69,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21.34,"additional_payer_notes":"APC"}]}]},{"description":"Group caregiver training","code_information":[{"code":"97552","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":6.8,"maximum":17.51,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9.07,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":17.51,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6.8,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9.25,"additional_payer_notes":"APC"}]}]},{"description":"Hc pro phone call 5-10 min","code_information":[{"code":"98966","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7.54,"maximum":19.4,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10.05,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":19.4,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7.54,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10.25,"additional_payer_notes":"APC"}]}]},{"description":"Hc pro phone call 11-20 min","code_information":[{"code":"98967","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":14.6,"maximum":37.58,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19.47,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":37.58,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14.6,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19.86,"additional_payer_notes":"APC"}]}]},{"description":"Hc pro phone call 21-30 min","code_information":[{"code":"98968","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":21.34,"maximum":54.93,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":28.46,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":54.93,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21.34,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":29.03,"additional_payer_notes":"APC"}]}]},{"description":"Qnhp ol dig e/m svc 5-10min","code_information":[{"code":"98970","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7.54,"maximum":19.4,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10.05,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":19.4,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7.54,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10.25,"additional_payer_notes":"APC"}]}]},{"description":"Qnhp ol dig em svc 11-20min","code_information":[{"code":"98971","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":13.82,"maximum":35.55,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18.42,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":35.55,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13.82,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18.79,"additional_payer_notes":"APC"}]}]},{"description":"Qnhp ol dig e/m svc 21+ min","code_information":[{"code":"98972","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":21.11,"maximum":54.33,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":28.15,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":54.33,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21.11,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":28.71,"additional_payer_notes":"APC"}]}]},{"description":"Rtm tx mgmt 1st 10 min","code_information":[{"code":"98979","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":8.32,"maximum":21.42,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11.1,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":21.42,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8.32,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11.32,"additional_payer_notes":"APC"}]}]},{"description":"Rem ther mntr 1st 20 min","code_information":[{"code":"98980","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":18.64,"maximum":47.98,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":24.86,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":47.98,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18.64,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25.36,"additional_payer_notes":"APC"}]}]},{"description":"Rem ther mntr ea addl 20 min","code_information":[{"code":"98981","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":18.39,"maximum":47.32,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":24.52,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":47.32,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18.39,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25.01,"additional_payer_notes":"APC"}]}]},{"description":"Vag inser rectal control sys","code_information":[{"code":"A4563","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1260.44,"maximum":3243.52,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1680.58,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3243.52,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1260.44,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1714.19,"additional_payer_notes":"APC"}]}]},{"description":"Ed svc CKD ind per session","code_information":[{"code":"G0420","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":81.71,"maximum":210.27,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":108.95,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":210.27,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":81.71,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":111.13,"additional_payer_notes":"APC"}]}]},{"description":"Ed svc CKD grp per session","code_information":[{"code":"G0421","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":19.72,"maximum":50.74,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26.29,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":50.74,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19.72,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26.82,"additional_payer_notes":"APC"}]}]},{"description":"PPPS, initial visit","code_information":[{"code":"G0438","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":125.24,"maximum":322.29,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":166.99,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":322.29,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":125.24,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":170.33,"additional_payer_notes":"APC"}]}]},{"description":"PPPS, subseq visit","code_information":[{"code":"G0439","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":98.78,"maximum":254.18,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":131.7,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":254.18,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":98.78,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":134.33,"additional_payer_notes":"APC"}]}]},{"description":"Initial care training 30 m","code_information":[{"code":"G0539","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":29.44,"maximum":75.77,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":39.26,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":75.77,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":29.44,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":40.05,"additional_payer_notes":"APC"}]}]},{"description":"Train for caregiver add 15","code_information":[{"code":"G0540","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":15.69,"maximum":40.38,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20.92,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":40.38,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15.69,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21.34,"additional_payer_notes":"APC"}]}]},{"description":"Safety plan interven","code_information":[{"code":"G0560","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":29.3,"maximum":75.41,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":39.07,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":75.41,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":29.3,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":39.85,"additional_payer_notes":"APC"}]}]},{"description":"Remot img sub by pt, non e/m","code_information":[{"code":"G2250","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":5.78,"maximum":14.88,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7.71,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":14.88,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5.78,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7.86,"additional_payer_notes":"APC"}]}]},{"description":"Brief chkin, 5-10, non-e/m","code_information":[{"code":"G2251","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":7.78,"maximum":20.01,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10.37,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":20.01,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7.78,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10.58,"additional_payer_notes":"APC"}]}]},{"description":"Brief chkin by md/qhp, 11-20","code_information":[{"code":"G2252","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":15.95,"maximum":41.05,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21.27,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":41.05,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15.95,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21.7,"additional_payer_notes":"APC"}]}]},{"description":"Removable soft interface le","code_information":[{"code":"K0672","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":78.16,"maximum":201.14,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":104.22,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":201.14,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":78.16,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":106.3,"additional_payer_notes":"APC"}]}]},{"description":"Aud osseo dev, abutment","code_information":[{"code":"L8693","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":1400.35,"maximum":3603.56,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1867.13,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":3603.56,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1400.35,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1904.47,"additional_payer_notes":"APC"}]}]},{"description":"Ext antenna phren nerve stim","code_information":[{"code":"L8696","type":"HCPCS"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","minimum":200.14,"maximum":515.04,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":266.86,"additional_payer_notes":"APC"},{"payer_name":"DOC","plan_name":"Government","methodology":"fee schedule","standard_charge_dollar":515.04,"additional_payer_notes":"APC"},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":200.14,"additional_payer_notes":"APC"},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":272.2,"additional_payer_notes":"APC"}]}]}],"modifier_information":[{"description":"Technical Component; represents the costs of equipment, supplies, and technician personnel for a procedure, excluding the physician's interpretation. It is used when only the technical portion of a test is billed, typically by hospitals, imaging centers, or independent diagnostic testing facilities","code":"TC","modifier_payer_information":[{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"DOC","plan_name":"Government","description":"The modified price is presented in the standard charge value."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","description":"The modified price is presented in the standard charge value."}]}]}